Scrotal Ultrasound The Essentials - HD

Introduction

My name is Wei Chong.
I'm from the University of North Carolina,
and I'm going to be talking about scrotal ultrasound,
scrotal ultrasound.

Normal Scrotal Anatomy

The essentials, the normal testis is ovoid
measuring four by three by three centimeters.
It is homogenous in echo texture,
apart from the linear echogenic mediastinum testis.
It is surrounded by an echogenic tica,
made up
of the tunica albuginea
and tunica vaginalis, which is made up
of two layers, visceral and parietal.
The tica is difficult to see in the absence of
a hydros eal.

So this patient has a small amount
of fluid in the scrotal sac,
and the tica appears as this echogenic,
thin white line.

So this is the diagram showing the anatomy
of the scrotum.
We see that the feminine for tubules here,
empty
into the reti testis area,
and these drain into the he the head of the epididymus,
which,
then empties towards the tail.
And the eventually the sperm goes into the,
vast deference.

So the mediastinum testis appears as an echogenic band
that runs along the length of the testis.
And this is considered normal.
It is actually an extension
of the tica into the interior of the testis.

Blood Supply

The blood supply of the scrotum
comes from the testicular artery, which supplies the testis.
This becomes the capsular artery, which then sends in
branches into the test, is known as cental arteries.
These then take a 180 degree turn
as once they reach the VT test
and,
reverse direction.
So the centripetal branches of the capsular artery are seen
to enter the testicular parenchyma running
towards the mediastinum.
These vessels are rise into the recurrent rami at the
mediastinum, then run in the opposite direction.
So you will see arterial flow running in two directions in a
normal testes.
The creter
and deferential arteries supply the,
scrotal sac and also anastomosis
with branches of the,
capsular artery.

Benign Scrotal Lesions

Rete Testis Ectasia

The RT testis form at the confluence of the seminar
for tubules, these can become ectatic
and produce an appearance of a honeycomb like network
of tubules near the mediastinum testis.
These, this is known as ectasia of the ret testis,
and this is a sagittal image showing dilated cystic tubular
structures along the length
of the mediastinum testis in the sagittal
and transverse plane, there's an association
with sperm seals,
but these cystic structures have no mass effect
and are considered benign.

Vas Deferens Dilatation

The vast deference is a thick wall tubular structure
that is a convoluted inferiorly
becoming straight superiorly.
It is between 1.5 and 2.7 millimeters in diameter.
It becomes dilated if obstructed,
and this is sometimes seen post vasectomy.
This is a patient with a markedly dilated vast deference,
running next to the,
tail of the,
epi is here.
And this clip shows,
echogenic foci within the,
vast deference.
These are actually,
spermatic fluid,
which is visible running within the,
vast deference.

Varicocele

Varicose seals are dilatations of
the testicular veins, which are common ex,
outside the testes and commoner on the left side.
Veins are considered
to become varicose seals when they get more than three
millimeters in diameter.
Val Salva is important to demonstrate flow
and thus confirming these are made of veins.
So this color Doppler image shows a al salvo maneuver being
performed on this patient,
and the tubular structures,
light up with color
and are shown to be vari C seals.

The seals can also occur inside the testis.
It's less common than the extra testicular varicose seal,
but they are associated with extra testicular varicose seal.
So this image shows a, the left testis with an intra
and extra testicular varicose seal.
This is the transverse image,
and the sagittal image also shows
multiple intra testicular varicose seals.
Intra testicular varis,
occur more commonly
around the mediastinum and present with infertility
or pain.

Cysts

Cyst can occur in within the testis
or within the tunica intra testicular cyst.
Usually asymptomatic and are simple cysts.
CLE cysts appear in the form of a palpable mass
and often associated with a history of trauma or infection.
They may have a calcified wall.
The cystic teratoma is a rare cystic tumor
that occurs within the testes,
but is associated with a complex cystic mass.

Epidermoid Cyst of the Testis

The epiderm assist of a test of the testis consists
of alternating rings of hyper and hypo echogenicity.
These correspond to the layers
of keratinizing squamous epithelium.
It has an echogenic center
and a characteristic onion ring, target,
or bullseye appearance caused by the deposition
of the layers of keratinizing squamous epithelium.

So the,
living portion
of this cy is right in the center, and it's,
and it's throwing off layers of,
Keratin creating these,
this,
onion ring appearance.
It's benign and makes up one to 2% of testicular tumors.

Epidermoid cysts can occur
outside the testis anywhere along the midline
of the median raffe from the distal penis to the anus.
They represent abnormal embryologic closure
of the median rafa and the urethral groove,
and they appear solid looking hypoechoic lesions
with scattered echogenic reflectors with no doppler signal.
The red arrow here marks the appearance
of an extra testicular epidermoid cyst,
and this is a closeup view showing the,
scattered echogenic reflectors
and,
solid looking hypoechoic lesions, but with no flow.

Fibroma of the Tunica

Fibroma of the tunica is the second most
common paricular tumor.
It is a well-defined hyper
or hypoechoic lesion arising from the tunica,
and it may have acoustic enhancement or shadowing.

Sperm Granuloma

Sperm granulomas can occur within the epidermis
or along the cause of the vast deference they're associated
with infection trauma or vasectomy.
They are a chronic inflammatory response, A foreign body,
giant cell reaction
to extravasated sperm from damaged tubules obstructed vast
deference on the gray scale image.
Here we see an a mass line adjacent to the,
testis, which is heterogeneous,
and there's a lot of peripheral
and central flow within this mass.
And this mass turned out to be a sperm granuloma,
and the flow was due to the chronic inflammatory response.
They're usually less than one centimeter in size,
and they're typically solid well-defined.
And hypoechoic.

Adrenal Rests

Adrenal rests are
hyperplastic adrenal cortices arising from AbiNet adrenal
cortical tissue adherent to the gonads.
In prenatal life,
they can form tumor like masses in response
to elevated levels of circulating A CTH in congenital
adrenal hyperplasia or Cushing syndrome,
and they're found in up to a quarter of patients
with Cushing syndrome.
This video clip shows,
an adrenal rest within,
the testis that the rest is, appears in
as an eccentrically located hypo coic mass lying
within the testis.
And the key to the diagnosis of adrenal rest is
that they're usually bilateral
and that they,
situated along the edge
of the testis IE eccentrically located,
they are hypo coic hypovascular lesions without mass effect.
So the, the vessels appear to run through this mass
with a without displacement
or distortion of the testicular contour are

Epididymal Cysts or Spermatic Cysts

epidermal cysts
or spermatic seals are, a common,
extra testicular finding.
The, the spermatic seals
or epidermal cyst can be echo free
or they can have internal echoes
that almost mimic a solid mass.

Scrotal Liths

Scrotal lifts are calcified shadowing mobile,
structures located within the,
scrotal sac.
These are both benign lesions.

Adenomatoid Tumor of the Epididymis

Adenoma oid tumor
of the epidermis is the calmest paricular tumor.
It's a benign, well circumscribed, extra testicular mass,
more echogenic than the testis.
This is another patient with an epi eno type tumor
of the epidermis situated in the tail of the epidermis,
and it shows up as an echogenic
around mass in the epidermal tail.

Polyorchidism or Testicular Duplication

Polygenism or testicular duplication,
appears in the form of an extra testis.
So this patient has a single testis on the left side.
On the right side, we see two
echogenic rounded structures that appear.
The extra testis appears identical to the normal one,
including the presence of a mediastinum testis, which is
how you can distinguish poly poly
organism from a extra testicular scrotal tumor.
This is a,
transverse image of,
of another patient showing the normal left testis
and a duplicated testis on the right side.
And the sagittal image shows the two testes
and that both testes have their own EPIs and own
and separate mediastinum Testes.
Polygenism is associated with crip orchid and hernia
and an increase in incidence
of testicular malignancy and torsion.
They may have duplicated epididymus, as I mentioned as,
and they may have two vast deference.

Sarcoidosis

Sarcoidosis can involve the urogenital tract in about 0.2%
of clinically diagnosed cases, sarcoidosis appears
as an irregular solid hypoechoic mass within the
epididymus and testis.
There's epidural involvement in 70% of cases.
It is painless and it tends to respond to steroids.
On the right is the EPIs of a patient
with scrotal sarcoidosis.
The epidermis is enlarged with a hypo coic
mass in the epidermal head.
And here we see that the enlargement of the epidural head
with an ill-defined hypoechoic lesion within
the epidermal head.
The testis here has a solid hypoechoic lesion,
which is,
the granuloma from sarcoidosis,
another patient with scrotal sarcoidosis
and irregular hypoechoic mass involving both the epidermis
and testis.

Scrotal Tuberculosis

scrotal tuberculosis.
The commonest site of extrapulmonary tuberculosis
is the scrotum.
It occurs as a result of retrograde extension
from the para prostate and seminal vesicles
or from hematogenous spread.
It usually starts in the epidermal tail
and causes an enlarge hypo coic epididymus with
or without calcifications.
Testicular involvement is late or due to inadequate therapy.
The testis is diffusely en large
and heterogeneously hypo coic tb abscesses are less vascular
and less painful than biogenic abscesses.
This is a gray scale image of scrotal tb.
There is a lot extra statistical mass with cystic areas
and calcification compressing the testes.
We see an enlarged epididymus, which is extremely vascular,
but has cystic necrotic areas.
This is a transverse image
of the testes showing a complex fluid collection within the
testes, as well as large extra testicular complex fluid
collections bilaterally, which were made up of.
TB.

Scrotal Hernia

Scrotal
hernia may contain small bowel, colon or omentum.
It extends into the inguinal canal
and may mimic a complex hydro seal.
So this is a clip
of a patient performing a Val Salva maneuver,
and as the patient performs the man maneuver,
we see the right test, A normal right scrotal sac here
and on the left side,
protrusion of
omentum into the left scrotal sac.
This is a still image
of a different patient showing echogenic material within the
right scrotal sac, which is continuous
with the inguinal canal.
And this was an,
fat from a right
indirect inguinal hernia.

Condyloma or Anogenital Warts

Condyloma or anno genital watts is are caused
by human papillomavirus.
They're most common.
They're the most common form of viral,
sexually transmitted disease
and have the highest incidences
amongst the college age population.
There appears exophytic co cauliflower like lesions,
which are itchy but not painful along the scrotal wall.
So this patient here has a solid hypo coin enlargement
of the scrotal wall that is compressing the testis.
And this is a sagittal image showing the normal,
testicular,
scrotal wall.
Um,
anteriorly.
While more posteriorly, we see marked thickening of the,
scrotal wall with,
hypoechoic heterogeneous mass.
You should wear gloves when scanning these patients
because this disease is highly contagious.

Testicular Cancer

Gonadal Stromal Tumors

Gonadal stromal tumors,
the calmness gonadal stromal tumor is the lady cell tumor.
They make up 5% of testicular tumors
and 90% of them are benign.
Small tumors are hypo coic.
While the larger tumors are complex with cystic changes
and an necrosis, this is a patient
with a gonadal stromal tumor,
that appears
as an ill-defined hypo coic mass.

Germ Cell Tumors

Testicular cancer is the commonest cancer in the 15
to 44 age group.
95% are germ cell tumors.
85% are painless,
but remember that 15% of testicular cancers,
present with pain.
It may be multifocal
and can present with a history of trauma.
Large tumors are hypervascular while small
ones are hypovascular.
The seminoma and the mixed ger germ cell tumor make up the
bulk of,
germ cell tumors of the testis.
The seminoma is the commonest adult testicular cancer,
while the mixed germ cell is the
commonest statistical cancer.
Overall, seminoma occurs,
at a peak
between the ages of 30
and 40, while mixed germ cell tumor affects under thirties.
Seminoma is associated with crypto organism on either side.
So if you have an scented testis on one side,
you have an increased chance of seminoma in both testes.
The mixed germ cell tumor contains more than
one germ cell component.
The seminoma is hypoechoic,
while the mixed germ cell tumor tends
to be more heterogeneous in echo texture, as in this case
where we have calcification and cystic changes.
Seminomas are radio sensitive, mixed germ sense.
Cell tumors are not as re radio sensitive
and may get treated with chemotherapy.

Burnt-Out Tumor

One manifestation of,
germ cell tumor is the so-called burnt out tumor.
So in in this situation, the patient presents
with extensive systemic metastases such as liver metastases
or retroperitoneal lymph nodes,
and you are asked to find the primary tumor when you examine
the test tubes is ultrasound.
All you might see is a small
heterogeneous area within the testes,
far smaller than you would expect in someone with
diffuse massive metastases.
And this is known as the burnt out tumor.
It's caused by regression of the primary tumor,
which has outrun its blood supply.
So you have a tumor that is very aggressive, it grows,
it metastasizes, then it outruns its blood supply
and it dies, or most of it dies,
leaving the small irregular area within the testes.
But don't be fooled, this is actually the, the cause
of all the massive metastases.
So on this color Doppler image, we see
that this small heterogeneous partly,
hyper coic
and partly hypo coic area has a little bit
of peripheral flow, but it has largely auto infarcted.
So the appearance of the burnt out tumors of a small hypo
or hyper coic area with calcification
and acoustic shadowing in the presence
of diffuse systemic metastases.

Endodermal Sinus Tumor or Yolk Sac Tumor

The endodermal sinus tumor
or yolk sac tumor is the calmness cyst tumor
in children under three.
It has a very good prognosis.
It is characterized by elevated serum alpha fetal protein
Imaging findings are non-specific,
but may contain it may contain gelatinous elements,
hence contributing to its partly cystic appearance
as in this case here
where we see a complex cystic leg lesion with solid elements
and cystic elements.

Testicular Microlithiasis

Testicular micro lithys is tiny foci
of calcification within the testis.
It is diagnosed when you have greater than five punctate
non shadowing foci.
There were many reports of associations
with germ cell tumors
and was once thought to be a risk factor
for testicular cancer, as in this case.
Here we see a testis with extensive multi,
multiple
micro ssis,
and we also see an irregular hypoechoic mass inside,
inside this test and which turned out to be a seminoma
Because of this association, it was once thought
that preventive screening should be performed on patients
with testicular micro ssis,
but it turns out that micro lehi is actually very common.
It's,
found in 5.6% of men
and up to 14% of uh, AF African American men
and longitudinal studies have shown that the vast majority
of these patients will not go on
to develop testicular cancer.
In fact, only five cases have been reported of patients
with micro SSIS that went on to develop testicular cancer.
Hence today follow up ultrasound for of, for
in, in patients with testicular micro catharsis is now
not recommended.
He has a patient with very extensive,
micro ssis of the
but but no testicular cancer.

Secondary Neoplasms

Lymphoma of the Testis

lymphoma of the testis
lymphoma is the calmest secondary testicular neoplasm.
It usually occurs in the elderly in patients Over 60
non-Hodgkin's is the calmest form of lymphoma.
It can appear in two ways as a diffuse
infiltrative form in which the testis is enlarged
and heterogeneous or
as focal hypo coic testicular masses that may shadow.
This is a, a patient with lymphoma of the testis in the form
of ill-defined hypoechoic solid masses within the testes.
Here. This patient's lymphoma, it's caused,
is shadowing
as is this patient who has an ill-defined heterogeneous mass
with acoustic shadowing.
This is a more ill-defined infiltrative form of lymphoma.
This is a patient with anaplastic large cell lymphoma
of the scrotal skin.
The mass here is actually in the scrotal skin
and scrotal wall, not in the actual testes or EPIs itself.
It is partly necrotic with internal flow on color doppler
and the mass was actually located between the testes
Hodgkin's lymphoma may also occur in the scrotum.
This is a case of Hodgkin's lymphoma involving the scrotal
wall, which is markedly thickened.
This one involves the spermatic cord where it appears
as a form of a mass with solid
and cystic components within the s somatic cord.

Leukemia of the Testis

leukemia of the testis.
The testis is a sanctuary for leukemic cells due
to the blood gonad barrier.
This prevents chemotherapeutic drugs from crossing over into
the testicle.
So leukemic cells can last longer in the testes
after they've been eliminated in the rest of the body.
Leukemia appears as focal masses in the EPIs or testis
or as a diffusely heterogeneous en large testis.
This patient has leukemic infiltration of his right testis,
which is larger and more vascular than the left.
It can appear as scrotal wall thickening.
This patient has a markedly thickened scrotal wall,
which is hypoechoic
and extremely hypervascular.

Elastography

elastography Elastography.
I'm sorry, start again. Okay, starting now.
Elastography elastography is very useful
for detecting a diffusely infiltrated test is due to
hematogenous malignancies such as leukemia
or lymphoma elasticity.
Imaging displays mechanical strain
where elasticity is defined as stress divided by strain,
and it's displayed in a number of ways.
In this particular format, the
non-compressible structure appears darker
and shows up better on the gray scale image.
So you have the hard lesion here embedded in soft tissue
that it shows up as black on the ELA effect image.
So, we are actually looking at the degree at which the,
testis is compressible,
and this is a leukemic testis,
which on gray scale the leukemic
area iss very difficult to see.
It appears as a slightly ill-defined hypoechoic area,
but on applying elastography, the area
of leukemia is much less compressible than the rest
of the test and appears black on this,
modality
and red on this one.
So elastography is actually very useful
for detecting the more diffusely infiltrated form of,
malignancy involving the testis.

Acute Scrotal Pain

acute scrotal pain.
Ultrasound is the preferred test for workup
of the acute scrotum and it's highly accurate
for differentiating surgical from non-surgical problems.
I have marked surgical problems here in red.
These are the conditions where the patient really needs
to be taken to the operating room on an emergent basis.
Scrotal inflammation can be caused by epididimitis
or epi, more oris.
These are usually treated conservatively with antibiotics,
but PHUs gangrene is a form of in,
scrotal inflammation
that needs,
immediate surgery.
Testicular to appendiceal torsion complications
of inguinal hernia repair trauma
and testicular cancer make up the,
main causes
of acute testicular pain.
And the ones that need to be diagnosed
because they need immediate surgery are torsion
complications of inguinal hernia repair, trauma
and testicular cancer.

Epididymo-Orchitis

Epidemo oras is usually a sexually transmitted disease
caused by occus chlamydia or e coli.
It causes an enlarged hypoechoic, testis and epididymus.
This is a patient with,
severe epididimitis note,
a heterogeneous enlarged testis as well
as a heterogeneous en large epididymus
and a compact fluid collection within the epidermis,
which turned out to be infected.
Pus. The affected side is usually
hyperemic unless infarction has occurred.
So, the color doppler here shows a markedly
hyperemic EPIs.
There will usually be a hydros eal,
which has complex internal echo, so-called dirty hydros.
Eal focal oris can mimic the tumor,
so look for epidermal involvement.
Tumors rarely involve both the epidermis and the testis.
So if you see a focal mass within the testis,
but an enlarged heterogeneous epidem is consider focal
bronchitis as the course This patient has
epididymitis affecting his right testis on the left side.
For comparison, we see a normal appearing
testis with normal flow.
The right testis is heterogeneous
and hypervascular, as is the right EPIs.
This patient has no flow within his testis,
and this is due to testicular infarction as a late
complication of oris.
So the testis appears heterogeneous, but there is no flow.
There is a complex hydros eal as is,
normally associated in in inflammatory
situation in the scrotal sac.
And the hydro seal has,
multiple internal septi.

Fournier's Gangrene

Phonons gangrene is an necrotizing fasciitis affecting the
perineum and genitalia.
It predominantly involves effects men by ratio of 10
to one and is predisposed by reduced cellular immunity such
as diabetes, HIV alcoholism,
chronic steroid use or malnutrition.
It is polymicrobial caused by e coli, bactes strep
or staphylococcus.
There is usually a history of
euro genital injury,
creating a portal of entry
for these organisms
or a history of urogenital surgery,
a**l rectal trauma or surgery such as, such
as rectal biopsy or Crohn's.
Also, predisposes infection leads to thrombosis
of subcutaneous blood vessels and gangrene of the skin.
This condition is a surgical emergency.
This patient presented with marked thickening
of the scrotal wall.
This is the normal test is here,
but we see the scrotal wall is markedly thickened
and heterogeneous and has areas of fluid within.
On this clip, we see echogenic foci in the scrotal wall
with dirty shadowing,
which is actually air within the scrotal wall,
and the corresponding CT demonstrates air in the scrotal sac
and in the scrotal wall.
And this was acute fous gangrene
and this is what happens if fous gangrene is not treated
promptly by surgical debridement.
This patient has a markedly thickened scrotal wall with air
and no flow at all inside the,
testis.
What you're seeing here in color,
is actually twinkle artifact from the air.
So this patient has developed testicular infarction
secondary to PHUs gangrene.

Mumps Orchitis

mumps oris
occurs in 18% of patients with mumps.
It may occur in the absence of titis
and is usually unilateral.
It appears as an enlarged hypo coic testis.
This patient has,
an abnormal left testis,
which is heterogeneous and enlarged compared
with the normal right testis.
Here. There may be hyperemia
and the scrotal wall will be thickened.
The EPIs is also enlarged
And there's usually no hydrocele.
Unlike the,
other causes of,
epi dermatitis described earlier.

Testicular Torsion

Testicular tro is an important diagnosis to make
and is presents with acute testicular pain.
It is difficult to differentiate clinically from
epidemo oris.
The odds of losing the testis in torsion are proportional
to the time elapsed from the onset of pain.
So the salvage rate of a testis in,
in torsion is 80 to a hundred percent.
If the surgery is performed within five to six hours
of the onset of pain, it falls
to 70% if surgery is performed within six to 12 hours
and down to 20% if surgery is delayed
for more than 12 hours.
So this is a condition that you don't want to delay.
Diagnosis, you want to make the diagnosis as quickly
as possible and communicate the,
diagnosis to the,
referring clinic clinician promptly Reduced
or absent testicular flow on color.
Doppler ultrasound on the painful side is a highly specific,
almost 100%
and very sensitive sign of testicular torsion.
The reason that,
it is not a hundred percent sensitive is
that you have a condition known astrogen detorsion
where the test is TAUs and then partially detours
and then TAUs again,
and you happen to scan the patient during the period of
Deion,
temporary detorsion there may be flow into
that testis during the window in which the
testis can be salvaged.
The gray scale appearance of the testis is usually normal.
Once the testis becomes enlarged
and hypo echogenic on the affected side, then
this is usually associated with a non-viable testis.
This is a late sign
and it usually means that the testis can no longer be saved.
So this is an appearance of late testicular torsion.
This patient presented with pain, a painful left testis.
Note that the testis is enlarged heterogeneous
and doesn't have any color flow.
There is a hypervascular scrotal wall.
This is a sympathetic reaction,
caused
by vaso dilatation in the creter and deferential arteries.
Torsion of the testis is often accompanied by,
an enlarged avascular epidemy,
so you should always look at the epididymus,
in,
someone with a suspected torsion.
So this patient has no flow in his testis
and in his epidermis,
and the epi demist is markedly enlarged on the,
this is a little, this is part of the left testis here,
and this is, this is more normal with the normal flow.
This patient presented with a painful left testis.
Does he have to well, on color doppler, he appears
to have color flow in both the right and the left testis,
but in fact, this patient does have torsion
because the spectral waveform shows an abnormal
Doppler spectrum from the left testis with,
flow only in sly and no diastolic flow.
Then the normal testicular waveform is low resistance,
so there should be forward flow both in s Sicily
and diastole on color doppler.
There should be continuous color in the,
in,
in a normal testis.
The reason that this patient's,
color doppler
of his left testis is flashing is that there is no flow
during diastole, and this is partial or incomplete torsion.
So if you happen to catch the torsion pro,
as it's in progress, you'll lose the venous flow first,
then you'll lose the diastolic flow.
And finally, all arterial flow.
So although flow is present, hide resistance wave forms
with decreased diastolic flow are found in the testicular
artery in,
this case.
And this is torsion in progress.

Torsion of the Appendix Testis

The appendix testis is a remnant of the malaria duct.
It's usually located at the superior pole in the groove
between the testicle and the epididymus.
It appears as a five millimeter soft tissue structure on the
testicular surface, iso coic to the testis
and is easier seen in a patient with a hydros seal.
So this patient has a hydros seal
and the appendix testis shows up
as a little protrusion here on the surface of the testis.
The appendix testis can to And when it, to us,
it produces acute scrotal pain
that is indistinguishable clinically from testicular to
however we can distinguish to of the appendix testis from
to of the testis.
With ultrasound sono graphically, the toast appendix appears
as a rounded mass on the surface of the testis.
On this clip here we see this rounded hypo quake area,
on the surface of the testis and on color doppler.
The, this mass does not demonstrate flow,
although there is sympathetic flow in the adjacent testis
and scrotal,
wall.
So the testis and EPIs will appear antigenically normal
with normal or increased flow in the vicinity
of the appendix while the ac the appendix test itself will
be enlarged hypoechoic and have no flow.
The reason that we need to make the diagnosis of torsion
of the appendix testis is that it is treated conservatively.
Unlike testicular torsion, which is requires,
immediate surgery.

Testicular Infarction

testicular infarction can be caused
by conditions other than torsion.
This patient presented
with acute right-sided testicular pain.
The ultrasound shows a hypoechoic testis
with no flow on color doppler, but this wasn't torsion.
This patient had had an inguinal hernia repair A few days
earlier, the testicular artery
and vein passed through the inguinal canal,
and one of the complications
of inguinal hernia repair is occlusion of the venous return
by the mesh or damage the testicular artery leading
to infarction of the testis.
This is another patient with,
infarction of the testis.
Following inguinal hernia repair, there is thickening
of the scrotal wall, no flow in an enlarged heterogeneous
testis and a complex hydros eal.
Other causes of testicular infarction are
end stage oras and sickle cell disease.

Blunt Testicular Trauma

Blunt testicular trauma.
The scrotum is an uncommon site
of trauma due to its mobility.
Athletic injury is the calmest cause making up to 50%
of cases, motor vehicle accidents make up 17%.
The right testis is affected more than the left
because of propensity to be trapped against the pubis
Testicular rupture defined as disruption of the CLE layer
or devascularization requires surgical exploration.
Hence, the purpose of ultrasound in the setting
of blunt testicular trauma is to, I identify either rupture
or devascularization.
It takes,
50 kilograms of force
to disrupt a normal testis.
It Finally, you should always consider
an underlying mass or tumor because a testis with a mass
or tumor is more susceptible
to rupture than a normal testis.
This is,
a patient with an intra testicular hematoma.
Note that the test is here, has a mass
that is compressing the, the testicular tissue.
This is a sagittal image and this is the transverse image,
and that this mass has no flow
and this turned out to be a hematoma.
This type of testicular injury is treated conservatively
because there is no rupture
or devascularization as shown by Kala Doppler.
It is important to follow up these patients
with a repeat ultrasound until the hematoma has resolved
to exclude the possibility.
The, that this, this is actually a hidden,
this is actually a testicular tumor.
This is a complex hydros eal,
which is actually a hemato seal within the scrotal sac.
The test is however, is preserved
and we can see layering fluid within the,
scrotal sac.
This patient under had blunt trauma
to the right scrotal sac,
and we see complex fluid,
this,
which it turned out
to be blood within the scrotal sac.
So traumatic high hemato seals
and hydros seals are also treated conservatively if
the testis is preserved.
If a trauma, if a hydrocele is seen in the context of trauma
that has no internal echoes,
this could represent rupture of the bulbous urethra.
Hemato seals will eventually,
resolve
and leave a,
hydro seal with,
very few internal echoes.
So,
a hydros seal
that has no internal echos can be an old hydro hemato seal,
or it could represent rupture of the bulbous urethra.
This is a patient with a,
an old hemato seal,
which is compressing the is here
A testicular fracture appears
as a hypoechoic irregular linear area within the testis,
but this patient here has a testicular fracture,
but the tunica is intact and
therefore this is treated conservatively.
This patient has a large intra testicular hematoma
that looks quite,
worrying,
but in fact, the blood supply to the testis is preserved
and the tunica is intact,
and the testis maintains its normal rounded shape.
This is also treated conservatively.
This is a testicular rupture.
I note that the tunica marked
by this red arrow here is broken.
The contour of the testis is irregular,
and as this clip here shows, there is a traumatic
hydro seal and the break in the tunica is
shown at,
at this point,
and there is protrusion
of the testicular material out into the,
scrotal sac.
So this requires surgery
and if performed within 72 hours will result in salvage in
80 to 90% of cases.
This is another case of testicular rupture
that requires surgery.
Note that there at the three o'clock position,
there is extrusion of the testicular contents here out
of the testis into the scrotal sac.
In penetrating injury,
the we may see echogenic foci within the scrotal wall.
This, this is a patient who was shot,
and we see multiple echogenic foci within the,
scrotal wall and intra,
scrotal wall hematoma.
Additionally, we may see foci
of air within the,
scrotal wall.
This is a somewhat unusual type of testicular injury.
This is a high voltage electrical injury.
There are two types of high voltage injury,
the flash injury, which is a limited or partial
or full thickness burn, which occurs at the site of,
entry of the electrical current.
A true electrical injury,
occurs when the electrical current passes through the body
and you get a burn at the entrance and exit point.
This patient was an electrical worker
who accidentally grasps a high tension wire.
The elec current entered through his hand
and unfortunately for him exited through his scrotum.
The sagittal image here shows a extremely heterogeneous
testes with no flow in either testes.
Both testes had been infarcted
because of a severe burn in,
involving,
both testes following exit of the,
electrical current
through the scrotum.

Conclusion

So in conclusion, assume
that intra testicular solid masses are malignant
testicular cancer can present
with a history of pain or trauma.
Testicular cancer is eminently treatable. This is Mr.
Lance Armstrong, who is,
famous for,
having,
one the Tour de France,
but he was a metastatic testicular cancer survivor.
There's now some doubts about how he won it,
but there's, there he was.
He still managed to compete despite being a metastatic
testicular cancer survivor.
Other causes of testicular infarction can mimic torsion
and look beyond the testicle at the scrotal wall.
Cord and appendix most,
94% extra testicular soft tissue masses are benign.
Thank you.