Table Of ContentSpringer-Verlag France S.A.R.L
Brigitte Martin
Atlas
of Scrotal
Ultrasound
Preface by Professor H. Hricak
with 71 0 Figures
Springer-Verlag France S.A.R.L
Brigitte Martin, M.D.
Service de Radiologie de l'Hopital Saint-Antoine
184, rue du Faubourg Saint-Antoine
75571 Paris Cedex 12
Diagrams of illustrations by Mare Donon
Title of the original French edition: Atlas d'echographie scrotale.
© Springer-Verlag France 1992
ISBN 978-3-642-85683-9 ISBN 978-3-642-85681-5 (eBook)
DOI 10.1007/978-3-642-85681-5
All translation, reproduction and adaptation rights reserved for all countries.
The law of March 11, 1957 forbids or reproductions intended for collective use. Any representation, partial or integral
reproduction made by any process whatsoever without the consent of the author of his executors or illicit and constitutes
a fraud dea1t with by Articles 425 and following ofthe Penal Cade.
© Springer-Verlag France 1992
Originally published by Springer-Verlag Paris in 1992
Softcover reprint of the hardcover 1s t edition 1992
The use of registred names, trademarks, etc. in this publicati an does not imply, even in the absence of a specific statement,
that such names are exempt from the relevant protective laws and regulations and therefore free for general use.
Product Liability : The publisher can give no guarantee for information about drug dosage and application there of
contained in this book. In every individual case the respective user must check its accuracy by consulting other
pharmaceutical litterature.
ISBN 978-3-642-85683-9
2918/3917/543210. Printed on acid free paper.
Preface
Ultrasonography is an established technique used as an sonographic findings are illustrated with high quality
adjunct to the physical examination in the evaluation images reflecting the author's long-term experience.
of scrotal diseases. This book provides the reader with The book is intended to be a complete guide to
a comprehensive overview of testicular diseases and the practical ultrasound applications of testicular diseases
appearance of these diseases on ultrasonography. for the physicians in training, general radiologists, and
Dr. Martin is one of the leading investigators who ultrasound specialists. The contents integrate the es
early recognized the value and enthusiastically pursued sential clinical characteristics of the various diseases
the capability of ultrasound for the diagnosis of scrotal (symptoms, physical findings, epidemiology) with in
diseases. Her experience has been gathered over seve formation concerning their diagnosis and treatment.
ral years, so the richness and depth of description of Based on extensive personal experience, the author
the panoply of scrotal diseases is indeed comprehen succeeds brilliantly in providing a comprehensive in
sive. The detailed description of the technique should sight into the problems of testicular diseases.
provide practical value for the practitioner. The des
cription of the embryology, epidemiology, anatomy Professor H. Hricak
and disease processes represents a comprehensive Urology and Radiology
treatise on ultrasound imaging of the scrotum. The UCSF, San Francisco
Preface of the french edition
Genital and more specifically scrotal ultrasound has - in the surveillance of an acute orchiepididyrnitis
from now on a significant role to play in the examina during which ultrasound permits the discovery in time
tion of the male urogenital system, as demonstrated by of a developing abcess or even an infectious testicle, or
this superbly illustrated atlas. in the context of the prostate where it may check on
So one must stipulate that in 1992 a clinical exami the condition of the deep genital tracts,
nation of the scrotal contents must if possible be - in the finding of supporting evidence, even reve
completed by an ultrasound examination. However, lation in clinically normal testicles, of existence of
this stipulation must be tempered according to whether tumors of the testicle,
the context of examination is either an acute or chronic - in the verification of testicular integrity when a
one. hydrocele of the tunica vaginalis exists.
In the acute stage of an emergency, whether
Finally, to be sure, testicular ultrasound is an inte
confronted or not with presence of a swollen injured
gral part of the battery of examinations performed in
scrotum, making a primary clinical diagnosis right
the conditions of intersexuality, unpalpable testicle,
away is more important than any of the imaging
and male infertility.
examinations. Therefore, the slightest suspicion of
torsion of the testis, whether based on either medical
One must lastly insist upon the routine use of
history or physical examination, is an emergency
testicular ultrasound in patients complaining of testicu
which must lead to immediate exploratory surgery.
lar pain whose clinical examination evidences no
Surgery is indicated irregardless of the result of an
anomalies in external genitalia. This pathological
ultrasound examination even if it was obtained under
context is frequently encountered, preoccupies pa
satisfactory conditions given the nature of the emer
tients, and frustrates clinicians. Testicular ultrasound is
gency. Furthermore, following a scrotal traumatic in
here of primordial importance. Exceptionally it can
jury, existence of a large distended scrotum must lead
evidence lesions susceptible to explain pain, but most
without delay to surgery which will permit evacuation
often it demonstrates an indernn testicle and envelopes
of the hematoma, an evaluation oflesions, and repara
which allows reassuring of the patient. Put into the
tion of the testicle.
patient's medical records, with this respect it has an
Indubitably, when satisfactory technical require
unquestionnable legal interest with regard to medical
ments are met for scrotal ultrasound and if it will not
care.
cause in the least a delay in surgery, it must be
encouraged to be performed. In fact, it permits lear Thus, in completing a careful clinical examination of
ning of the ultrasound semiology for these types of external genitalia, genital ultrasound results in diagnos
lesions through comparison of clinical, anatomical and tic precision, but in no way and under no pretext can
ultrasound information. be substituted for the rigorous discipline of careful
In cases other than emergencies, the value of scrotal examination of the scrotal contents.
and genital ultrasound is manifestly evident such as in
the following situations : Professor L. Boccon-Gibod
Foreword
This Atlas of scrotal ultrasound was conceived princi cian and Radiologist ; the acute scrotum, the chroni
pally as an aid to the daily clinical practice of Radiolo cally enlarged scrotum, the clinically normal scrotum
gists and Clinicians. The format of the Atlas has been with a suspected underlying tumour and infertility. The
influenced by this aim, namely the order of the chap concluding three chapters deal with the post-operative
ters and the short text supplemented by the tables and scrotum, intrascrotal calcifications and cystic structu
decision-making algorithms. The images form the lar res. These are arranged in the form of gamuts allowing
gest portion of the book. The text of each chapter is the ultrasonologist to easily make a differential diagno
deliberately separate from the images. Each image is sis when confronted with an intrascrotal calcification
illustrated by a clearly labelled diagram and detailed or cyst.
description. This layout enables the reader to refer to The Atlas is mainly concerned with pathology of the
the book to a variable level of detail. This may either adult scrotum, but several ultrasound examinations in
be a superficial reference to the anotated diagrams, infants are included to illustrate some of the congenital
perhaps encompassing the Legends, or a more detailed anomalies.
reference including all the texts of each chapter. This It is not possible to conclude this preamble without
very pragmatic approach has led us to abandon any thanking all those who contributed to the preparation
reference to the bibliography. of this work. Firstly I would like to thank those
Clinicians who have had confidence in me, particularly
Duplex Doppler Ultrasound is not included in this
Professor L. Boccon-Gibod who provided me with the
Atlas of imaging for two reasons. The principal reason
essential link with a Urologist and Dr. J. Belaisch to
is that, despite the extreme interest in colour Doppler
whom I owe my training in the still poorly understood
at the moment, our own experience indicates that in
field of male infertility.
the vast majority of cases a good understanding of
I would also like to specially thank Professor
conventional ultrasound of the scrotum is sufficient to
H. Hricak who particularly wished to preface the
make the diagnosis and the role of Doppler is limited
English version of this Atlas. All this help and good
to confirming it. The second reason is the limited
will would not have been enough without the assis
availability of Doppler ultrasound equipment in many
tance of the Radiology Department where I routinely
places where it is reserved for vascular and abdominal
work at the Saint Antoine Hospital in Paris. A very
investigations.
special thanks to Professor J.M. Tubiana for his encou
The Atlas is divided into eight chapters. The first ragement and guidance during the preparation of this
chapter contains a review of the embryology and book as well as to all the ultrasound unit team with
ultrasound anatomy essential for the performance of which I use to work.
scrotal ultrasound and the understanding of congenital Finally I would like to express my love and thanks
anomalies which the Practitioner may encounter. The to my family, particularly my husband for all his help
following four chapters are concerned with the four despite all the restrictions imposed on us during the
major areas of pathology which present to the Clini- preparation of this Atlas.
Table of contents
Preface, Professor H. Hricak . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V
Preface of the french edition, Professor L. Boccon-Gibod ........ VII
0 • • •
Foreword . IX
0 0 0. 0 0 0 0 0 0 0 0 0 0 •• 0. 0 0. 0 0 0 0 0 0 ••••••• 0 ••• 0. 0. 0 0 0 0 0 0.......
Embryology ; technical notes and ultrasound anatomy
0 0 0 0 0 0 0 0 • 0 •••••
Review of the embryology
0 0 0 0 0 0 •• 0 • 0 ••• 0 0 0 0 • 0 0 0 0 0 0 0 0 0 • 0 • 0 ••••• 0 0 0 0 0
The outlines
0 0 0 0 0 0 0 0 0 0 •• 0 • 0 0 0 0 0 0 0 0 0 • 0 •••••••• 0 •• 0 • 0 0 0 0 0 0 0 0 •••••
Congenital anomalies 2
0 0 0 0 0 0 0 0 0 •••••••••• 0 0 0 • 0 0 0 0 0 0 0 ••••••• 0 0 • 0 0 ° 0
Dystrophic cysts 5
0 0 0 0 • 0 0 ••• 0 0 0 0 0 0 0 0 0 0 0 0 0 ••••• 0 •• 0 • 0 0 0 0 0 0 0 0 •••• 0 • 0
Ultrasound anatomy 5
0 0 0 0 0 0 0 0 0 ••••• 0 •• 0 • 0 • 0 0 0 0 0 0 0 0 0 0 •• 0 ••• 0 • 0 0 0 0 0 0 0 •
Technique and performance of the examination .. 5
0 0 0 0 0 0 0 0 0 • 0 ° 0 0 0 0 • 0 ° 0 0
The testis . 7
0 0 0 0 0 0 0 0 0 • • • 0 • • 0 0 • 0 0 0 0 0 0 0 0 0 • • • • • • 0 • • • 0 0 0 0 0 0 0 0 0 0 • • • • •
The excretory genital passages .. 7
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 • 0 • 0 • 0 • 0 0 0 0 0 0 0 0 0 0 0 0 0
The vessels ..... 9
0 ••••••••• 0 0 0 0 0 0 0 0 0 0 ••• 0 •• 0 0 • 0 0 0 0 0 0 0 0 • 0 0 • 0 •••• 0
The spermatic cord 11
0 0 • 0 • 0 0 0 0 0 0 ••• 0 • 0 •• 0 0 0 0 0 0 0 0 0 • 0 0 •••••• 0 •••• 0 0 0
The nerves II
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 •••• 0 •• 0 0 0 0 0 0 0 0 0 0 0 ••••••• 0 • 0 ••• 0 0 0 0 0
The investing layers of the scrotal sac . II
0 • 0 0 0 0 0 0 0 0 0 0 •••••••• 0 • 0 • 0 0 0 0 0 °
The acute scrotum ... 21
0 • 0 •• 0 • 0 0 0 0 0 0 0 0 0 0 ••• 0 0 0 • 0 0 0 0 0 0 0 0 0 0 • 0 ••••• 0 • 0
Inflammatory conditions of the scrotal contents 21
0 0 0 0 0 0 0 0 0 ••••••••• 0 0 0 • 0 0 °
Torsions of the spermatic cord 23
0 0 0 0 0 0 0 ••• 0 • 0 0 0 0 0 0 0 0 0 0 0 0 ••••••• 0 0 0 0 0 0 °
Testicular tumors 23
0 0 0 0 0 • 0 0 0 0 0 0 0 0 0 • 0 0 0 0 0 0 0 0 0 0 0 0 0 0 •• 0 0 0 0 0 0 • 0 0 0 ° 0 0 0 0 0 0
Ultrasound findings . 24
0 0 0 0 0 0 0 0 0 • 0 • 0 0 0 0 0 0 • 0 0 0 0 0 0 • 0 0 0 0 0 0 0 0 •• 0 0 0 ° 0 0 0 0
Traumatisms 24
0 0 0 0 0 0 0 0 0 0 0 0 0 0 • 0 0 0 0 0 0 0 0 • 0 0 0 0 0 0 0 0 0 0 0 0 0 0 •• 0 • 0 ° 0 0 0 0 •• 0 0 °
Ultrasound findings 24
0 0 0 0 0 0 0 0 0 0 • 0 0 0 0 0 0 0 0 0 0 0 0 0 0 • 0 0 0 0 0 0 0 0 • 0 • 0 0 ° 0 0 0 0 0
The chronically enlarged scrotum 57
0 0 0 0 0. 0 0 •• 0 ••••••• 0 0 0 0 0 0 0 0 0 •• 0. 0 0.
Hydroceles 57
0 0 0 0 0 0 0 0 0 0 0 • 0 •• 0 • 0 •• 0 • 0 0 0 0 0 0 0 0 0 0 0 0 0 0 • 0 •• 0 •••••• 0 0 0 0 0 0 0
Definition 57
0 0 0 0 0 0 • 0 ••••••• 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 • 0 •••••• 0 • 0 0 0 0 0 0 0 0
Ultrasound findings and characteristics of a hydrocele 57
0 0 0 0 ••••••• 0 0 0 0 0 0 0
Associated signs 58
0 0 0 0 0 0 0 • 0 0 0 0 0 • 0 • • 0 0 • 0 0 0 0 0 0 • 0 • 0 0 0 0 0 0 0 0 0 0 0 • • 0 0 • • • •
Testicular tumours 59
0 0 0 0 0 0 •• 0 0 0 0 0 ••• 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 • 0 0 • 0 0 •• 0 • •
Ultrasound diagnosis . 59
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 • 0 • 0 • 0 0 0 0 0 0 0 0 0 0 0 • 0 •
Follow-up 60
0 0 0 0 0 0 0 0 ••••••• 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 • 0 ••• 0 0 0 0 0 0 • 0 0 • • • • •
Tumours and pseudo tumours of the testicular appendages . 60
0 0 0 0 • • • • • • • • • • • •
Tumours of the testicular appendages 60
0 0 0 0 0 0 • 0 0 0 ••••• 0 0 0 • 0 0 •••••• 0 0 0 0
Adenomatoid tumour 60
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 • 0 •• 0 • 0 ••• 0 0 0 0 0 • 0 0 0 0 0 0 0 0 0 0 0 0
Fibrous pseudotumour 61
0 0 0 • 0 • 0 0 ••••••••••• 0 • 0 0 0 0 • 0 •••• 0 0 ••••••••• 0
Cystadenoma of the head of the epididymis ....... 61
0 0 0 0 ••• 0 0 0 • 0 •••• 0 0 0
Rhabdomyosarcoma 61
0 • 0 •• 0 • 0 • 0 0 •••••••• 0 0 0 0 0 0 0 • 0 •• 0 • 0 0 ••••• 0 0 0 • • •
Mesothelial hyperplasia and mesothelioma of the tunica vaginalis 61
0 0 0 0 0 0 0 0 0
Pseudotumours 6 1
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 • • • • • • 0 0 0 0 0 • • 0 0 • 0 0 0 0 0 0 0
XII Table of contents
Impalpable testicular tumours within a clinically normal scrotal sac 91
Investigation of the aetiology of lymphadenopathy . . . . . . . . . . . . . . . . . . . . . . . 91
Investigation of the aetiology of gynaecomastia . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Unexplained and persistent scrotal pain in a young adult . . . . . . . . . . . . . . . . . . 92
Male infertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
The concept of genital ultrasound . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 1
Indications for genital ultrasound . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 1
The important steps in the performance of genital ultrasound . . . . . . . . . . . . . . 10 2
Examination of the scrotum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
Examination of the pelvis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
Post-surgery scrotal sac . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
Surgery of the testis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 3
Orchidectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 3
Orchidopexy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
Lowering of ectopic testes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
Tumourectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 5
Surgery of the testicular appendages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 5
Tunica vaginalis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 5
Epididymis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
Vas deferens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
Surgery of infertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
Varicocelectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
Epididymo-deferential anastomosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
Neo-spermatocele . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
Calcifications of structures within the scrotum
and the periscrotal region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
Gamut of the causes of calcifications of the testicular appendages
in relation to their localisation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 7
Gamut of the causes of calcification within the testis . . . . . . . . . . . . . . . . . . . . . 15 8
Gamut of the causes of calcification of the penis . . . . . . . . . . . . . . . . . . . . . . . . 158
Principal types and characteristics of calcified lesions
of the testicular appendages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 8
Cystic structures of the scrotal contents . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 5
Ultrasound appearances of an intra-scrotal cystic lesion . . . . . . . . . . . . . . . . . . . 17 5
Criteria of a simple cyst . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 5
Cyst of/or in the region of the epididymis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176
Congenital cysts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 6
Acquired cysts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . l 7 6
Cysts of the tunica vaginalis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 6
Cysts of the spermatic cord . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 6
Cysts of the tunica albuginea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 6
Cysts of the testicular parenchyma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 6
Alphabetical index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
