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AJR Integrative Imaging LIFELONG LEARNING FOR RADIOLOGY |
1 Section of Abdominal Imaging, Imaging Institute, Cleveland Clinic, 9500 Euclid
Ave.–A21, Cleveland, OH 44195.
2 Present address: Sections of Abdominal Imaging and Ultrasound, Department of
Radiology, University of California San Francisco, San Francisco, CA.
Received January 18, 2008; accepted after revision January 29, 2008.
Address correspondence to E. M. Remer
(remere1{at}ccf.org).
Sonography is the primary technique for the imaging evaluation of diseases of the scrotum. Imaging features of disease should be correlated with clinical features to guide management. The educational objectives of this self-assessment module are for the participant to exercise, self-assess, and improve his or her understanding of clinical and sonographic features of diseases of the scrotum.
Keywords: acute testicular torsion • extratesticular scrotal masses • scrotum • segmental testicular infarction • testicular microlithiasis
INTRODUCTION
This self-assessment module on sonography of the scrotum has an educational component and a self-assessment component. The educational component consists of four required articles that the participant should read. The self-assessment component consists of 10 multiple-choice questions with solutions. All of these materials are available on the ARRS Web site (www.arrs.org). To claim CME and SAM credit, each participant must enter his or her responses to the questions online.
EDUCATIONAL OBJECTIVES
By completing this educational activity, the participant will:
REQUIRED READING
INSTRUCTIONS
| QUESTION 1 Which sonographic feature is most specific for acute testicular torsion?
QUESTION 2 Which of the following is TRUE regarding segmental testicular infarction?
QUESTION 3 Which sonographic feature is most sensitive for scrotal inflammation?
QUESTION 4 In the United States, what is the most common causative organism in acute epididymoorchitis in men older than 50 years?
QUESTION 5 Which of the following is NOT a current management recommendation for patients with testicular microlithiasis?
QUESTION 6 Sonography of a nontender, palpable testicular mass in a young adult man shows a well-circumscribed mass in the testis with alternating hyperechoic and hypoechoic rings. Which of the following is the most likely diagnosis?
QUESTION 7 Which of the following is TRUE regarding extratesticular scrotal masses?
QUESTION 8 Which of the following is the most common tumor involving the spermatic cord?
QUESTION 9 Which of the following is TRUE regarding adenomatoid tumors of the scrotum?
QUESTION 10 In children, which of the following is TRUE regarding extratesticular masses detected on sonography?
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Solution to Question 1
In torsion, the testis becomes enlarged and heterogeneous within the first
6 hours. Heterogeneous echotexture, however, is a common finding on sonography
for the evaluation of acute scrotal pain regardless of cause. Option A is not
the best response. Testicular enlargement (option C) and hydrocele (option D)
are frequent, but nonspecific, findings in patients with testicular torsion.
Unilateral absent flow is the most specific sign of acute testicular torsion
[1]. However, intermittent or
incomplete torsion may result in false-negative studies. Option B is the
best response.
Solution to Question 2
Segmental testicular infarction is an ischemic process observed on
sonography as a focal rounded or wedge-shaped avascular area, most often in
the upper or middle portion of the testis. Option A is not the best response.
Differentiation from a small, hypovascular, intratesticular tumor on
sonography is difficult and, in many cases, the diagnosis is made after
orchiectomy. Option B is not the best response. MRI may prove helpful to make
a more specific preoperative diagnosis
[2]. Although no clear cause
has been determined, the proposed mechanism is torsion and detorsion of the
testis producing ischemia in the upper pole of the testis, a region with an
inconstant collateral arterial supply. Option C is not the best response. The
list of conditions associated with segmental testicular infarction is long and
includes acute epididymoorchitis, polycythemia, sickle cell disease,
hypersensitivity angiitis, Wegener's granulomatosis, and pelvic surgery,
especially herniorrhaphy. Option D is the best response
[3].
Solution to Question 3
The hallmark of scrotal inflammation is hyperemia of the epididymis,
testis, or both, on color Doppler sonography. The sensitivity of color Doppler
sonography for scrotal inflammation is close to 100%. Furthermore, in 20% of
patients with epididymitis and 40% of patients with orchitis, gray-scale
sonography is normal and hyperemia may be the only finding
[4]. Option D is the best
response. Scrotal skin thickening, reactive hydrocele, and increased
epididymal echotexture are frequent, but nonspecific, findings in patients
with acute scrotal pain. Options A, B, and C are not the best responses.
Epididymal enlargement can be seen in torsion, trauma, epididymitis, and
infiltrative processes such as leukemia and lymphoma. Option E is not the best
response.
Solution to Question 4
Worldwide, approximately 2–4% of tuberculous infections involve the
genitals; however, epididymal tuberculosis is uncommon in the United States
[5]. Option A is not the best
response. Infectious epididymoorchitis is usually the result of descending
infection caused by urinary tract pathogens, most commonly Escherichia
coli in older men. Option B is the best response. In young adults,
scrotal infection most commonly results from sexually transmitted diseases.
Options C and D are not the best responses. Pseudomonas organisms,
Proteus mirabilis, and Klebsiella organisms are less common
urinary tract pathogens and less common causes of epididymitis. Option E is
not the best response.
Solution to Question 5
Microlithiasis is often discovered incidentally on sonography performed for
scrotal pain or trauma. A lack of consensus exists regarding the preferred
follow-up of microlithiasis in patients without a concurrent neoplasm, and
many differing recommendations can be found in the literature and in practice
[6]. Most authors agree that at
least annual physical examinations and scrotal sonography are prudent. Options
A and B, which are correct, are not the best responses. Others have gone
further, advocating testicular biopsy to detect concurrent premalignant
intratubular germ cell neoplasia. Option C, which is correct, is not the best
response. Because the relative risk of concurrent neoplasm in a patient with
testicular microlithiasis has been reported to be as high as 21.6-fold
[7], some experts recommend
screening CT of the chest, abdomen, and pelvis when microlithiasis is
detected. Option D, which is correct, is not the best response. Unlike
prophylactic mastectomy in high-risk women, prophylactic orchiectomy for
testicular microlithiasis has not been advocated in the literature. Option
E, which is not correct, is the best response.
Solution to Question 6
Seminoma is the most common type of testicular tumor. It usually is a
well-circumscribed, hypoechoic mass containing low-level echoes, but not
calcifications. Option A is not the best response. Lymphoma typically presents
as either focal or more diffuse hypoechoic regions with increased Doppler flow
and occasional involvement of the adjacent epididymis. Option B is not the
best response. Alternating bands of increased and decreased echogenicity, the
so-called onion-ring or onion-skin appearance, are characteristic of an
epidermoid cyst; however, the sonographic appearance is variable
[8]. Epidermoid cysts with a
target appearance, a sharply defined mass with a rim of calcium, and a solid
mass with an echogenic rim have been described
[9]. Option C is the best
response. Adenomatoid tumors are mixed-echogenicity tumors of the
epididymis. Option D is not the best response. Lipomas typically arise in the
spermatic cord. Option E is not the best response.
Solution to Question 7
In contrast to testicular masses, most extratesticular scrotal masses are
benign [10]. Cystic scrotal
masses are especially likely to be benign. Option A is not the best response.
Papillary cystadenoma, a benign tumor of the epididymis, has a strong
association with von Hippel-Lindau (VHL) disease. Bilateral epididymal
cystadenomas are virtually pathognomonic for VHL. Option B is the best
response. Supernumerary testes are rare, usually presenting as a painless,
scrotal mass. Twenty percent of supernumerary testes are inguinal, 75% are
intrascrotal, and 20% are retroperitoneal
[10]. Option C is not the best
response. Adenomatoid tumor is the most common epididymal tumor; however,
lipomas, which usually occur in the spermatic cord, are the most common
extratesticular scrotal tumor
[10]. Option D is not the best
response.
Solution to Question 8
Lipomas are the most common extratesticular scrotal tumor, arising most
often in the spermatic cord. Option D is the best response. They
account for approximately half of all cord tumors. Other benign tumors of the
cord include leiomyoma, lymphangioma, and dermoid, but these are much less
common. Option A is not the best response. Rhabdomyosarcoma and liposarcoma
are the most common sarcomas of the scrotum, usually arising from the mesoderm
of the spermatic cord [10].
Rhabdomyosarcomas predominantly occur in children and often present with
retroperitoneal adenopathy and distant metastasis. Option B is not the best
response. Lymphoma involving the epididymis or spermatic cord without
testicular involvement is extremely rare. Option C is not the best response.
Adenomatoid tumors involve the epididymis. Option E is not the best
response.
Solution to Question 9
Adenomatoid tumors of the epididymis account for approximately 30% of
paratesticular neoplasms. They are invariably benign
[10]. Option A is not the best
response. Although adenomatoid tumors can occur anywhere in the epididymis,
they most often arise in the epididymal tail. Option B is not the best
response. Intratesticular extension can be seen, in which case it can be
indistinguishable from germ cell tumor. Option C is the best response.
Most adenomatoid tumors are diagnosed in men between the ages of 20 and 50
years. Option D is not the best response.
Solution to Question 10
Extratesticular masses are much more likely to be malignant in children
than in adults [10]. Option A
is not the best response. Approximately 50% of painless extratesticular
scrotal masses in children are malignant, with rhabdomyosarcoma being the most
common [11]. Painful masses
are less likely to be malignant, and often represent entities such as abscess,
torsed appendix, and epididymal inflammation. Option B is not the best
response. The sonographic appearance of rhabdomyosarcoma may range from mostly
solid to primarily cystic with solid nodules; therefore, the presence of
cystic components may be associated with malignancy. Option C is not the best
response. Antecedent trauma suggests fibrous pseudotumor, a reactive
nonneoplastic lesion caused by fibroinflammatory reaction to infection or
trauma that manifests as one or more painless masses that involve the tunica.
Option D is the best response.
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