Scrotal Masses 98-100% accuracy in distinguishing intra and extra-testicular masses. *** Most extratesticular masses are benign & most intratesticular masses are malignant Malignant lesions are msotly hypoechoic. Malignant neoplasia pts usually presents as painless , unlateral testicular mass . Clinically it is important to differentiate between Seminomas and Non Seminomatous germ cell tumors.

1. Guided by Prof Dr. Dharmraj Meena
Prepared by Dr Vrishit Saraswat

2.  Ovoid gland
 Adult Size: L 3-5cm (1.5cm)
B 2-4cm (1.0cm)
A-P 3cm
 Weight 13-19gm
 Weight and size decrease with age.

14.  98-100% accuracy in distinguishing intra and
extra-testicular masses.
 *** Most extratesticular masses are benign & most
intratesticular masses are malignant
 Malignant lesions are msotly hypoechoic.
 Malignant neoplasia pts usually presents as
painless , unlateral testicular mass .
 Clinically it is important to differentiate
between Seminomas and Non Seminomatous
germ cell tumors.

15. Seminoma
 Most common single cell type , in adults.
 40-50% of testicular malignancy
 4th -5th decade
 Rarely before puberty
 Less progressive, usually confined with in
tunica albugenia.
 Most fav prognosis of all malignant testicular
tumors.
 Lymphatic spread.

16.  Most common type of tumor in cryptorchid
testies, with increased risk of contralateral
involvement.
 Macroscopically , homogenous, solid , round
tumor of varying size.
 US features- hypoechoic,heterogenous, with
low level echos without calcification
 Rarely cystic or necrotic***

22. Nonseminomatous GST
 Includes yolksac tumor, embryonal carcinoma,
teratomas, choriocarcinoma & Mixed GCT.
 2nd n 3rd decade
 Frequently invade tunica albugenia
 More aggressive
 Visceral metastases common.
 US features- More heterogenous, both solid
and cystic component, coarse calcification
common***
 Its not possible to distinguish various types of
NSGCT on USG.

23. Mixed GCT
 MC NSGCT
 2nd MC pri testicular malignancy
 40% of all GCT
 Though mixed NSGC component,
seminomatous component may also be present.
 MC combination= Teratoma & embryonal Cell
Ca, (teratocarcinoma: old name)

24. Teratomas
 5-10% of pri testicular malignancy.
 WHO classified it in 3 cat. – (i)mature
(ii) immature (iii) teratoma with malignant
transformation.
 Metastasize via lymphatics with 5 yrs.
 Bi-modal age distribution – infancy and early
childhood & 3rd decade of life.
 In infancy- usually immature
 In adults – usually malignant
 AFP & hCG levels elevated.

25.  US features- well defined , markedly
inhomogenous mass with cystic areas and
dense echogenic calcification (focal
calcification, cartilage, immature bone, fibrosis)
Embryonal cell carcinoma
 Rare tumor
 2-3% of pri testicular malignancy
 MC GCT in less 2yr old*****
 US features- similar to other NSGCT
 AFP elevated

26. Choriocarcinoma
 Rarest***
 0.5%
 2nd & 3rd decade
 Highly malignant and metastasize via blood.
 ***Hemorrhagic metastases- hemoptysis,
hemetemesis, CNS-related symptoms.
 ***Gynecomastia commonly found duw to
elevated levels of hCG.
 Metastases may be present without e/o
choriocarcinoma in testicles
 Hemorrhage an dfocal necrosis of tumor with
calcification is unique feature on USG

32.  Neoplasm containing leydig , sertoli, thecal,
granulosa or leutin cells in various degree of
differentiation.
 When mixed with GST, k/a gonadoblastoma
 Majority of gonadoblastoma occurs in pts with
cryptorchidism, hypospadias and males with
internal female sec sex organs.
Leydig cell tumors
 MC stromal tumor
 20-50yrs of age cont…

33.  Painless testicular enlargement or palpable
mass.
 Presents with gynecomastia due to secretion of
androgens or estrogens.
 Impotence, loss of libido or precocious
virilization may also occur in young males.
 US features- homogeneous, small, hypoechoic.
25% of tumors may show hemorrhage and
necrosis. On CD – may show peripheral
vascularity.

34. Sertoli cell tumor
 Rare
 Can occur in any age group.
 Painless testicular mass
 Associated with testicular feminization***
Klinefelters Syn, peutz-jeghers syn.
 US feature- small hypoechoic mass lesion
similar to leydig cell tumor
 The Large cell calcifying Sertoli cell tumor
subtype are distinctive and are often bilateral
and amy be almost calcified.

39.  US is important tool in diagnosing primary
occult, not palpable tumor (on clinical exam)
with
retroperitoneal/supraclavicular/mediastinal
metastases
 Unlike mediastinal and CNS extragonadal
tumors which r often primarylesions,
Retroperitoneal GCT are usually metastases
from Primary Testicular GCT.

42.  The primary tumor may regress , despite
widespread advanced lesion disease, resulting
in echogenic fibrous and possible calcific scar(
possible due to vascular compromise from
tumor out growing its vascular supply)
 The sonographic finding of an echogenic focus
with or without posterior acoustic shadowing
is not specific for a “burned-out” tumor, but it
strongly suggests this diagnosis in the context
of histologically proven testicular metastases.

44.  Incidentally discovered nonpalpable lesions are
often benign.
 And if tumor markers and the chest radiograph
are normal, patients can undergo an excisional
testicular biopsy using an inguinal, organ-
sparing approach.
 Sonographic follow-up rather than excision of
an incidentally detected lesion
(“incidentaloma”) is only recommended if
there is a strong clinical suggestion that the
lesion is nonneoplastic (i.e., recent history of
trauma or infection).

45. Malignant lymphoma
 MC tumor in age >60
 MC b/l testicular tumor
 US features are non specific , quite similar to
seminomas.Ob CD ,shows diffuse vas. Mimics
inflammation(but not painful)
Leukemia
 2nd MC metastatic tumor
 Testis acts as “sanctuary site” for leukemia cells
during chemotherapy. Bcoz of blood-testis barrier
 US features are non specific, similar to lymphoma.

46. Myeloma/plasmacytoma
 Single or multiple nodules that appear
hypoechoic and homogenous

52.  The d/d for a patient presenting with acute
scrotum include
 testicular torsion,
 epididymo-orchitis,
 torsion of the testicular appendages,
 and acute idiopathic scrotal edema,
 Clinical history along with usg examination
helps to achieve the correct diagnosis in most
of the cases.

54.  Necrotizing fascitis of perineum
 50-70 yr MC’ly affected
 DM
 Surgical debridement required
 High morbidity and mortality
 US- Scrotal wall thickening with air foci/gas

56.  Testicular torsion can be extravaginal or
intravaginal.
 Intravaginal torsion, the most common type,
occurs between 3 and 20 years of age, with an
incidence of 65% between 12 and 18 years. “bell
and clapper testis.”
 The horizontal lie of the testis has been linked with
the bell clapper deformity in 100% of patients who
have had surgery.
 In most people, this anomaly is bilateral, which
warrants orchidopexy of the contralateral testis in
cases of torsion of the testis.

58.  TORSION is not an “ALL OR NONE”
phenomenon.
 Sonography of acute scrotum should include study
of the spermatic cord. The sonographic real-time
whirlpool sign is the most specific and sensitive
sign of torsion, both complete and incomplete.
Intermittent testicular torsion is a challenging
clinical condition with a spectrum of clinical and
sonographic features.
 side-by-side comparison images of both testicles
with grayscale and spectral Doppler imaging to
assess for symmetry is very important

59.  Grayscale appearance of the testicle may be normal at this point.
Grayscale abnormalities, such as heterogeneous echo texture,
occur late and usually reflect a testicle that is no longer viable.
 Thus in acute conditoins The following features are looked for:
 (1) tortuosity of the cord,
 (2) an acute change in the direction of the cord, and
 (3) the presence of the whirlpool sign.
 The whirlpool sign was elicited in the following manner. When
tortuosity of the spermatic cord was seen, a short axis scan of the
cord above the level of tortuosity was obtained. Then the
transducer was moved down along the cord, and a rotation of the
cord structures was looked for. If an acute rotation was seen, it
was taken as a positive whirlpool sign. Then the same technique
was repeated with color Doppler sonography.

60.  In testicular torsion, venous obstruction occurs
first, followed by obstruction of arterial flow and
ultimately by testicular ischemia.
 The extent of testicular ischemia depends on the
degree of torsion, which ranges from 180° to 720°
or greater.
 The testicular salvage rate depends on the degree
of torsion and the duration of ischemia.
 A nearly 100% salvage rate exists within the first 6
hours after the onset of symptoms; a 70% rate,
within 6–12 hours; and a 20% rate, within 12–24
hours

61.  On Doppler ultrasound the blood flow within the
symptomatic testicle will be decreased or absent.
 The presence of blood flow documented with color
Doppler imaging alone cannot completely exclude
torsion.
 In partial torsion or torsion/detorsion, flow can be
present while the exam is performed; sometimes,
compensatory hyperemia is actually present.
 In partial torsion, flow may be present on color
Doppler, but spectral imaging can show high
resistance waveforms within the testicular artery.

62.  the whirlpool sign in the spermatic cord on real-
time gray scale imaging and absent intratesticular
flow on color Doppler studies. On a static image,
the mass of the whirlpool had the appearance of a
doughnut, a target with concentric rings, a snail
shell, or a storm on a weather map. The
appearance was best seen with the transducer at
different angles.
 The mass of the whirlpool was seen just outside
the external ring , at a varying distance above the
testis, or posterior to the testis
 there was no flow in the cord distal to the
whirlpool and within the testis

67.  Gray-scale images are nonspecific for testicular
torsion and often appear normal if the torsion has
just occurred.
 Testicular swelling and decreased echogenicity are
the most commonly encountered findings 4–6
hours after the onset of torsion.
 At 24 hours after onset, the testis has a
heterogeneous echotexture secondary to vascular
congestion, hemorrhage, and infarction; this
condition is referred to as late or missed torsion.
 An enlarged hypoechoic epididymal head may be
visible because the deferential artery supplying the
epididymis is often involved in the torsion

68.  Torsion of the appendix testis and appendix
epididymis present with acute scrotal pain, but
there are usually no other physical symptoms.
 The cremasteric reflex can still be elicited.
 The classic finding at physical examination is a
small firm nodule that is palpable on the
superior aspect of the testis and exhibits bluish
discoloration through the overlying skin; this is
called the “blue dot” sign.

69.  mass of varying size and echo pattern in
relation to the head of the epididymis and
upper pole of the testis.
 increased flow seen in the testis and
epididymis.
 no flow seen in the masses in all the patients.
 straight spermatic cord and a normal testis.
 A minimal hydrocele may be present

70.  Torsion of cord plus horizontal axis seen in
complete and incomplete/partial torsion of
testis.
 Segmental infarction – no whirlpool but
horizontal axis and areas of hypoechoic lesion
 A consistent sonographic sign described in
ITT/torsion-detorsion is the horizontal lie of
the testis.

72.  Age group- post pubertal in 70% cases.
 Cause vary with age group.
 Scrotal pain associated with epididymitis is
usually relieved when the testes are elevated
over the symphysis pubis (the Prehn sign)
 Complications of acute epididymitis include
chronic pain, infarction, abscess, gangrene,
infertility, atrophy, and pyocele

73.  acute epididymitis include an enlarged
hypoechoic or hyperechoic (presumably
secondary to hemorrhage) epididymis.
 reactive hydrocele or pyocele with scrotal wall
thickenining
 Diffuse testicular involvement is confirmed by
the presence of testicular enlargement and an
inhomogeneous testicular echotexture.
 D/D – lymphoma, leukemia, malignancy

74.  At color and power Doppler US, the hallmark of
scrotal infection is hyperemia of the epididymis,
testis, or both
 pectral waveform and resistive index can also
provide useful information, because inflammation
of the epididymis and testis is associated with
decreased vascular resistance
 Use of a peak systolic velocity threshold of 15
cm/sec results in a diagnostic accuracy of 90% for
orchitis and 93% for epididymitis.
 Reversal of flow during diastole in acute
epididymo-orchitis is suggestive of venous
infarction.

79.  Blunt force
 Penetrating injury
Athletic injuries being the most frequent cause.
The right side is more likely to be injured due to
trapping of the testicle against the pubis.
Ultrasound is used to evaluate the integrity of the tunica
and the testicular blood supply.
TWO TYPES

80.  More than 80% of ruptured testes can be
salvaged, with a high success rate, if surgical
repair is performed within 72 hours of
testicular injury.
 Findings of a heterogeneous echotexture within
the testis, testicular contour abnormality, and
disruption of the tunica albuginea are
considered very sensitive and specific for the
diagnosis of testicular rupture.
 Absence of normal vascularity within the testis
may help characterize a rupture.

81. The demonstration at US of a discontinuity in
the tunica albuginea in a patient with a clinical
history of scrotal trauma supports a
straightforward diagnosis of tunica albuginea
disruption.
At US, the normal tunica albuginea appears as
two parallel hyperechoic layers outlining the
testis. disruption of the Tunica Albuginea
Disruption of the Tunica Albuginea

83.  Abnormality in the contour of the testis
 results from extrusion of the testicular parenchyma
after disruption of the tunica albuginea.
 In the presence of a large extratesticular hematocele
or large scrotal wall hematoma that may obscure a
site of tunica disruption, an abnormality in the
contour of the testis is considered indirect evidence
of rupture.

84.  Heterogeneous Echotexture of the Testis
 a heterogeneous echotexture also may be seen in the
presence of intratesticular hematomas without a
tunica albuginea rupture; therefore, it should not be
considered indicative of testicular rupture

86.  Absence of Vascularity in the Testis
 Tunica albuginea rupture is almost always associated
with a disruption of the tunica vasculosa because of the
close apposition of the latter to the tunica albuginea.
 Rupture of the testis results in a loss of vascularity to a
portion or the entirety of the testis, depending on the
grade of injury.
 The avascular, lacerated portion of the ruptured testis is
usually debrided, and the vascular portions are left
behind.
 The absence of vascularity in a focal area of the testis may
be secondary to an intratesticular hematoma, which, if it
is large, may require surgical evacuation

91.  Testicular fracture refers to a break or
discontinuity in the normal testicular
parenchyma.
 A testicular fracture line is identified at US as a
linear hypoechoic and avascular area within
the testis, a finding that may or may not be
associated with a tunica albuginea rupture
 Color Doppler imaging plays a significant role
in guiding management in such cases.

93.  Testicular dislocation, which is more often
unilateral than bilateral, most commonly results
from impact against the fuel tank in motorcycle
accident.
 Patients with a wide external inguinal ring, an
indirect inguinal hernia, or an atrophic testis are
more vulnerable to testicular dislocation due to
trauma.
 computed tomography (CT) of the pelvis may be
helpful for localizing a dislocated testis.
 Delayed diagnosis of a dislocated testis and its
tardy repositioning may lead to irreversible
changes within the testis and predispose it to
malignant degeneration.

94.  Gunshot injury > stab injury .
 More commonly billateral.
 Penetrating injuries range from a small
insignificant hematocele to testicular rupture
 Presence of air within the scrotum (a finding
that may be intra- or extratesticular), an
intratesticular missile track, and the presence of
one or more intra- or extratesticular foreign
bodies

96.  Hematoma (Hematocele).
 Extratesticular hematoceles, or collections of blood within
the tunica vaginalis, are the most common finding in the
scrotum after blunt injury.
 Acute hematoceles are echogenic in appearance.
 chronic hematoceles tend to become anechoic over time
and develop septa and loculations that may show internal
fluid-fluid levels and faint echoes.
 A chronic hematocele that does not resolve may become
calcified and may mimic an extratesticular calcified mass
at imaging
 The presence of a large hematocele is an indication
for surgical exploration irrespective of any US
evidence of tunica albuginea rupture