Discussion in 'Spot Diagnosis' started by bb100, Mar 9, 2013.
Ultasounography of testis
what is the diagnosis ?
hint- this case is a intrascrotal- extratesticular cystic lesion
Those above 18 - male genital organs on display, viewer discretion advised.
Even if u r a day shy of 18 – ask ur mumma or puppa if it’s ok.
I am posting a few images of the normal gray-scale anatomy and then attempt to solve the case posted by bb100 ( so that everybody can make sense of what is going on )
First a review of the normal anatomy
Now a look at the standard views
Normal Gray scale anatomy
After we have had the orientation of the anatomy, the next logical step is to pick up any abnormality and in case of the contents of the scrotum we have to look for the alignment, size and echogenicity of:
3) Spermatic cord
Now to pick up the subtleties, it takes at least a couple of years of practice and a very smart brain ( which by default, all radiologists possess ), becos the radiologists ( just like the pathologists ) r mostly the people who arrive at a diagnosis in the most perplexing of cases.
Now in the image posted by bb100, I see a hypoechoic cystic structure. I will enlist the possibilities and any strong arguments for or against. Pls. note, we don’t have the opp testis as control 4 comparison….so I hav to base the arguments accordingly. Also the hx will definitely help narrow down the possibilities, but I will try to argue just based on what is shown in the image ( in the true spirit of spot diagnosis )
The differentials ( I have put the less likely ones first and the most likely ones in the end )
1) Hydrocele of tunica vaginalis – possible, but we should be able to see the testis (hyperechoic) indenting into the distended tunica vaginalis ( hypoechoic ). Nothing of that sort here, both in the long and short axis view. A large hydrocele will displace the testis, but when u have a complete cross-section, u ought to see atleast the elbow of the testis
2) Testicular torsion – We don’t know if its color Doppler, becos if its color Doppler and u see no vessels in the testis, then the deduction is elementary. However if this is normal gray scale, then yes a contorted testis will enlarge and become hypoechoic ( becos, the veins pinch of first and the flow in the artery continues, until the pressure shuts it out as well ). But we will see some echogenicity and not a totally hypoechoic cystic swelling, as in our challenge.
Pls note: in a partially torsioned testis u will have some flow and so a presence of flow on color Doppler doesn’t rule out – Testicular torsion and on the other hand ability to demonstrate flow within the normal asymptomatic testis ( using the same Doppler settings ) is critical to the diagnosis of torsion.
3) Epididymo-orchitis – even this can look hypoechogenic and can mimic testicular torsion on gray-scale, but Color Doppler will show a hyperemic state (compared to the opp side, if it’s normal) and help differentiate the two. Again u won’t have an almost anechoic picture as in our case.
4) Testicular abscess will look hypeoechoic with a lot of scattered debris, but if the entire testis is involved then the person will surely have a Fournier’s gangrene and no radiologist will want to do his ultrasound ( I bet )
5) Varicocele – u will see a bunch of tubes (in long axis view), which in cross – section will show a multi-cystic structure and not a single hypoechoic swelling. Color Doppler will confirm the diagnosis, but a physical exam would have clinched it ( well in advance ).
6) Encysted hydrocele of the spermatic cord – possible and the structure distal ( in long axis view ), shud be epididymus….but the echogenicity will be more coarse and than the testis)
2 strong possibilities ( Epididymal cyst and Spermatocele )
7) Epididymal cyst – possible and a large one can displace the testis
8) Spermatocele (represents cystic dilatation of tubules of the efferent ductules in the head of the epididymis) - again a large spermatocele can make it impossible to have the testis in the same frame and can be seen as a cystic swelling separate from the testis ( as in our case ). Spematoceles can be septate, so presense of septa or multilocularity doesn’t go against the diagnosis.
Both epididymal cyst and spermatocele r hard to differentiate on ultrasound ( as both r located typically at the head of the testis)and physical exam ( with both presenting as painless scrotal masses, similar to testicular tumors and unlike testicular torsion or epididymo-orchtis )
Aspiration holds the key ( clear fluid – epididymal cyst, milky fluid – spermatocele )
in the interest of completeness, i am posting an image of color doppler of testis
& how do we know, which is artery and which is vein
Ans - by marrying color doppler with pulse ave doppler and homing the sampling gate onto the desired vessel. If we get a flat waveform then it's a venous structure and if it's pulsatile....
@ bb100 - i had solved the challenge, b4 i saw the hint...but i was preparing a detailed reply. So pls. give me full credit / praise etc. if my ans is correct and correct me ( without shouting P: ) if i am wrong somewhere.
correct answer is spermatocele... many thanks to neo-star for this excellent Explanations
and thanks to u as well..i hav carried a couple all my life, but never bothered to understand them. Ur challenge gave me the motivation to do so :hhh:
Separate names with a comma.