Sem 4 repro PBl 1

Testicular cacinoma
Testicular and scrotal ultrasound
Primary modality for imaging most of the male reproductive system
Correlate patients sign and symptom..no ionizing
MRI is occasionally used for problem solving if the diagnosis is unclear on
ultrasound
Cyst or fluid filled mass is unlikely malignancy

Technique
A high-frequency transducer (9-15 MHz) is usually used for evaluation of testicles and scrotum,
except in certain circumstances (e.g. massive hydrocele), when a lower MHz transducer is used.

patient is supine
patient upright for when looking for an inguinal hernia

scrotum is supported on a towel laid over the thighs

testicles should be evaluated in both long and short axes

if a scrotal mass is found, one of the primary roles of ultrasound is to determine if
it intratesticular or extratesticular

intratesticular mass: generally malignant

extratesticular mass: 3-6% malignant

colour and spectral Doppler parameters should be set for low flow
power Doppler may be necessary to prove testicular torsion

important: both a short axis grayscale and a colour Doppler image should be obtained
which image both testicles at the same time ("buddy shot" or "sunglasses view"), to compare
relative echogenicity and blood flow

scrotum should be examined for extratesticular masses or processes

Normal ultrasound anatomy

Testis

homogeneous echogenicity
o

a prepubertal testis has a slightly decreased echogenicity relative to an adult

mildly coarse echotexture

adult diameter measures between 3-5 cm, with a volume of ~20 cm 3

the tunica (vaginalis/albuginea) appears as an echogenic outline of the testicle:

o

the tunica invaginates to form the linear echogenic testicular mediastinum

the rete testis can be identified in ~20% of patients

hypoechoic region near the mediastinum

more noticeable if dilated

appendix testis: attached to upper pole of testicle, near the epididymis

not usually seen unless torsed

spectral Doppler: the testis demonstrates a low-resistance arterial waveform

Epididymis

epididymal head: round or oblong structure located near the superior pole of the testicle
o

isoechoic or mildly hyperechoic relative to the testicle

measures 5-12 mm

epididymal body: extends down the posterior aspect of the testicle

measures 2-4 mm

epididymal tail: curved structure at the inferior pole of the testicle and becomes the
proximal vas deferens
measures 2-5 mm

appendix epididymis: attached at the epididymal head

not normally seen unless torsed

spectral Doppler: epididymis demonstrates a low-resistance arterial waveform

Scrotum

normal scrotal skin thickness varies between 2-8 mm

Germ cell tumor of the testis

Testicular seminoma
Ultrasound is the first line imaging modality if a patient presents with a testicular abnormality.

seminomas usually appear as a homogeneous intratesticular mass of low echogenicity

compared to normal testicular tissue

the mass is usually oval and well-defined in the absence of local invasion
usually confined within the tunica albuginea, rarely extending to paratesticular

o
structures

internal blood flow is seen on color Dopper imaging

cystic regions and calcifications are less common than in non-seminomatous germ cell
tumours
larger seminomas can have a heterogenous appearance

non-seminomatous germ cell tumour

In contrast to seminomas NSGCT tend to be more heterogeneous with frequent cystic areas or
calcification. They tend to be more aggressive than seminomas and tunica invasion is common. The
appearance of individual tumour will of course vary depending on the location. Please refer to the
parent article germ cell tumours for links to specific locations.
Imaging is also essential for staging of NSGCT which is location dependent.

Hydrocele
Ultrasound
Ultrasound is the first modality usually used to evaluate hydroceles. It presents as a simple fluid
collection surrounding the testis. It is avascular on Doppler evaluation. It may contain septations,
calcifications and cholesterol 2.
A funiculocele is a sub type of hydrocele, however, it doesn't surround the testis. They can also
appear larger with straining (valsalva) 2. It may contain fibrous adhesions, giving a beaded
appearance to the spermatic cord (pachyvaginalitis) 3.
The encysted subtype shows no communication with the peritoneum and it usually only involves the
spermatic cord.