Testicular microlithiasis: prevalence and tumor risk in a population referred for scrotal sonography

OBJECTIVE: Considerable accrued evidence points to an association between testicular microlithiasis, intratubular germ cell neoplasia, and testicular tumor. This study assesses both the prevalence of testicular microlithiasis revealed on sonography in a referred population and the concurrent tumor risk. MATERIALS AND METHODS: Over a 32-month period (April 1996 through November 1998), 4892 scrotal sonographic examinations were performed in 4819 patients at four referral centers. All patients underwent high-resolution (7- to 10-MHz) imaging. Using a computerized word search (n = 4102; testicular microlithiasis, calcification, microliths, calcific foci, tumor, neoplasm, cancer, hyperecho, hypoecho, heterogen, and carcinoma) and manual retrieval (n = 790), cases of tumor, testicular microlithiasis (>5 microliths per sonogram), and testicular microlithiasis plus tumor were pulled and retrospectively reviewed. The presence and type of tumor were confirmed at histology after orchidectomy. RESULTS: Fifty-four tumors were found among 4892 scrotal sonograms (28 seminomas, 14 teratomas, 8 mixed germ cell tumors, 2 Leydig cell tumors, and 2 non-Hodgkin's lymphomas). Testicular microlithiasis was present in 33 patients, giving a prevalence of 0.68%. Concurrent tumor and testicular microlithiasis were detected in seven patients, a relative risk of tumor in testicular microlithiasis was 21.6-fold (95% confidence limits: 10. 6-fold, 44.2-fold). In one patient with testicular microlithiasis, a previous orchidectomy for mixed germ cell tumor had been performed (not included in the relative risk calculation). CONCLUSION: In a referred population of 4819 patients the prevalence of testicular microlithiasis was 0.68% and the relative risk of concurrent tumor was 21.6-fold. Sonographic surveillance of testicular microlithiasis cases for tumor is mandatory.     

High-frequency scrotal sonography

High-frequency real-time sonography has enhanced accuracy in the diagnosis of scrotal abnormalities. Results of 48 scrotal scans of 92 testes are presented. There were 22 testicular lesions, nine seminomas, four embryonal cell carcinomas, one case of metastatic prostatic carcinoma, one benign "keratin cyst," three testicular infarcts, three atrophied testes, and one case of testicular torsion. Hypoechoic tumors and infarcts have a similar appearance. Extratesticular abnormalities included spermatoceles, varicoceles, epididymitis, hydroceles, and a scrotal hematoma. Sonography accurately distinguished between testicular and extratesticular masses in all cases in this series and pathologic correlations were obtained for all testicular masses. Simultaneous real-time contact scanning and palpation facilitated accurate diagnosis.     

The normal and abnormal scrotum in children: evaluation with color Doppler sonography.

The use of color Doppler sonography to evaluate the symptomatic testes in children with scrotal pain or swelling was prospectively studied with a fourth-generation color sonographic unit with a 7-MHz linear transducer. The 32 patients were 1 day to 18 years old (mean age, 8.6 years). Results were correlated with scintigraphic findings in 23 patients, with the final diagnosis established by surgery in 12 patients, and with clinical follow-up in all patients. Eight cases of testicular torsion, including two of acute torsion and six of late torsion, were correctly detected by color Doppler sonography and confirmed surgically. In the remaining patients, perfusion of the testis was correctly detected by color Doppler examination. The final diagnoses in these patients included torsion of the appendix testis (15 patients), epididymitis (five patients), epididymo-orchitis (one patient), yolk sac tumor of the testis (one patient), hydrocele (one patient), and local reaction to an insect bite (one patient). The ability to detect blood flow in the normal contralateral testis was also evaluated in 28 patients. Blood flow was demonstrated in normal testes larger than 1 cm3. Detection of flow in the very small normal prepubertal testis was often difficult, and no flow was identified in one testis. Flow was identified in central arteries in only six of 13 testes smaller than 1 cm3. We conclude that color Doppler sonography is helpful in the initial evaluation of pediatric testes, providing accurate evaluation of the involved hemi-scrotum in our patients and also providing the benefit of both structural and flow information. Until our sensitivity to low-velocity flow improves, we would not suggest the exclusive use of color Doppler sonography in the evaluation of testicular perfusion in the prepubertal patient. We advocate the addition of testicular scintigraphy to corroborate the presence of testicular perfusion when flow in intratesticular arteries cannot be established with certainty by color Doppler sonography.     

Scrotal sonography in infants and children

In this review we will attempt to summarize the use of scrotal sonography in infants and children. The material is gathered from the literature and from our own experience of 197 sonograms performed on 175 pediatric patients. Included will be information on testicular development and descent, normal sonographic anatomy, classification of scrotal disease, and the final diagnoses of the sonograms. Scrotal sonography has proven useful in evaluating undescended testes in the inguinal canal and just inside the inguinal ring. It is of limited value when the testes are in the abdomen. Sonography can often distinguish the various causes of nonpainful scrotal masses such as tumors, hydrocele, and meconium peritonitis. Sonography is highly accurate in distinguishing normal from abnormal scrotal contents and in separating testicular from extratesticular masses. However, sonography does have limitations in distinguishing benign from malignant neoplasms or from some inflammatory lesions.

Sonography can be successfully used in the differential diagnosis of the painful scrotum especially with color flow Doppler. Inflammatory diseases that often involve the epididymis can be distinguished from torsion. Torsion of the appendages has been diagnosed.

In cases of scrotal trauma, management decisions are often based on the sonographic findings. Conditions that require surgical management such as testicular rupture or large testicular hematomas can be recognized. Information is included on a variety of miscellaneous conditions such as hydrocele, varicocele, and ambiguous genitalia in which sonography has proven valuable.     

Testicular adrenal rest tissue in congenital adrenal hyperplasia: serial sonographic and clinical findings

OBJECTIVE: The purpose of this study was to describe the serial sonographic findings and clinical and laboratory data obtained during follow-up of patients with congenital adrenal hyperplasia in whom testicular adrenal rest tissue develops. MATERIALS AND METHODS: We retrospectively reviewed testicular sonography and laboratory data for 12 patients with congenital adrenal hyperplasia who also had intratesticular masses consistent with adrenal rest tissue. The studies were done during follow-up that ranged from 7 months to 10 years. RESULTS: During follow-up of 11 of the 12 patients after the initial sonographic diagnosis, the testicular adrenal rest tissue either remained stable in size (n = 1), grew larger or smaller (n = 9), disappeared (n = 4), or reappeared after disappearing (n = 3). In one patient, the testicular adrenal rest tissue grew very rapidly in a 1-month interval. Discordant changes in the testicular adrenal rest tissue were noted in 10 patients with bilateral masses. We found no relationship between the change in size of the masses and clinical control (based on 17-hydroxyprogesterone level) at the time of sonography. CONCLUSION: In patients with congenital adrenal hyperplasia who have testicular masses detected sonographically, testicular adrenal rest tissue is the most likely diagnosis. Testicular adrenal rest tissue may remain stable in size, grow larger or smaller, or disappear during sonographic follow-up. The change in size may be marked, may occur very rapidly, and, in our study cohort, was not related to short-term clinical control based on 17-hydroxyprogesterone level at the time of sonography.     

Sonography of testicular microlithiasis

The sonographic appearance of testicular microlithiasis detected in a patient presenting with torsion is described. A "speckled" pattern of multiple, tiny bright echoes is produced by calcific concretions in the seminiferous tubules and seems to be characteristic of microlithiasis. Although this condition is not treatable, it should be recognized because it is often associated with extratesticular abnormalities and can obscure superimposed testicular disease.     

Scrotal trauma: a cause of testicular atrophy.

Scrotal trauma is often mentioned as a cause of testicular atrophy yet there have been few studies documenting the effect of scrotal trauma on testicular size months or years following injury. We performed clinical and sonographic examinations in 10 patients who had suffered blunt scrotal trauma. A significant reduction in volume of the injured testis was observed in 5/10 cases at follow-up sonography. In two cases the affected testis was heterogeneous and colour flow Doppler examination showed reduced flow. In three cases the testis was homogeneous but reduced in volume and in the remaining five cases the affected testis appeared normal. We conclude that testicular atrophy is a sequel of scrotal trauma and occurred in 50% of patients in this study.     

Comparison of tuberculous and pyogenic epididymal abscesses: clinical, gray-scale sonographic, and color Doppler sonographic features

OBJECTIVE: The purpose of this study was to evaluate the capability of clinical, gray-scale sonographic, and color Doppler sonographic features for differentiating tuberculous and pyogenic epididymal abscesses. MATERIALS AND METHODS: Retrospective analysis was performed in 10 cases of tuberculous epididymal abscess and in 13 cases of pyogenic epididymal abscess. The following clinical, gray-scale sonographic, and color Doppler sonographic features were analyzed: patient's age; duration of symptoms; scrotal tenderness; presence of sinus tract; concurrent tuberculosis in other organs; location, size, and echogenicity of the abscess; hyperechoic rim; testicular involvement; hydrocele; and blood flow in the epididymal lesion. RESULTS: Tuberculous epididymal abscess had a longer duration of symptoms (p = 0.0001) and a lower frequency of scrotal tenderness (p = 0.0048) than pyogenic epididymal abscess. The size of the abscess was larger in tuberculous epididymal abscess than in pyogenic epididymal abscess (p = 0.0002). The degree of blood flow in the peripheral portion of the abscess was lower in tuberculous epididymal abscess (p = 0.001). The patient's age, location and echogeninicity of the abscess, presence of sinus tract, hyperechoic rim, testicular involvement, and hydrocele did not differ between the tuberculous and pyogenic epididymal abscesses. CONCLUSION: Some clinical findings, gray-scale sonography, and color Doppler sonography were useful in differentiating tuberculous epididymal abscess from pyogenic epididymal abscess. The presence of long-term scrotal swelling without tenderness and a lower degree of blood flow in the peripheral portion of a large abscess are suggestive of tuberculous epididymal abscess.     

彩色多普勒超声在急性阴囊肿痛诊断中的应用

目的评价彩色多普勒超声(CD)在急性阴囊肿痛诊断及鉴别诊断中的应用价值。方法应用CD对53例急性阴囊肿痛患者进行急诊检查。观察阴囊内容物的形态、回声、结构及血流变化。经手术或临床治疗随访证实诊断。结果53例阴囊急症中,37例经非手术治疗及超声随访证实诊断,16例经手术及病理确诊。CD诊断准确率98%(52/53)。其中,睾丸扭转92%(12/13),睾丸、附睾炎100%(28/28),阴囊外伤100%(9/9),阴囊皮肤感染100%(3/3)。结论CD不仅能够区别睾丸扭转和炎症,并能鉴别肿瘤与炎症,还可评价阴囊外伤的程度及预后,因而它可作为诊断急性阴囊肿痛的首选方法。     

Testicular microlithiasis: US findings in six pediatric cases and literature review

The aim of this article is to report on six pediatric cases of testicular microlithiasis (TM) and to review literature reports, in order to schedule US and/or other control examinations, particularly when concomitant focal or diffuse alterations of the testicular parenchymal structure are present, considering the possible association of TM with testicular tumors. Six patients (age range 4–12 years) underwent US examination for scrotal trauma (two cases) unilateral cryptorchidism (one case) follow-up after orchidopexy for bilateral cryptorchidism (one case), and varicocele (two cases). Five examinations were performed with high-frequency probes (10/13 MHz) and seven with 5/7.5-MHz frequency transducers. Follow-up US examinations were performed at different times depending on initial clinical indications, presence of underlying disease, and initial US findings. Two of the six patients underwent three US examinations, two patients underwent two US examinations, and the remaining two patients underwent only one US examination. The patients underwent a total of 12 US examinations. Microliths were bilateral in four patients and unilateral in two patients. In these two latter cases, the contralateral testis was, in one case, cryptorchid and could not be evaluated by US; in the other case it was small and hyperechogenic with orchidopexy sequelae. In three cases microliths were distributed throughout the testis. In the remaining three cases they were present in limited areas of parenchyma. As to the importance of microliths, it was defined as mild in three cases and moderate/severe in three cases. Intratubular testicular microlithiasis is a well-proved histological finding (biopsy or autopsy). More recent is the US demonstration of TM with consequent definition of its pattern: usually bilateral hyperechogenic multiple small foci without acoustic shadows with complete or partial extension to the parenchyma. Testicular microlithiasis is a rare finding. Moreover, the pediatric cases reported in the literature are very few. However, the use of high-frequency US transducers (10–13 MHz) has recently allowed an easier demonstration of this disease also in children. Of particular interest is the study of the still-debated association of microliths with other diseases such as neoplasms. Some aspects need further investigation, namely the real incidence of microliths in the healthy population, the incidence of tumors in patients with microliths, the differences between adults and children, and the different types of follow-up at different ages. In pediatric age, if TM represents an isolated sign, patients need non-invasive US follow-up until adult age. Only if TM is in association with focal lesions of testis parenchyma is it mandatory to perform biopsy or surgical treatment. Received: 17 June 1998; Revision received: 26 August 1998; Accepted: 21 September 1998     

Ultrasound of the scrotal contents

The technique, interpretation, and clinical applications of scrotal ultrasound are examined. The sonographic appearance of the normal scrotal contents and commonly encountered pathologic conditions are illustrated. A clinically-useful classification of scrotal pathology is based on ultrasound’s ability to anatomically localize scrotal pathology into 1 of 3 categories: extratesticular, testicular, or combined extratesticular and testicular. Prognostic and management decisions may be made on the basis of this classification.     

Adult ovarian granulosa cell tumors: spectrum of sonographic and CT findings with pathologic correlation

OBJECTIVE: The objective of this study was to evaluate the spectrum of sonographic and CT findings in adult ovarian granulosa cell tumors with pathologic correlation. MATERIALS AND METHODS: Transabdominal sonograms and CT scans in 13 patients with pathologically proven adult ovarian granulosa cell tumors were retrospectively reviewed. Morphologic characteristics of the lesions shown on sonography and CT were correlated with the histopathologic findings. RESULTS: On the basis of sonographic and CT findings, 13 cases of adult ovarian granulosa cell tumor were categorized into five morphologic patterns: multilocular cystic (n = 6), thick-walled unilocular cystic (n = 2), thin-walled unilocular cystic (n = 1), homogeneously solid (n = 2), and heterogeneously solid (n = 2) masses. Histopathologically, the multilocular cystic masses were characterized by a predominately macrofollicular pattern of granulosa cells and multiple cystic spaces with watery fluid or hemorrhage. Unilocular central cystic masses seen on CT correlated pathologically with confluence and expansion of the cystic spaces. Homogeneously solid masses seen on sonography and CT were correlated with evenly distributed trabecular or diffuse patterns in the tumor cells. Intratumoral bleeding, infarcts, fibrous degeneration, and irregularly arranged tumor cells yielded heterogeneously solid tumors. CONCLUSION: Adult ovarian granulosa cell tumors have a varied histologic appearance and a varied arrangement of tumor cells, both of which can create a spectrum of imaging manifestations. Appreciation of these manifestations is helpful in the diagnosis of this tumor.     

US findings in the scrotum of extreme mountain bikers

PURPOSE: To sonographically investigate whether mountain bikers have a higher prevalence of scrotal abnormalities compared with that in nonbikers. MATERIALS AND METHODS: Eighty-five male mountain bikers (mean age, 25 years; age range, 17-45 years) and 31 healthy nonbikers (mean age, 24 years; age range, 15-37 years) were examined for scrotal findings at ultrasonography (US). Only male subjects with a history of extensive off-road biking (> or =2 h/d 6 d/wk; covered distance, >5,000 km/y) were assigned to the group of mountain bikers, whereas the control group did not engage in bicycling. In addition to clinical evaluation, US examination of the scrotum was performed by using a linear-array transducer operating at a frequency of 8.0 MHZ: RESULTS: Eighty (94%) mountain bikers had abnormal findings at scrotal US. Thirty-nine (46%) had a history of intermittent scrotal tenderness or discomfort but no severe scrotal trauma. Abnormal findings at US included scrotal calculi in 69 (81%), epididymal cysts in 39 (46%), epididymal calcifications in 34 (40%), testicular calcifications in 27 (32%), hydroceles in 24 (28%), varicoceles in nine (11%), and testicular microlithiasis in one (1%). In the control group, abnormal findings were noted in five (16%), all of whom had epididymal cysts. The overall difference in the number of scrotal abnormalities in bikers compared with the number in nonbikers was significant (P <.0001, chi2 test). CONCLUSION: US shows a significantly higher prevalence of extratesticular and testicular disorders in these mountain bikers compared with nonbikers.     

Color Doppler sonography of normal and torsed testicular appendages in children

OBJECTIVE: The purpose of our study was to determine the size and appearance of normal and torsed testicular appendages on color Doppler sonography. SUBJECTS AND METHODS: Thirty-three patients with acute scrotal pain underwent gray-scale and color Doppler sonography and subsequent surgery. Twenty-two patients had torsion of the appendix testis, six had epididymitis, three had torsion of the testis, and two had torsion of the appendix epididymidis. The testicular appendages of 30 patients and the testes of three were excised and sent to the laboratory for histopathologic examination. RESULTS: A testicular appendage was identified on color Doppler sonography in 23 patients (21 patients with torsed appendages and two patients with epididymitis). The torsed appendixes testis measured from 4.1 to 16.3 mm, and the normal appendixes in the two patients with epididymitis measured 4.1 and 5.6 mm. With the visualization of an appendix larger than 5.6 mm as the sonographic diagnostic criterion for torsion of a testicular appendage, sensitivity was 68.2% (95% confidence interval (CI), 45.1-85.3%), and specificity was 100% (CI, 74.7-100%). CONCLUSION. The identification of a testicular appendage larger than 5.6 mm is suggestive of torsion. Therefore, depending on the patients' clinical conditions, these cases can be treated conservatively when an appendage larger than 5.6 mm is identified.     

Ruptured extratesticular epidermal inclusion cyst mimicking polyorchidism with torsion on sonography

The sonographic appearance of epidermal inclusion cysts varies in accordance with the contents of the cyst, ranging from an anechoic lesion to a hyperechoic solid appearing mass. Supernumerary testes are an uncommon congenital abnormality, in which more than two testes are present. We present a rare case of a ruptured scrotal extratesticular epidermal inclusion cyst, which had the sonographic appearance of a supernumerary testicle with torsion.     

Testes and scrotum: MR imaging at 1.5 T

Magnetic resonance (MR) images of the scrotum were obtained at 1.5 T in 20 subjects, 13 patients with intrascrotal pathologic conditions and seven healthy subjects. Characteristic MR imaging signals obtained on T1- and T2-weighted images allowed differentiation of testis from epididymis and spermatic cord. Masses were differentiated from normal testicular parenchyma in all cases. Atrophic or ischemic testes had lower signal intensity than normal testes on T2-weighted images. Hematoma displayed a characteristic high intensity on both T1- and T2-weighted images. Intratesticular and extratesticular pathologic conditions were readily differentiated. These results suggest that MR imaging is useful in the diagnosis of scrotal and testicular abnormalities.     

Testicular microlithiasis: what is its association with testicular cancer?

PURPOSE: To determine the prevalence of testicular microlithiasis in patients who were referred for scrotal ultrasonography (US) at a tertiary care cancer center and to evaluate the association between microlithiasis and cancer. MATERIALS AND METHODS: Testicular sonograms obtained in 528 men were retrospectively reviewed to identify patients with US findings suggestive of microlithiasis, intratesticular masses, and intratesticular heterogeneous changes. The association of US findings with medical records and with histopathologic findings that were available in 95 patients was evaluated. Statistical analysis was performed to determine the relationship of testicular cancer, intratesticular mass, and microlithiasis. RESULTS: Forty-eight (9%) of the 528 patients had microlithiasis; 13 of these (27%) had testicular cancers. Of the 480 patients without microlithiasis, 38 (8%) had testicular cancer. Ninety patients had an intratesticular mass, of whom 23 (26%) had microlithiasis. Forty-three (12 with microlithiasis) patients with a mass had testicular cancer, 43 (10 with microlithiasis) had benign findings or nontesticular malignant histopathologic findings, and four (one with microlithiasis) had no pathologic findings. CONCLUSION: Intratesticular microlithiasis is highly associated with confirmed testicular cancer, as well as with US evidence of testicular mass.     

急性阴囊闭合性损伤的磁共振成像与彩色多普勒超声诊断

目的探讨磁共振成像（magnetic resonance imaging,MRI）与彩色多普勒超声在急性阴囊闭合性损伤中的诊断价值。方法收集急性阴囊闭合性损伤患者8例,所有病例全部经MRI及彩色多普勒超声检查,回顾性分析及比较MRI及彩色多普勒超声图像。结果8例急性阴囊闭合性损伤患者中,MRI示睾丸损伤出血8例（其中自膜下少量积血2例）,睾丸增大、阴囊肿大皮肤增厚、鞘膜积液8例,白膜毛糙3例,附睾增大5例（其中附睾损伤出血3例）,腹股沟区淋巴结肿大4例。彩色多普勒超声示睾丸损伤出血6例,睾丸增大6例,阴囊肿大、皮肤增厚8例,鞘膜积液6例,白膜异常未见,附睾增大2例,腹股沟区淋巴结肿大未见。结论MRI能清楚显示急性阴囊闭合性损伤,是目前诊断急性阴囊闭合性损伤的精确影像检查方法。     

肺泡微石症的影像学诊断

目的：探讨肺泡微石症的影像学特征。方法;报道肺泡微石症6例,全部病例均行胸部X线检查,2例行常规CT,1例行HRCT。并对全部影像学表现进行了回顾性分析。结果：6例胸片表现为弥漫粟粒样微细结节（2例）。“鱼子样”或“暴风沙样”（2例）、“白肺样”（1例）及高密度“面纱样”改变（1例）,CT可明确肺内微细结节的钙化密度,肺尖部气肿样改变及支气管血管束增粗并呈钙化密度,HRCT则可进一步显示肺野磨砂玻璃样改变,小叶间隔,叶间胸膜及支气管血管束钙化密度与串珠状增厚,小叶中心分布的微细结节与胸膜下蜂窝,结论：肺泡微石症是一种罕见病,其影像学表现具有特征性,影像学检查尤以HRCT检查对该病的诊断有决定性作用。     

Changes in the epididymis after vasectomy: sonographic findings

Scrotal sonograms were obtained in 31 men before vasectomy and at 2 and 12 months after vasectomy to determine the effect of the surgery on the sonographic appearance of the testis and epididymis. The sonographic appearance of the testis was unchanged after vasectomy. However, in 14 men (45%), there were persistent changes in the epididymis. These consisted of enlargement (14 patients), development of cysts (11 patients), and an inhomogeneous echo pattern (five patients). The presence of these sonographic changes was unrelated to symptoms. The history of vasectomy in men referred for scrotal sonography should be noted so that the altered sonographic appearance of the epididymis may be interpreted properly.