Testicular Ultrasound Alexis P Langsfeld MD St Luke’s-Roosevelt Emergency Department Ultrasound Division

Male Anatomy Testes are oval shaped inside scrotum Average size 4 x 3 x 2.5 10-19 gms Surrounded by tunica vaginalis Tunica albuginea separates lobes within the testes Epididymis tail forms vas deferens

Male Anatomy

Testicular Anatomy

Vascular Supply Arterial flow from aorta by testicular artery Deferential and cremasteric arteries supply extra testicular components, collaterals to testes Venous flow via testicular vein

Technique Reassurance Analgesia Warm Gel Frog leg Towel under scrotum and over penis Unaffected testes first

Technique High frequency probe Color and Spectral Doppler Spectral allows differentiation between arterial and venous Flow Venous flow is compromised first

Technique B-mode 2 views View full testes with color flow Identify blood flow around epididymis Identify vascular pulse Color-flow doppler to assess for venous vs. arterial flow. Venous flow is affected first in early vascular insufficiency

Sonographic Appearance Homogenous, similar to liver Minimal low flow throughout Epididymis superior to testes Extra testicular structure more ecchogenic Appendix testes superior aspect of testes normally covered by epididymal head

Normal Testicular Exam

Identify Testicle Epididymis Head Body Tail Arterial Flow Venous Flow

Views Longitudinal and cross section

Indications Testicular pain Testicular mass Testicular Trauma

Differential Diagnosis Epididymitis Orchitis Trauma Torsion Varicoceale/ Hydroceal Hernia

Epididymitis Most common cause of ED presentation for scrotal pain Infection and inflammation within the epididymis GC/ Chlamydia < 35 E-Coli >35 Gradual onset Poor historians Pain threshold

Epididymitis

Epididymitis

Hydrocele Fluid around testes Result from communication w/ abdominal cavity Often congenital My be result of trauma, infection,neoplasm, or torsion

Hydrocele

Varicocele Vessels in scrotum due to structural defect “Bag of worms” Can cause infertility by keeping testes at higher heat Gradual onset

varicocele

Vacicocele

Hernia Bowel contents fall through abdominal wall defect into scrotum Can become incarcerated/ torse Inflammation can cause vessel compression Gradual onset

Mass Generally slow growing Non-Acute Hydrocele / Varicocele Neoplasm Generally soft & non-tender Neoplasm Firm Risk of hemorrhage

Testicular Cancer

Trauma Swelling and pain after direct trauma Laceration, Hemorrhage, Contusion, Capsular rupture, Torsion Poor physical exam Ultrasound evaluation Necessary

Torsion To Be discussed at later lecture

Epididymitis vs. Torsion Epididimitis Enlarged Hypoechoic Increased Vascularity Torsion Enlarged Hypoechoic Decreased vascularity

Epididymitis vs. Torsion 20% overlap in symptoms Difficult to differentiate with swelling and tenderness Different treatment plans

Appendix Testes Torsion To be discussed at later Lecture

Conclusion Image in 2 views Use color to asses blood flow Use doppler to quantify blood flow Take the testicles seriously

Resa Lewis for Images Ultrasound Division Thank You Resa Lewis for Images Ultrasound Division