DOI: 10.1148/rg.255045109
Gray-Scale and Color Doppler Sonography of Scrotal Disorders in Children: An Update1
Celestino Aso, MD,
Goya Enríquez, MD,
Marta Fité, MD,
Nuria Torán, MD,
Carmen Piró,
Joaquim Piqueras, MD and
Javier Lucaya, MD
1 From the Departments of Pediatric Radiology (C.A., G.E., M.F., J.P., J.L.), Pathology (N.T.), and Pediatric Surgery (C.P.), Vall d’Hebron Children’s Hospital, Ps Vall d’Hebron 119–129, 08035 Barcelona, Spain. Recipient of a Certificate of Merit award for an education exhibit at the 2003 RSNA Annual Meeting. Received May 18, 2004; revision requested October 13 and received January 13, 2005; accepted January 17. All authors have no financial relationships to disclose.
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Figure 1a. Normal scrotal anatomy and testicular vascularization in a 13-year-old boy. (a) Longitudinal US scan shows the testis (T), which is moderately echogenic and homogeneous. The head of the epididymis (E) lies superior to the testis and has similar echogenicity. The body of the epididymis is located behind the testis, and the tail of the epididymis (t) is located at the inferior pole of the testis. The tunica albuginea (arrows) is seen as a peripheral echogenic line. (b) Longitudinal US scan shows the mediastinum (m) as an echogenic band running across the testis. (c) Color Doppler image shows part of the capsular artery (arrowheads) and the centripetal and centrifugal intratesticular rami.
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Figure 1b. Normal scrotal anatomy and testicular vascularization in a 13-year-old boy. (a) Longitudinal US scan shows the testis (T), which is moderately echogenic and homogeneous. The head of the epididymis (E) lies superior to the testis and has similar echogenicity. The body of the epididymis is located behind the testis, and the tail of the epididymis (t) is located at the inferior pole of the testis. The tunica albuginea (arrows) is seen as a peripheral echogenic line. (b) Longitudinal US scan shows the mediastinum (m) as an echogenic band running across the testis. (c) Color Doppler image shows part of the capsular artery (arrowheads) and the centripetal and centrifugal intratesticular rami.
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Figure 1c. Normal scrotal anatomy and testicular vascularization in a 13-year-old boy. (a) Longitudinal US scan shows the testis (T), which is moderately echogenic and homogeneous. The head of the epididymis (E) lies superior to the testis and has similar echogenicity. The body of the epididymis is located behind the testis, and the tail of the epididymis (t) is located at the inferior pole of the testis. The tunica albuginea (arrows) is seen as a peripheral echogenic line. (b) Longitudinal US scan shows the mediastinum (m) as an echogenic band running across the testis. (c) Color Doppler image shows part of the capsular artery (arrowheads) and the centripetal and centrifugal intratesticular rami.
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Figure 2a. Inguinoscrotal hernia in a 5-month-old boy with scrotal swelling. (a) Longitudinal US scan shows a single intestinal loop that has developed a circular configuration to adapt to the scrotum (arrows). The omentum (O) is seen as an echogenic structure. (b) Color Doppler image shows blood flow signal in both the intestinal loop and the omentum. (c) Intraoperative photograph demonstrates the US findings.
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Figure 2b. Inguinoscrotal hernia in a 5-month-old boy with scrotal swelling. (a) Longitudinal US scan shows a single intestinal loop that has developed a circular configuration to adapt to the scrotum (arrows). The omentum (O) is seen as an echogenic structure. (b) Color Doppler image shows blood flow signal in both the intestinal loop and the omentum. (c) Intraoperative photograph demonstrates the US findings.
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Figure 2c. Inguinoscrotal hernia in a 5-month-old boy with scrotal swelling. (a) Longitudinal US scan shows a single intestinal loop that has developed a circular configuration to adapt to the scrotum (arrows). The omentum (O) is seen as an echogenic structure. (b) Color Doppler image shows blood flow signal in both the intestinal loop and the omentum. (c) Intraoperative photograph demonstrates the US findings.
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Figure 3. Hydrocele containing cholesterol crystals. Longitudinal US scan of the right hemiscrotum shows a fluid collection (F) surrounding the testis (T) except where the tunica vaginalis is attached to the scrotal wall (arrows). Weak echoes produced by cholesterol crystals are seen within the fluid.
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Figure 4a. Left varicocele in a 15-year-old boy. (a) Longitudinal US scan of the left hemiscrotum shows multiple anechoic structures (arrows) in the supratesticular region and extending behind the upper pole of the testis (T). (b) Color Doppler image shows that the anechoic structures are vascular. (c) Pulsed-wave Doppler image shows a venous waveform with increased flow during the Valsalva maneuver (arrow).
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Figure 4b. Left varicocele in a 15-year-old boy. (a) Longitudinal US scan of the left hemiscrotum shows multiple anechoic structures (arrows) in the supratesticular region and extending behind the upper pole of the testis (T). (b) Color Doppler image shows that the anechoic structures are vascular. (c) Pulsed-wave Doppler image shows a venous waveform with increased flow during the Valsalva maneuver (arrow).
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Figure 4c. Left varicocele in a 15-year-old boy. (a) Longitudinal US scan of the left hemiscrotum shows multiple anechoic structures (arrows) in the supratesticular region and extending behind the upper pole of the testis (T). (b) Color Doppler image shows that the anechoic structures are vascular. (c) Pulsed-wave Doppler image shows a venous waveform with increased flow during the Valsalva maneuver (arrow).
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Figure 5a. Ectopic vas deferens in a newborn with imperforate anus and left-sided scrotal swelling. (a) Voiding cystourethrogram shows the bladder (B) and a left-sided tubular structure (arrow), which represents an aberrant left vas deferens that terminates within the bladder instead of within the seminal vesicle. (b) Plain radiograph obtained after voiding shows right vesicoureteral reflux (arrowheads) and the left vas deferens (arrow) extending from the bladder to the scrotum.
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Figure 5b. Ectopic vas deferens in a newborn with imperforate anus and left-sided scrotal swelling. (a) Voiding cystourethrogram shows the bladder (B) and a left-sided tubular structure (arrow), which represents an aberrant left vas deferens that terminates within the bladder instead of within the seminal vesicle. (b) Plain radiograph obtained after voiding shows right vesicoureteral reflux (arrowheads) and the left vas deferens (arrow) extending from the bladder to the scrotum.
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Figure 6a. Clinically proved epididymitis in an 11-year-old boy. (a) Longitudinal US scan of the right hemiscrotum shows an enlarged hypoechoic epididymal head (E), reactive hydrocele (h), and thickening of the scrotal wall (*). m = mediastinum. (b) Color and pulsed-wave Doppler image shows increased vascularity in the epididymal head with a low-flow, low-resistance waveform pattern.
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Figure 6b. Clinically proved epididymitis in an 11-year-old boy. (a) Longitudinal US scan of the right hemiscrotum shows an enlarged hypoechoic epididymal head (E), reactive hydrocele (h), and thickening of the scrotal wall (*). m = mediastinum. (b) Color and pulsed-wave Doppler image shows increased vascularity in the epididymal head with a low-flow, low-resistance waveform pattern.
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Figure 7. Acute epididymitis in a 9-year-old boy with scrotal pain and redness. Longitudinal US scan shows that the epididymal head and body (arrows) are enlarged and hypoechoic relative to the normal testis (T). Wall thickening (*) and reactive hydrocele (h) are also seen. Power Doppler imaging showed increased perfusion of the epididymis.
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Figure 8. Granulomatous epididymitis in a 17-year-old boy with a painful scrotal mass. Longitudinal US scan shows a heterogeneous extratesticular mass (cursors) that replaces the epididymal tail. The mass resolved with medical treatment.
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Figure 9a. Normal and twisted testicular appendages. (a) Longitudinal power Doppler image of a 10-year-old boy with a hydrocele shows the normal appendix testis as a round structure (arrow) that is isoechoic relative to the testis and is supplied by a branch of the capsular artery. (b) Longitudinal US scan of the left hemiscrotum in a patient with scrotal pain and swelling shows a highly echogenic well-defined mass (arrows) at the upper pole of the epididymis (E). The mass represents a twisted epididymal appendage. T = testis. (c) Color Doppler image of the same patient shows that the twisted appendage is avascular (arrows). Mild reactive hypervascularity is seen at the epididymal head and scrotal tunics.
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Figure 9b. Normal and twisted testicular appendages. (a) Longitudinal power Doppler image of a 10-year-old boy with a hydrocele shows the normal appendix testis as a round structure (arrow) that is isoechoic relative to the testis and is supplied by a branch of the capsular artery. (b) Longitudinal US scan of the left hemiscrotum in a patient with scrotal pain and swelling shows a highly echogenic well-defined mass (arrows) at the upper pole of the epididymis (E). The mass represents a twisted epididymal appendage. T = testis. (c) Color Doppler image of the same patient shows that the twisted appendage is avascular (arrows). Mild reactive hypervascularity is seen at the epididymal head and scrotal tunics.
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Figure 9c. Normal and twisted testicular appendages. (a) Longitudinal power Doppler image of a 10-year-old boy with a hydrocele shows the normal appendix testis as a round structure (arrow) that is isoechoic relative to the testis and is supplied by a branch of the capsular artery. (b) Longitudinal US scan of the left hemiscrotum in a patient with scrotal pain and swelling shows a highly echogenic well-defined mass (arrows) at the upper pole of the epididymis (E). The mass represents a twisted epididymal appendage. T = testis. (c) Color Doppler image of the same patient shows that the twisted appendage is avascular (arrows). Mild reactive hypervascularity is seen at the epididymal head and scrotal tunics.
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Figure 10a. Testicular torsion in a newborn with discoloration of the right testicle at birth. (a) Longitudinal US scan shows the testis (T) surrounded by a highly echogenic tunica (arrows), which is probably calcified. A complex hydrocele (h) with several septa occupies the scrotal sac. (b) Intraoperative photograph shows extravaginal torsion of the spermatic cord and the necrotic testis.
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Figure 10b. Testicular torsion in a newborn with discoloration of the right testicle at birth. (a) Longitudinal US scan shows the testis (T) surrounded by a highly echogenic tunica (arrows), which is probably calcified. A complex hydrocele (h) with several septa occupies the scrotal sac. (b) Intraoperative photograph shows extravaginal torsion of the spermatic cord and the necrotic testis.
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Figure 11a. Testicular torsion in a 13-year-old boy. (a) Longitudinal US scan obtained at the level of the external inguinal ring shows an abrupt change in the configuration of the spermatic cord (arrow), a finding suggestive of torsion at this point. (b) Intraoperative photograph shows that the point of cord twisting is at the level of the external inguinal canal (arrow).
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Figure 11b. Testicular torsion in a 13-year-old boy. (a) Longitudinal US scan obtained at the level of the external inguinal ring shows an abrupt change in the configuration of the spermatic cord (arrow), a finding suggestive of torsion at this point. (b) Intraoperative photograph shows that the point of cord twisting is at the level of the external inguinal canal (arrow).
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Figure 12a. Testicular torsion in a 12-year-old boy with right-sided scrotal pain of sudden onset. (a) Longitudinal US scan of the right hemiscrotum shows a round supratesticular mass (M), which represents an edematous spermatic cord. There are several anechoic structures (arrowheads) within the mass, which probably represent obstructed and dilated lymphatic vessels. T = testis. (b) Bilateral transverse color Doppler images show no color flow signals in the right testis, which is enlarged and has heterogeneous echogenicity. Reactive hydrocele (h) and thickening of the scrotal wall (*) are also seen. Testicular torsion and bell clapper deformity were confirmed at surgery.
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Figure 12b. Testicular torsion in a 12-year-old boy with right-sided scrotal pain of sudden onset. (a) Longitudinal US scan of the right hemiscrotum shows a round supratesticular mass (M), which represents an edematous spermatic cord. There are several anechoic structures (arrowheads) within the mass, which probably represent obstructed and dilated lymphatic vessels. T = testis. (b) Bilateral transverse color Doppler images show no color flow signals in the right testis, which is enlarged and has heterogeneous echogenicity. Reactive hydrocele (h) and thickening of the scrotal wall (*) are also seen. Testicular torsion and bell clapper deformity were confirmed at surgery.
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Figure 13. Epididymal cyst in a boy with a palpable scrotal mass. Longitudinal US scan shows a cystic lesion (C) that demonstrates increased sound transmission and replaces almost the entire epididymal head. This US appearance is indistinguishable from that of a spermatocele. T = testis.
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Figure 14a. Histologically proved yolk sac tumor in a 1-year-old boy with a painless unilateral scrotal mass. (a) Longitudinal US scan of the left hemiscrotum shows a solid tumor (T) replacing the entire testis. The cystic areas (arrowheads) represent tumor necrosis. (b) Contrast-enhanced abdominal CT scan, obtained during the initial work-up, shows retroperitoneal lymphadenopathy (L) with necrotic areas.
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Figure 14b. Histologically proved yolk sac tumor in a 1-year-old boy with a painless unilateral scrotal mass. (a) Longitudinal US scan of the left hemiscrotum shows a solid tumor (T) replacing the entire testis. The cystic areas (arrowheads) represent tumor necrosis. (b) Contrast-enhanced abdominal CT scan, obtained during the initial work-up, shows retroperitoneal lymphadenopathy (L) with necrotic areas.
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Figure 15. Histologically proved mature teratoma in a 4-year-old boy with a painless scrotal mass. Longitudinal US scan shows a cystic mass (M) with echogenic borders and peripheral solid components (arrows). A rim of normal testis (T) is also seen.
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Figure 16a. Surgically proved intratesticular epidermoid cyst. (a) Longitudinal US scan shows a well-circumscribed, solid-appearing intratesticular mass (M) with a hypoechoic halo. T = testis. (b) Color Doppler image shows no blood flow signal within the mass. At conservative surgery, the mass was found to be filled with a cheesy material.
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Figure 16b. Surgically proved intratesticular epidermoid cyst. (a) Longitudinal US scan shows a well-circumscribed, solid-appearing intratesticular mass (M) with a hypoechoic halo. T = testis. (b) Color Doppler image shows no blood flow signal within the mass. At conservative surgery, the mass was found to be filled with a cheesy material.
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Figure 17a. Bilateral Sertoli cell tumors in a 3-year-old boy with Peutz-Jeghers syndrome. (a) Photograph of the lips shows melanin pigmentation, which is characteristic of Peutz-Jeghers syndrome. (b) Longitudinal US scan of the left hemiscrotum shows several echogenic lesions (arrows), which represent a burned-out Sertoli cell tumor. Similar lesions were seen in the right hemi-scrotum. (Case courtesy of Manuel Herrera, PhD, Hospital Son Dureta, Palma de Mallorca, Spain.)
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Figure 17b. Bilateral Sertoli cell tumors in a 3-year-old boy with Peutz-Jeghers syndrome. (a) Photograph of the lips shows melanin pigmentation, which is characteristic of Peutz-Jeghers syndrome. (b) Longitudinal US scan of the left hemiscrotum shows several echogenic lesions (arrows), which represent a burned-out Sertoli cell tumor. Similar lesions were seen in the right hemi-scrotum. (Case courtesy of Manuel Herrera, PhD, Hospital Son Dureta, Palma de Mallorca, Spain.)
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Figure 18a. Typical US appearances of testicular microlithiasis. (a) Longitudinal US scan shows punctate echogenic foci (more than five) in the central portion of the testis. (b) Longitudinal US scan of another patient shows echogenic foci clustered in the periphery of the testis (T). E = epididymis. The lesions were discovered at scrotal US performed for unrelated reasons.
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Figure 18b. Typical US appearances of testicular microlithiasis. (a) Longitudinal US scan shows punctate echogenic foci (more than five) in the central portion of the testis. (b) Longitudinal US scan of another patient shows echogenic foci clustered in the periphery of the testis (T). E = epididymis. The lesions were discovered at scrotal US performed for unrelated reasons.
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Figure 19a. Extratesticular hematoma in a 15-year-old boy who was struck in the groin. (a) Longitudinal US scan of the right hemiscrotum obtained 4 days after the injury shows a complex extratesticular mass (arrows), which represents the subacute stage of a hematoma. T = testis. (b) Bilateral transverse color Doppler images show decreased color signal in the affected hemiscrotum. The patient was treated surgically.
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Figure 19b. Extratesticular hematoma in a 15-year-old boy who was struck in the groin. (a) Longitudinal US scan of the right hemiscrotum obtained 4 days after the injury shows a complex extratesticular mass (arrows), which represents the subacute stage of a hematoma. T = testis. (b) Bilateral transverse color Doppler images show decreased color signal in the affected hemiscrotum. The patient was treated surgically.
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Figure 20a. Henoch-Schönlein purpura in a 9-year-old boy with bilateral scrotal pain and swelling. (a) Longitudinal US scan of the right hemiscrotum shows thickening of the scrotal wall (*) and scrotal tunica (arrows), an enlarged epididymal head (E), and a small hydrocele (h). Similar findings were seen in the left hemiscrotum. (b) Photograph obtained 2 days later shows widespread typical lesions of Henoch-Schönlein purpura, which occurred on both legs.
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Figure 20b. Henoch-Schönlein purpura in a 9-year-old boy with bilateral scrotal pain and swelling. (a) Longitudinal US scan of the right hemiscrotum shows thickening of the scrotal wall (*) and scrotal tunica (arrows), an enlarged epididymal head (E), and a small hydrocele (h). Similar findings were seen in the left hemiscrotum. (b) Photograph obtained 2 days later shows widespread typical lesions of Henoch-Schönlein purpura, which occurred on both legs.
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Figure 21. Idiopathic scrotal edema in a 1-year-old boy. Transverse US scan of both hemiscrota shows marked thickening of the scrotal walls ( ). The testes (T) and their tunicae appear normal. Increased vascularity was seen at color Doppler imaging.
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Figure 22a. Scrotal lesions associated with congenital adrenal hyperplasia. (a) Longitudinal US scan shows a large hypoechoic mass (M) with undulating margins replacing nearly the entire testis (T). The mediastinum (m) is included in the mass. (b) Longitudinal US scan of another patient shows a hypoechoic nodule in the epididymal head (arrow). In addition, several hypoechoic lesions are seen in the upper pole of the testis.
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Figure 22b. Scrotal lesions associated with congenital adrenal hyperplasia. (a) Longitudinal US scan shows a large hypoechoic mass (M) with undulating margins replacing nearly the entire testis (T). The mediastinum (m) is included in the mass. (b) Longitudinal US scan of another patient shows a hypoechoic nodule in the epididymal head (arrow). In addition, several hypoechoic lesions are seen in the upper pole of the testis.
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Copyright © 2005 by the Radiological Society of North America.
