Diagnostic Ultrasound - Abdomen and Pelvis
Focal Testicular Mass Testicular Lymphoma, Leukemia, and Metastases Gonadal Stromal Tumor (Left) Sagittal grayscale ultrasound of the testis in a patient with multiple myeloma shows a focal welldefined echogenic mass , surgically confirmed to be a metastatic lesion. (Right) Transverse grayscale ultrasound of the testis in a 25-year-old man shows a focal well-defined hypoechoic mass , surgically confirmed to be a Leydig cell tumor. Differential Diagnoses: Scrotum Gonadal Stromal Tumor Testicular Epidermoid Cyst (Left) Sagittal grayscale ultrasound of the testis in a 30-year-old man shows a focal well-defined heterogeneous mass , with calcifications and cystic areas, surgically confirmed to be a Sertoli cell tumor. (Right) Sagittal grayscale ultrasound of the testis in a 15-year-old male shows a focal well-defined hypoechoic mass , with concentric onion skin pattern, surgically confirmed to be epidermoid cyst. Testicular Adrenal Rests Testicular Sarcoid (Left) Transverse grayscale ultrasound of both testes in a 16-year-old male with congenital adrenal hyperplasia shows bilateral hypoechoic masses , consistent with intratesticular hyperplastic adrenal rests. (Right) Sagittal grayscale ultrasound of the testis in a patient with known sarcoidosis shows a focal welldefined hypoechoic mass , surgically confirmed to be testicular sarcoid. 1017
Focal Extratesticular Mass 1018 Differential Diagnoses: Scrotum DIFFERENTIAL DIAGNOSIS Common • Epididymitis • Spermatocele • Epididymal Cyst • Varicocele • Spermatic Cord Torsion Less Common • Hematoma • Adenomatoid Tumor • Inguinal Hernia • Fatty Deposition • Encysted Hydrocele of Cord • Papillary Cystadenoma • Lipoma • Epididymal/Scrotal Wall Abscess • Fibrous Pseudotumor • Leiomyoma Rare but Important • Sarcoidosis • Rare Tumors ○ Liposarcoma of Spermatic Cord ○ Sclerosing Lipogranuloma ○ Leiomyosarcoma ○ Malignant Schwannoma ○ Epididymal Rhabdomyosarcoma • Metastases • Tuberculous Epididymitis • Funiculitis • Vasitis ESSENTIAL INFORMATION Key Differential Diagnosis Issues • Diagnosis based on combination of clinical and sonographic features • Acute pain ○ Epididymitis ○ Hematoma ○ Torsion ○ Strangulated inguinoscrotal hernia • Chronic pain ○ Varicocele ○ Tumors • Incidental finding ○ Epididymal cyst ○ Spermatocele Helpful Clues for Common Diagnoses • Epididymitis ○ Most common cause of acutely painful scrotum ○ Hyperemic epididymis &/or testis on color Doppler ultrasound – Compare with contralateral side – Epididymis appears hypervascular compared to adjacent testicle ○ Acute epididymitis – Enlarged, heterogeneous, predominantly hypoechoic epididymis – Reactive thickening of scrotal wall ± hydrocele – Urinary tract pathogens typical in older men – STDs in younger men ○ Chronic epididymitis – Granulomatous infection caused by tuberculosis, brucellosis, syphilis, and fungal infection – Usually bilateral involvement – Enlarged epididymis with heterogeneous appearance, ranging from hypoechoic to hyperechoic, ± calcification • Spermatocele ○ Size: 1-2 cm, may be very large ○ Retention cyst of tubules connecting rete testis to head of epididymis – Obstruction and dilatation of efferent ductal system – Usually seen in individuals with previous vasectomy ○ Appearance – Cystic with low-level mobile internal echoes – Contain nonviable sperm – Rarely spermatoceles may be hyperechoic – Large spermatoceles may have internal septations – Acoustic streaming of low level internal echoes: Falling snow sign on color Doppler sonography • Epididymal Cyst ○ Usually ≤ 1 cm ○ Well-defined anechoic lesion with posterior acoustic enhancement ○ Large cysts (true cysts or spermatocele) may have septation and may be confused with hydroceles – Cysts displace testis, while hydrocele envelop it • Varicocele ○ Dilatation of veins of pampiniform plexus > 3 mm in diameter due to reflux in internal spermatic vein ○ Best imaging tool: Color Doppler US – Dilated serpiginous veins behind superior pole of testis – Veins enlarge with Valsalva maneuver • Spermatic Cord Torsion ○ Twisting of testicle and spermatic cord within scrotum leads to testicular ischemia and infarction ○ Twisted spermatic cord cranial to testis and epididymis often becomes edematous and mass-like, which can appear as extratesticular torsion knot with whirlpool appearance – Surgical emergency requiring emergent reduction to preserve viable testis Helpful Clues for Less Common Diagnoses • Hematoma ○ Associated with trauma, torsion ○ Complex echogenic fluid with layering debris ± internal septation; varies with chronicity ○ Must confirm intact testicular vascularity as enlarging hematoma may compress testicular vessels ○ Carefully evaluate tunical albungina of testicle for associated testicular rupture (surgical emergency) • Adenomatoid Tumor ○ Most common tumor of epididymis – 1/3 of all paratesticular neoplasms
- Page 988 and 989: Cystic Renal Mass Multicystic Dyspl
- Page 990 and 991: Solid Renal Mass • Horseshoe Kidn
- Page 992 and 993: Solid Renal Mass Renal Lymphoma Ren
- Page 994 and 995: Renal Pseudotumor Column of Bertin
- Page 996 and 997: Dilated Renal Pelvis • Intrarenal
- Page 998 and 999: Dilated Renal Pelvis Pyonephrosis P
- Page 1000 and 1001: PART III SECTION 7 Abdominal Wall/P
- Page 1002 and 1003: Diffuse Peritoneal Fluid Hemoperito
- Page 1004 and 1005: Solid Peritoneal Mass - Higher dens
- Page 1006 and 1007: Solid Peritoneal Mass Mimics Benign
- Page 1008 and 1009: Cystic Peritoneal Mass ○ Women of
- Page 1010 and 1011: Cystic Peritoneal Mass Pseudomyxoma
- Page 1012 and 1013: PART III SECTION 8 Prostate Enlarge
- Page 1014 and 1015: Enlarged Prostate Benign Prostatic
- Page 1016 and 1017: Focal Lesion in Prostate ○ Variab
- Page 1018 and 1019: Focal Lesion in Prostate Müllerian
- Page 1020 and 1021: PART III SECTION 9 Bowel Bowel Wall
- Page 1022 and 1023: Bowel Wall Thickening - Distal ileu
- Page 1024 and 1025: Bowel Wall Thickening Crohn Disease
- Page 1026 and 1027: Bowel Wall Thickening Clostridium D
- Page 1028 and 1029: PART III SECTION 10 Scrotum 1008
- Page 1030 and 1031: Diffuse Testicular Enlargement Test
- Page 1032 and 1033: Decreased Testicular Size Testicula
- Page 1034 and 1035: Testicular Calcifications Sertoli C
- Page 1036 and 1037: Focal Testicular Mass - Most common
- Page 1040 and 1041: Focal Extratesticular Mass - 3-50 m
- Page 1042 and 1043: Focal Extratesticular Mass Inguinal
- Page 1044 and 1045: Focal Extratesticular Mass Liposarc
- Page 1046 and 1047: Extratesticular Cystic Mass Varicoc
- Page 1048 and 1049: PART III SECTION 11 Female Pelvis
- Page 1050 and 1051: Cystic Adnexal Mass □ Hemorrhagic
- Page 1052 and 1053: Cystic Adnexal Mass Dermoid (Mature
- Page 1054 and 1055: Solid Adnexal Mass - May masquerade
- Page 1056 and 1057: Solid Adnexal Mass Fibrothecoma Hem
- Page 1058 and 1059: Extraovarian Adnexal Mass Helpful C
- Page 1060 and 1061: Extraovarian Adnexal Mass Paraovari
- Page 1062 and 1063: Extraovarian Adnexal Mass Lymph Nod
- Page 1064 and 1065: Enlarged Ovary - Often bilateral (5
- Page 1066 and 1067: Enlarged Ovary Theca Lutein Cysts T
- Page 1068 and 1069: Enlarged Uterus Leiomyoma Adenomyos
- Page 1070 and 1071: Abnormal Endometrium ○ Multiple e
- Page 1072 and 1073: Abnormal Endometrium Pregnancy and
- Page 1074 and 1075: Abnormal Endometrium Tamoxifen-Indu
- Page 1076 and 1077: INDEX A Abdominal aorta, 34, 40, 42
- Page 1078 and 1079: INDEX - myelolipoma vs., 590 - stag
- Page 1080 and 1081: INDEX Biliary cyst. See Choledochal
- Page 1082 and 1083: INDEX Caroli disease, 204-207 - bil
- Page 1084 and 1085: INDEX - solid renal mass vs., 968 -
- Page 1086 and 1087: INDEX diagnostic checklist, 839 dif
Focal Testicular Mass<br />
Testicular Lymphoma, Leukemia, <strong>and</strong><br />
Metastases<br />
Gonadal Stromal Tumor<br />
(Left) Sagittal grayscale<br />
ultrasound of the testis in a<br />
patient with multiple<br />
myeloma shows a focal welldefined<br />
echogenic mass ,<br />
surgically confirmed to be a<br />
metastatic lesion. (Right)<br />
Transverse grayscale<br />
ultrasound of the testis in a<br />
25-year-old man shows a focal<br />
well-defined hypoechoic mass<br />
, surgically confirmed to be<br />
a Leydig cell tumor.<br />
Differential Diagnoses: Scrotum<br />
Gonadal Stromal Tumor<br />
Testicular Epidermoid Cyst<br />
(Left) Sagittal grayscale<br />
ultrasound of the testis in a<br />
30-year-old man shows a focal<br />
well-defined heterogeneous<br />
mass , with calcifications<br />
<strong>and</strong> cystic areas, surgically<br />
confirmed to be a Sertoli cell<br />
tumor. (Right) Sagittal<br />
grayscale ultrasound of the<br />
testis in a 15-year-old male<br />
shows a focal well-defined<br />
hypoechoic mass , with<br />
concentric onion skin pattern,<br />
surgically confirmed to be<br />
epidermoid cyst.<br />
Testicular Adrenal Rests<br />
Testicular Sarcoid<br />
(Left) Transverse grayscale<br />
ultrasound of both testes in a<br />
16-year-old male with<br />
congenital adrenal hyperplasia<br />
shows bilateral hypoechoic<br />
masses , consistent with<br />
intratesticular hyperplastic<br />
adrenal rests. (Right) Sagittal<br />
grayscale ultrasound of the<br />
testis in a patient with known<br />
sarcoidosis shows a focal welldefined<br />
hypoechoic mass ,<br />
surgically confirmed to be<br />
testicular sarcoid.<br />
1017
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