Testicle ultrasound

Definition:

Testicle ultrasound is an imaging test that examines the testicles and other parts inside the scrotum. The
testicles are the male reproductive organs that produce sperm and the hormone testosterone . They are
located in the scrotum , the flesh-covered sac that hangs between the legs at the base of the penis .

Alternative Names: Scrotal ultrasound; Testicular sonogram

How the test is performed:

You lie on your back with your legs spread. The health care provider drapes a cloth or applies wide strips
of adhesive tape across your thighs under the scrotum. The scrotal sac will be slightly raised, with the
testicles lying side by side.

A clear gel is applied to the scrotal sac to help transmit the sound waves. A handheld probe (the
ultrasound transducer) is then moved over the scrotum. The ultrasound machine sends out high-
frequency sound waves, which reflect off areas in the scrotum to create a picture.

How to prepare for the test:

No special preparation is needed for this test.

For children, the preparation you can provide for this test depends on your child's age, past experiences,
and level of trust. For specific information on how to prepare your teen, see adolescent test or
procedure preparation (12 - 18 years). This test is rarely done on children younger than age 12.

How the test will feel: There is little discomfort. The conducting gel may feel slightly cold and wet.
Why the test is performed:

A testicle ultrasound is done to help determine why one or both testicles have become larger, or to find
the reason for pain in the testicles. It can also show how blood flows through the testicles.

Normal Values: The testicles and other areas in the scrotum appear normal.
What abnormal results mean:

Possible causes of abnormal results include:

 Infection with or without abscess

 Noncancerous (benign) cyst
 Testicular torsion
 Testicular tumor

What the risks are:

There are no known risks. You will not be exposed to ionizing radiation with this test. Ionizing radiation
procedures such as x-ray carry a small cancer risk and may damage sperm, but this test does not.
Detection of Scrotal Pathology with Ultrasound
Introduction
Sonography plays an important role in evaluating testicular size, differentiating between intratesticular
or extratesticular abnormalities causing scrotal enlargement or a palpable mass, finding an occult
(concealed) neoplasm, evaluating the condition of the testicle in cases of trauma or infection, and
determining the presence or absence of a varicocele in an infertility workup. The majority of
extratesticular masses are benign, but the majority of intratesticular masses are malignant. It is also
important for the sonographer to describe the appearance of the mass, to determine if it is cystic or
solid, well-defined or irregular.

Clinically a scrotal mass may be present or found on physical examination. Sometimes the mass is
accompanied by pain as hemorrhage into the tumor can produce pain and tenderness. The clinical
findings, pertinent lab data, and sonographic evaluation will be presented for the major

Sonographic Examination of the Scrotum

A complete history should be taken or reviewed prior to the sonographic evaluation of the scrotum. The
patient should be asked to lie down on the examination table. The patient is placed in the supine
position, a sheet is provided for coverage. The sonographer should avoid a cold room to reduce testicular
retraction and skin thickening. A small towel is placed under the scrotal sac to provide stability for the
ultrasound examination. The penis is gently drawn up toward the patient’s lower abdomen and covered
with a towel. Warm gel is then applied freely to the scrotal sac. To optimally visualize the scrotum, a high
resolution linear array (7.5MHz or higher) is usually the ideal transducer to employ for this study.

Both testicles should be scanned completely, in both the longitudinal and transverse planes. The initial
scan should evaluate both testes on the same image. This will allow the sonographer to assess the
homogeneity of the testes, evaluate size, and to determine if any apparent asymmetry is present.
Transverse scans of each testis are then made beginning at the most superior part of the testes and
scanning inferiorly. Representative images are made at the upper, mid, and lower planes of the right and
left testis. Longitudinal scans of each testis are also made to include the lateral, mid, and medial portions.

The rete testes drain from the testes into the efferent ductules which drain into
the tubules that form the epididymal head. The head of the epididymis is
triangular with rounded edges and its echogenicity is similar to that of the testis.
It rests on the upper pole of the testis. The epididymal head and body, and the
tail (if possible) should also be evaluated. The tail is small and located more
posteriorly and is therefore more difficult to image. The spermatic cord area
should be scanned from the inguinal canal to the scrotum. A separate image of
the epididymal head in relation to the superior portion of the testicle should be obtained.
 The normal testes should appear as small homogeneous ovoid structures with an
echogenicity texture similar to the thyroid. The echogenic mediastinal stripe may
be seen to flow through the mid section of the testis. The Doppler settings for
color flow should be set for low volume, low velocity flow to optimize
visualization of the small testicular arteries.

Pathology of the Scrotum

Infections: Epididymitis and Orchitis.
Epididymitis. The epididymis functions as a storage, transport, and maturation place for sperm before
ejaculation. Epididymitis is a condition in which the epididymis becomes inflamed and tender.

The patient may present with fever and chills, pain in the inguinal region, and a swollen epididymis. The
inflammation may spread into the testicular area (orchitis). The infection is usually unilateral.
Epididymitis may be caused by a complication of infections and conditions associated with sexually
transmitted disease, tuberculosis, mumps. Prostatitis, urethritis, or prolonged use of an indwelling
catheter.

Epididymitis is most common between the ages of 18 and 40, but it can also be found in children. Young
boys with painful urination, a previous history of urinary tract infection, abnormal bladder function, or
abnormalities of the genitals are more likely to develop epididymitis.

Sonographically the acute epididymitis usually shows enlargement of the epididymal head with
decreased echogenicity secondary to edema. A reactive hydrocele may be present. Color Doppler
findings include an increased amount of flow in and around the epididymis. If an abscess has formed,
complex cystic areas may be identified in the epididymis.

Orchitis. Once the infection has spread to the testicle, it is termed orchitis. The
testicle may appear normal or enlarged in size and the echogenicity may be
decreased or heterogeneous. Reactive hydroceles and skin thickening are
associated with orchitis. As in many infections, there will be increased color
Dopplor flow to the infected testes. Chronic orchitis appears as layers of
heterogeneous disruption within the testicle. Focal orchitis may occur without
involvement of the epididymis and has the same appearance as a neoplasm,
although clinical symptoms such as fever and increased white blood cell count strongly would suggest an
infectious process.
 Trauma. A direct blow to the scrotal sac can cause significant testicular
parenchymal injury or hemorrhage and can definitely alter the normal
homogeneous appearance of the testicle. Hematomas in the epididymis or
scrotal wall may have variable sonographic appearances. Just like hematomas in
other parts of the body, their appearance may vary depending upon the age of
the hematoma. At first the hematoma will be hypoechoic as the red blood cells
fill the space; as the hematoma ages, its appearance becomes more echogenic as
clot begins to form within the bleed.

Torsion. The testicle is attached to the scrotum at the bare area. If the bare area
is small, a tiny remnant stalk of tunica vaginalis allows the testicle to be mobile.
Torsion occurs when the testicle revolves one or more times on this short stalk,
which obstructs blood flow to the testicle, resulting in severe pain. Torsion is
more common in males under 25 years of age with a peak incidence at 13 years.
Once torsion occurs, the testicle becomes congested and edematous because of
the veins in the twisted cord. Pressure within the testicle then begins to build up
because of the arterial obstruction which then leads to the testicular ischemia. It is important to
diagnose this abnormality early because necrosis of the torsed testicle will occur within 24 hours.

Sonographically, a torsed testicle appears normal in the first four hours of torsion. Although the realtime
appearance of the testes is normal, Color and pulsed-Doppler appearances are abnormal. There is an
absence of flow in the testicle and the epididymis. After four hours, the torsed testicle appears enlarged
and hypoechoic. The testicle may have some inhomogenous appearances as a result of hemorrhage.
Other findings include enlargement of the epidiymis, a reactive hydrocele, and scrotal wall thickening.

Hydrocele

A hydrocele is a collection of fluid between the visceral and parietal layers of the
tunica vaginalis. Hydroceles can be congenital, idiopathic, or acquired. Acquired
hydroceles are the results of infarction, inflammation, neoplasm, or trauma.

Sonographically hydroceles may appears as anechoic fluid in the scrotal sac

surrounding the testicle and epididymis. Occasionally, small particles and septations are seen within the
fluid.
 Varicocele

A varicocele is the abnormal dilation and tortuosity of the veins in the

pampiniform plexus that run along the spermatic cord into the scrotum. The
spermatic cord provides nourishment through the blood vessels and contains
nerves and lymph glands as well as the vas deferens. Varicoceles are reported to
be found in 15% of all males. They are found to be the cause of infertility in 30-
40% of the cases. The varicoceles develop when a defective valve in the vein allows the normal one-way
flow of blood to back up into the abdomen. Blood then flows from the abdomen into the scrotum where
a hostile environment for sperm development is created. Most varicoceles develop slowly and do not
show symptoms. Some are large and visible as twisting veins in the scrotal sac. These veins disappear
when lying down and the valsalva maneuver (bear down or cough) is used to demonstrated their filling
distention.

They are more common on the left side, but do also occur bilaterally. The right internal spermatic vein
drains directly into the inferior vena cava, whereas the left internal spermatic vein drains into the left
renal vein at a 90-degree angle. This angle prevents the formation of a valve. As a result, 85-99% of the
varicoceles are left-sided and only 1% are bilateral.

Varicoceles may cause infertility because they are associated with low sperm counts and decreased
mobility. Sonographically they appear as an extratesticular collection of tortuous tubular structures.

Inguinal Hernia

Inguinal hernias occur because of protrusion of peritoneal contents, usually omentum or bowel, through
a patent processus vaginalis. Hernias are classified as direct or indirect by their relationship to the
inferior epigastric artery (IEA). Direct hernias are located medial to the IEA, while indirect hernias are
lateral to the IEA.[8]Fluid or air-filled loops of bowel with peristalsis in the scrotal sac are diagnostic of an
inguinal hernia (Figure 9). Hyperechoic areas are likely to represent omentum. Incarceration of a hernia
is most common before 6 months of age and in adulthood and is more common in indirect hernias. The
presence of an akinetic dilated loop of bowel within the scrotum has a 90% sensitivity and specificity for
strangulation. Be wary of contraction of the dartos muscle, which can cause movement that may mimic
bowel peristalsis. The bowel wall can be thickened and hyperemic with incarcerated hernias. A Richter
hernia consists of herniation of only the antimesenteric border of the bowel and may not result in
intestinal obstruction. The diagnosis of Richter hernia is difficult to make sonographically.

JAN KARL ROELHSEN A. ANGELES GROUP 18-SBC CON

MS. BALDO