Role of Doppler sonography in the diagnosis of cystic lymphangioma of the scrotum

Cystic lymphangioma is a congenital lymphatic malformation that is a rare cause of extratesticular scrotal masses in children; it is frequently misdiagnosed preoperatively. Complete excision is curative, but recurrence may result from incomplete excision. We report a case of cystic lymphangioma of the scrotum in a 3-year-old boy, which had been previously diagnosed as a hydrocele. Gray-scale sonography showed a multicystic extratesticular lesion; color Doppler sonography further characterized the lesion by showing blood flow within the septa. CT scanning ruled out extrascrotal involvement. The cystic mass was surgically resected. The appearance of the lesion both macroscopically and microscopically was consistent with a diagnosis of cystic lymphangioma. The child recovered uneventfully and was discharged on the third day after surgery; no evidence of recurrence was found in 6 months of follow-up. In such cases of scrotal masses in children, gray-scale and color Doppler sonography, followed by CT or MRI, are useful in diagnosing cystic lymphangioma, differentiating it from other lesions, and defining its extent, thus allowing proper surgical planning.     

Sonographic findings in a case of scrotal lymphangioma in a 68‐year‐old male

Lymphangiomas are benign tumors resulting from a congenital lymphatic malformation in infant and children. Most common sites are head, neck and axilla, and scrotal lymphangioma is very rare. Lymphangiomas are classified as capillary, cavernous, and cystic type and cystic type is most common. Complete surgical excision is definitive treatment and incomplete excision leads to local recurrence. We report a case of scrotal lymphangioma in 68‐year‐old male patient. Gray‐scale sonography revealed multiseptated, hypoechoic mass abutting the upper pole of the normal right testis. Color Doppler sonography showed no remarkable blood flow in the mass. MRI demonstrated multispetated extratesticular and extraepididymal mass in the right scrotum. Surgical excision was performed and the histopathologic diagnosis was a cystic lymphangioma. In conclusion when multiseptated cystic scrotal mass was discovered in an elderly patient, scrotal lymphangioma should be included in differential diagnosis. © 2009 Wiley Periodicals, Inc. J Clin Ultrasound 2009     

Sonographic spectrum of scrotal abnormalities in infertile men

PURPOSE: To use sonography to detect scrotal abnormalities in infertile men. MATERIAL AND METHODS: Two hundred thirty-four infertile men, including 176 oligospermic (sperm count < 10 x 10(6)/ml), 58 azoospermic, and 150 normospermic men (control group) were evaluated prospectively for the presence of intra- and extratesticular abnormalities using high-frequency transducers and color Doppler imaging. Medical and surgical history, testicular volume, semen parameters, and hormonal levels were recorded. RESULTS: A statistically significant increase in the prevalence of abnormal scrotal findings detected with sonography was observed in the study group compared with controls. These included varicocele in 35.5% versus 16% (p < 0.01), hydrocele in 16.7% versus 8.7% (p < 0.05), testicular microlithiasis in 9.8% versus 2% (p < 0.01), epididymal enlargement in 9% versus 2.6% (p < 0.05), and epididymal cyst in 7.7% versus 2% (p < 0.05). Testicular tumor was not seen in either group. A statistically significant decrease in testicular volume, sperm concentration, normal morphology, and forward motility of the sperm was noted in the study group compared with controls (p < 0.01). CONCLUSION: The various intra- and extratesticular abnormalities were demonstrated in infertile men. Sonography should be used routinely in the work-up of male infertility.     

Sonography of Pediatric Scrotal Swelling

Sonography is the preferred imaging method for the evaluation of pediatric scrotal swelling. By identifying the site of origin and whether a mass is solid or cystic, the diagnosis is usually readily made, making ultrasound especially valuable in patient management. Scrotal pathology differs in pediatric patients, especially prior to puberty, making understanding of pediatric conditions essential. This article reviews the common intra- and extratesticular causes of pediatric scrotal swelling and their sonographic appearances.     

Cystic lesions and scrotal fluid collections in adults: Ultrasound findings

The widespread use of scrotal ultrasonography (US) has led to increased detection of testicular and extratesticular pathologies. Cystic or encapsulated fluid collections are relatively common benign lesions that usually present as palpable testicular lumps. Most cysts arise in the epidydimis, but all anatomical structures of the scrotum can be the site of their origin. US may suggest a specific diagnosis for a wide variety of intrascrotal cystic and fluid lesions and appropriately guide therapeutic options. US should be used as an adjunctive diagnostic modality after clinical evaluation of a scrotal lesion associated or not with the presence of a lump.     

Thrombotic and Nonthrombotic Types of Intratesticular Varicoceles: Value of Sonography for the Diagnosis

An intratesticular varicocele is an uncommon entity, and its clinical importance remains unclear. The diagnosis can be made in the case of an intratesticular tortuous vein that shows retrograde flow on color Doppler sonography. The anatomic location and course of the intratesticular varicocele within the testicular parenchyma and its association with the existence of an ipsilateral extratesticular varicocele may vary among patients. The pathophysiologic mechanisms remain unclear; however, it may be questioned whether there is an association between testicular atrophy and intratesticular varicocele development. Although the diagnosis is usually made incidentally, patients may rarely present with acute scrotal pain due to acute thrombosis of an intratesticular varicocele.     

Sonographic appearance of aggressive angiomyxoma of the scrotum.

Aggressive angiomyxoma (AAM) is a rare, locally infiltrative tumor that occurs almost exclusively in the pelvic and perineal regions of women of childbearing age. We report the unusual case of a 26-year-old man with an AAM presenting as a slowly enlarging scrotal mass. Gray-scale scrotal sonography demonstrated a well-demarcated, hypoechoic, extratesticular, extraepididymal mass with multiple thin, echogenic internal septa. The mass arose inferior to the left testicle and displaced the testicle cephalad. Color Doppler sonography revealed surrounding vascularity but no Doppler signals within the mass. The testicles and epididymides demonstrated normal echogenicity and vascularity. Histologic examination of the excised mass revealed a well-demarcated, nonencapsulated lesion composed of spindle-shaped cells in a myxoid background with a prominent vascular component.     

Ultrasound of the scrotum

Ultrasound plays an important role in the diagnostic workup of scrotal diseases. It can differentiate a testicular mass from an extratesticular mass and determine whether the mass is cystic, solid, or complex. Using this information a likely diagnosis can be ascertained. In the acute scrotum, acute epididymitis/epididymo-orchitis can in most cases be distinguished from testicular torsion. Following scrotal trauma, surgery is needed to salvage the testis if there is testicular disruption and ultrasound can help with this diagnostic dilemma. When a large hydrocele is present, ultrasound allows evaluation of the underlying testis and epididymis and it can detect varicoceles, especially in the infertile male. In patients at risk for a testicular tumor (cryptorchid testis, testicular microlithiasis), ultrasound is the best imaging modality for follow-up. CT, MRI, and nuclear medicine scanning may be necessary for further evaluation of scrotal diseases and this will be briefly addressed.     

Significant predictors for determination of testicular rupture on sonography: a prospective study.

OBJECTIVE: The purpose of this study was to evaluate prospectively useful sonographic diagnostic criteria for testicular rupture in patients with blunt scrotal trauma and to determine significant predictors among the criteria. METHODS: From July 2004 to February 2007, 29 consecutive patients (mean age, 22.8 years; range, 20-43 years) with blunt scrotal trauma who underwent scrotal sonography were enrolled. Ten ruptured testes and 6 intact testes were confirmed by surgery, and an additional 13 intact testes were confirmed by a physical examination. The sonographic findings were recorded with respect to contour irregularity, the presence of intratesticular and extratesticular heterogeneous echoes, loss of blood flow on color Doppler sonography, and engorgement of the pampiniform plexus by consensus between 2 radiologists. The sonographic findings used to diagnose testicular rupture were analyzed by the Fisher exact test, and significant predictors were determined by multiple regression analysis. RESULTS: The ruptured testes showed contour irregularity (P=.0002), a heterogeneous intratesticular echo pattern (P=.0077), and loss of blood flow on color Doppler sonography (P=.0093). Engorgement of the pampiniform plexus was seen in most nonruptured testes (P=.0178). Contour irregularity was the only significant predictor for the diagnosis of testicular rupture (P=.0002). On the basis of this single predictor, diagnostic predictive values for sonography were calculated; the accuracy, sensitivity, and specificity were all 90%. The positive predictive value and negative predictive value were 82% and 94%, respectively. CONCLUSIONS: Among the useful sonographic criteria, contour irregularity is the only significant predictor for the diagnosis of testicular rupture in patients with blunt scrotal trauma.     

Intrauterine/newborn testicular torsion

Although spermatic cord torsion in the neonate is uncommon, early recognition with prompt surgical exploration and detorsion of the cord can result in preservation of some testicular tissue. Palpation of the infantile testes can be difficult, and distinguishing testicular from extratesticular abnormalities may not be possible. High-resolution real-time ultrasonography is an effective, noninvasive method of differentiating between the two. If sonography demonstrates and abnormal testicle, prompt surgical exploration is indicated.     

儿童阴囊内睾丸外肿物的CT和MRI表现

目的探讨儿童阴囊内睾丸外肿物的CT和MR特征。方法回顾性分析经手术病理证实的10例阴囊内睾丸外肿物的CT和MRI资料及临床病理资料,并进行文献复习。结果良性病变7例:婴儿纤维性错构瘤2例,异位副脾、血管畸形、静脉型血管瘤、脓肿、囊肿各1例;恶性病变3例,均为横纹肌肉瘤。临床表现均为阴囊区无痛性肿块,实验室检查多无特点。而影像学表现各异:婴儿纤维性错构瘤表现为阴囊区近腹股沟不均匀密度/信号肿物,增强后轻-中度强化;异位副脾表现为紧贴左侧睾丸上方边界清楚且密度均匀的结节灶,增强后明显均匀强化;血管畸形表现为阴囊内鞘膜下不规则形肿物,T_2WI部分见流空信号,增强后早期明显强化;静脉型血管瘤合并血栓形成表现为睾丸上方精索内侧类圆形边界清楚肿物,呈软组织密度,增强后大部分未见强化;脓肿表现为阴囊纵隔区类圆形肿物,边界模糊,T_2WI呈不均匀稍高信号,DWI呈高信号;囊肿表现为附睾头区典型边界清楚类圆形水样密度灶,增强后未见强化;横纹肌肉瘤表现为睾丸旁密度不均匀肿块,增强后明显强化,其中1例侵犯睾丸并远处转移。结论儿童阴囊内睾丸外肿物种类繁多,以良性病变多见,临床表现无特异性,部分病变具有一定的影像特征,推荐术前选择超声结合MRI检查。     

Prenatal diagnosis of fetal chest lymphangioma.

OBJECTIVE: Prenatally diagnosed cystic nuchal hygroma is often associated with chromosomal anomalies and hydrops fetalis. Chest lymphangioma diagnosed later in gestation appears to be a completely different disease, with a low incidence of chromosomal and structural anomalies. METHODS: Two chest cavernous lymphangiomas of the fetus are presented. The sonographic images, chromosomal analyses, and macroscopic and microscopic evaluations are described. RESULTS: Fetal chest cavernous lymphangiomas were identified at 15 and 22 weeks' gestation. In the first case, the couple decided to interrupt gestation. In the second case, prenatal sonography showed a multilocular, cystic lymphangioma external to the chest wall with no flow on Doppler sonography. Follow-up sonography revealed normal fetal growth and slow enlargement of the cystic mass surrounding the left chest cavity. The neonate was delivered without complications and was treated surgically. CONCLUSIONS: The chest lymphangioma appears to be a lesion usually not associated with other congenital abnormalities. The prenatal diagnosis of chest wall lymphangioma is relatively easy sonographically, and the treatment of choice is surgical excision. The outcome is relatively favorable, with a low incidence of chromosomal and structural anomalies.     

Color Doppler sonography in evaluation of spermatoceles: the "falling snow" sign.

OBJECTIVE: Doppler sonography is not commonly used in evaluation of cystic lesions with internal echoes. Here we report the use of the mechanical properties of color Doppler sonography to further characterize 3 spermatoceles. METHODS: Three patients who came to University of California San Francisco Imaging Center with painless unilateral scrotal enlargement were evaluated with sonography and were found to have large spermatoceles. Color Doppler sonography was applied to these spermatoceles, and digital video clips were obtained as the color beam was instituted. RESULTS: When color Doppler sonography was applied to each spermatocele, the internal echoes moved away from the transducer, resulting in an appearance similar to falling snow. CONCLUSIONS: The "falling snow" sign can be used to enhance the diagnosis of a spermatocele as well as to evaluate a superficial cystic lesion with echogenic fluid and internal microdebris that is difficult to distinguish from a solid mass.     

Torsion of the spermatic cord: the main gray-scale and doppler sonographic signs

Scrotal ultrasonography (US) is usually the initial imaging modality for evaluating patients who present with acute pathologic conditions of the scrotum. Acute epididymitis, acute epididymo-orchitis, torsion of the spermatic cord (TSC), and other acute scrotal abnormalities may have similar findings at clinical examination. Pain and swelling make the clinical examination difficult, sometimes practically impossible, potentially resulting in management delays. The objective of this review is to summarize the main clinical signs of the TSC and to illustrate and briefly discuss the US features of this entity, including gray-scale imaging, color Doppler with spectral analysis, and power Doppler sonography. Although TSC can occur at any age, it is most common in adolescent boys. The intensity of the symptoms and the US findings vary with the duration of the torsion, number of twists in the spermatic cord (degree of rotation), and how tightly the vessels of the cord are compressed. An enlarged, more spherical, and diffusely hypoechogenic testis without detectable arterial and venous testicular flow at color and power Doppler US is considered diagnostic of acute testicular ischemia. The presence of a color or power Doppler signal in one part of the testis does not exclude TSC. Positive blood flow but significantly diminished, usually near or inside the mediastinum, may be found, mainly in the partial or incomplete TSC. Identification of a large echogenic extratesticular mass distal to the site of the torsion, frequently misinterpreted as a chronic epididymitis, can be the key to the diagnosis of TSC. When a small arterial sign is found a low amplitude waveform is present with an increased resistive index on the affected side due to a diminished, absent, or reversed diastolic flow. Gray-scale imaging, color Doppler, power Doppler and pulsed Doppler with spectral analysis are very effective to make or exclude the diagnosis of TSC.     

Diagnostic capabilities of high-resolution scrotal ultrasonography: prospective evaluation

The use of scrotal ultrasonography has been advanced with the development of high-resolution real-time equipment. A group of 284 consecutive patients referred for scrotal examination was studied ultrasonically and followed over a three-year period. Abnormal scrotal contents were accurately detected in 98.5 per cent of cases. Separation of testicular from extratesticular pathology was 99 per cent accurate. While all malignant testicular lesions could be identified, there were examples which could not be differentiated from benign lesions prior to surgical exploration and biopsy. However, there are many examples where the ultrasound results can change clinical management of the patient.     

Fetal therapy: state of the art.

OBJECTIVE: To review our experience with the use of sonography in evaluating potential candidates for in utero fetal therapy performed at The Center for Fetal Diagnosis and Treatment at The Children's Hospital of Philadelphia. METHODS: This review article was designed to discuss open hysterotomy for the 4 fetal surgical procedures that have been performed at our institution. The procedures included surgical repair of myelomeningocele, resection of sacrococcygeal teratoma in fetuses with nonimmune hydrops, resection of an enlarging congenital cystic adenomatoid malformation that is not amenable to thoracoamniotic shunting, and tracheal clip occlusion for severe left congenital diaphragmatic hernia. RESULTS: For each surgical procedure, the use of sonography in the prenatal diagnosis of the congenital anomaly was detailed, as were indications for surgery and surgical procedures, postoperative monitoring and finally delivery, postnatal treatment, and long-term follow-up. Three of the procedures have been reasonably successful with rather dramatic results in some cases such that these techniques are still being performed. The 1 exception was open hysterotomy for the tracheal clip procedure for congenital diaphragmatic hernia, which has been abandoned. CONCLUSIONS: Fetal therapy is a rapidly evolving specialty, which is being practiced at several centers in this country. Sonography is an integral part of this specialty practice and has been used extensively in the diagnosis of some congenital anomalies that have debilitating or lethal consequences for the fetus. Technologic improvements in both sonography and magnetic resonance imaging have assisted tremendously in the many advances herein reported in the diagnosis and treatment of the above-described 4 congenital anomalies.     

Sonographic follow-up of ethanolamine oleate sclerotherapy for hydrocele

Sclerotherapy has gained increasing popularity during the last few years as a treatment for hydrocele. Little is known of the natural course of intrascrotal changes, however, nor of their timetable after therapy. In the present trial scrotal ultrasonography was performed before the sclerotherapy and during the follow-up examination in the case of 70 symptomatic consecutive outpatients ranging in age from 19 to 85 years (mean, 58 years) with 71 hydroceles treated by ethanolamine oleate sclerotherapy. Posttreatment sonographic findings typically included heterogeneously echogenic extratesticular masses, cystic areas with peritesticular hyperechoic lines, and a thickened scrotal wall. All the lesions showed improvement. Sonography proved to be useful for differentiating hydroceles from spermatoceles and for evaluating the need for a renewed treatment during follow-up. Ethanolamine oleate was effective as a sclerosant, as 86% of cases were cured or significantly improved. Complications were mild and uncommon, and no intratesticular or epididymal changes were observed. Ethanolamine oleate sclerotherapy can be recommended as a treatment of choice for hydrocele.     

Prenatal sonographic detection of pericardial teratoma

Patients with pericardial teratomas usually present shortly after birth with cardiorespiratory distress or in utero with hydrops fetalis. We report a case in which the tumor was diagnosed in utero using sonography during a routine obstetric examination. Sonograms showed a 3-cm echogenic mass compressing the right atrium. The lesion was inhomogeneous with solid and cystic areas. The fetus was followed to term, and additional radiologic studies were performed before the infant underwent surgery. Prenatal identification of a pericardial teratoma is essential for planning fetal management and delivery and potential prenatal surgery.     

Transvaginal sonography of the uterine cavity with hysteroscopic correlation in the investigation of infertility.

This report describes the correlation of hysteroscopic findings with preoperative transvaginal sonography in 200 patients being investigated for infertility. Real-time ultrasound examination was performed on days 7, 14 and 21 in spontaneous ovulatory cycles. Diagnostic hysteroscopy was performed in the subsequent cycle. The abnormalities detected using transvaginal sonography were intrauterine adhesions, submucous fibroids, endometrial polyps, endometritis and a non-specific irregular endometrium. A total of 182 patients were diagnosed correctly to have an abnormality by transvaginal sonography giving a false-positive rate of 5.5%. The sensitivity of transvaginal sonography in detecting endometrial pathology was 98.9% with a positive predictive value of 94.3%. The positive predictive values for specific abnormalities were 98.5% for intrauterine adhesions, 91.7% for submucous fibroids, 91.4% for endometrial polyps, 85.7% for endometritis and 85.7% for irregular endometrium. These data show a strong correlation between findings from transvaginal sonography and hysteroscopy. Transvaginal sonography may be used to detect intrauterine pathology and identify patients in whom hysteroscopy and hysteroscopic surgery are indicated.     

Scrotal enlargement in boys with a history of scrotal trauma: two unusual findings

The presentation of a boy with an acutely painful scrotum is often associated with a history of trauma. Two recent patients with a history of scrotal trauma and an enlarged hemiscrotum were found on surgical exploration to have unusual causes for the scrotal enlargement. In the first case, there was bleeding from omentum in an incarcerated inguinal hernia, and in the second, there was bleeding into a scrotal cystic lymphangioma. Fewer than 40 cases of scrotal lymphangioma have been reported.