1. Doppler ultrasound of acute scrotum
Samir Haffar M.D.
Assistant Professor of Internal Medicine
2. Doppler ultrasound of acute scrotum
• Normal anatomy of scrotum
• Normal US of scrotum
• Normal Doppler US of scrotum
• Doppler US of acute scrotum
3. Diagrammatic representation
of testis in cross-section
Dogra et al. Ultrasound Clin 2006 ; 1 : 55 – 66.
250 – 400 lobules
Each lobule contains 1 – 3 seminiferous tubules
Sspermatocyte – Sertoli cell – Leydig cell (testesterone)
4. Rete testis within mediastinum testis
Carkaci S et al. J Clin Ultrasound 2010 ; 38 : 21 – 37.
Rete testis drains into epididymis through 10 – 15 efferent ductules
Epididymis consists of head, body, & tail
Tail of epididymis continues as vas deferens
5. Anatomy of epididymis
6 cm in length – Best evaluated in longitudinal view
• Head Superior pole of testes
5 – 12 mm Usually isoechoic to testis
• Body Posterolateral aspect of testis
2 – 4 mm Usually hypoechoic to testis
• Tail Inferior pole of testes
5 – 12 mm Usually hypoechoic to testes
Curves to form ductus deferens
Lee JC et al. Ultrasound Quarterly 2008 ; 24 : 3 – 16.
6. Arterial supply & venous drainage of scrotal contents
Zwiebel WJ et al. Introduction to vascular ultrasonography.
Elesevier Saunders, Philadelphia, USA, 5th edition, 2005.
8. Wittenberg AF et al. Curr Probl Diagn Radiol 2006 ; 35 : 12 – 21.
Testicular artery
Deferential artery
Cremasteric artery
Pampiniform venous plexus
Vas deferens
Genito-femoral nerve
Components of spermatic cord
9. Doppler ultrasound of acute scrotum
• Normal anatomy of scrotum
• Normal US of scrotum
• Normal Doppler US of scrotum
• Doppler US of acute scrotum
10. Equipment
Canadian Association for Radiologists
• Real time linear or curved linear transducers
• Highest frequency: 7 MHz or higher
• Sufficient resolution to detect characteristics of lesions
• Highest possible Doppler frequencies: 5 to 10 MHz
• Total US exposure as low as reasonably achievable
ALARA principle
• Standoff pads can be used to improve imaging
www.car.ca
Atri M et al. CAR standard for performing scrotal ultrasound examinations. April 28, 2011
11. Sonographic technique of scrotum – 1
• Supine position & scrotum supported by towel
• Testes examined in two planes: longitudinal & transverse
• Skin thickness in each hemi-scrotum evaluated
• Color & pulsed Doppler optimized for low-flow velocity
• Compare both testes for size, echogenicity & vascularity
• Compare both epididymis for size, echogenicity & vascularity
Dogra et al. Ultrasound Clin 2006 ; 1 : 55 – 66.
12. Scanning technique of scrotum – 2
• Bilateral testicular spectral Doppler tracings recorded
• Palpable scrotal lesion Palpate lesion & put probe on it
• Acute scrotum Asymptomatic side scanned first
Power Doppler also used
• Tumor of testis found Search for abdominal adenopathies
• Additional techniques Valsalva or upright positioning
Dogra et al. Ultrasound Clin 2006 ; 1 : 55 – 66.
13. Tunica vaginalis
Scrotal wall thickness: Normal value 2 – 8 mm
Tunica vaginalis: Small amount of fluid between two layers
Tapping CR & Cast JE. Ultrasound 2008 ; 16 : 226 – 233.
14. Tunica albuginea
Echogenic line surrounding testis
Better visualized in presence of small amount of fluid
Dogra VS et al. Ultrasound Clin 2006 ; 1 : 55 – 66.
Longitudinal sonogram of testis
15. Normal adult testis
Length: 4 – 5 cm
Width: 2 – 4 cm
Antero-posterior: 3 cm
Cokkinos DD et al. Curr Probl Diagn Radiol 2011 ; 40 : 1 – 14.
Transverse viewLongitudinal view
16. Side-by-side comparaison image
Gray scale image Color Doppler
Median raphe
McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
18. Normal rete testis
Normal structure seen in 20% of patients
Hypoechoic striated appearance of rete testis
Finger-like projections into parenchyma
Adjacent to mediastinum testis
Wittenberg AF et al. Curr Probl Diagn Radiol 2006 ; 35 : 12 – 21.
19. “two-tone testes”
Stewart VR & Sidhu PS. Clin Radiology 2007 ; 62 : 289 – 302.
Portion nearest probe: normal testicular reflectivity
Portion distal to vessel: decreased testicular reflectivity
Refractive artefact through walls of trans-mediastinal vessels
Trans-mediastinal vessels causing „„two-tone‟‟ artefact
20. • Presentation Painless mass – More often on left
• Two types Type 1: reproductive potential
Type 2: no reproductive potential
• Association Cryptorchidism, indirect inguinal hernia,
hydrocoele, microlithiasis, rete testis, cancer
• US features Well-defined testis with identical reflectivity
Color Doppler as ipsilateral testis
Mediastinum observed helps in diagnosis
• Management Conservative
Polyorchidism
100 reported cases – More than two testes
Stewart VR & Sidhu PS. Clin Radiology 2007 ; 62 : 289 – 302.
21. Polyorchidism
Fewer than 100 reported cases
Carkaci S et al. J Clin Ultrasound 2010 ; 38 : 21 – 37.
Normal vascularity in
both left testes
Color Doppler USCoronal gray-scale US
Normal right testis
Two normal left testes
Two testes on left
Normal right testis
T2-weighted MRI
22. Normal epididymis
Deurdulian C et al. RadioGraphics 2007 ; 27 : 357 – 369.
Normal epididymal head
Isoechoic to testis
Sagittal US image
Normal epididymal body & tail
Hypoechoic to testis
Coronal US image
23. Scrotal appendages
Sellars MEK et al. Eur Radiol 2003 ; 13 : 127 – 135.
Appendix testis: Upper pole of testis – 90%
Appendix epididymis: Head of epididymis – 6%
On occasion, both appendages may be seen in same patient
5 scrotal appendages formed during development
24. Testicular appendages
Detectable only when hydrocele is present
Woodward PJ et al. RadioGraphics 2003 ; 23 : 215 – 240.
Appendix testis
Upper pole of testis
Müllerian duct remnant
Appendix epididymis
Head of epididymis
Mesonephric remnant
25. Doppler ultrasound of acute scrotum
• Normal anatomy of scrotum
• Normal US of scrotum
• Normal Doppler US of scrotum
• Doppler US of acute scrotum
26. Doppler ultrasound of scrotum
• Color, power & spectral Doppler
• Low flow settings
• Identical Doppler settings to evaluate symmetry of flow
Flow in symptomatic side vs asymptomatic side
• If color Doppler imaging cannot detect flow
Use of power Doppler to increase flow sensitivity
27. • Increased gain
• Decreased PRF
• Small color box
• Low wall filter
Low flow settings
28. Side-by-side comparaison image
Color Doppler image
McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
Important component of each testicular examination
29. Prominent trans-mediastinal artery & vein
Normal variant
Branch of testicular artery traverses toward center of testis
Seen unilaterally in 50% or bilaterally in 25%
Usually in superior half of testis
Usually accompanied by large vein
Stewart VR & Sidhu PS. Clin Radiology 2007 ; 62 : 289 – 302.
30. Centripetal artery & recurrent rami
Centripetal artery coursing toward mediastinum
Then curving back as recurrent rami
Transverse color Doppler US of normal testis
Cindy A et al. J Diag Med Sonography 2006 ; 22 : 221 – 230.
31. Flow in intra-testicular, epididymal
& cremasteric artery
1 Dogra et al. Ultrasound Clin 2006 ; 1 : 55 – 66.
2 Schneble F et al. Ultraschall Med 2011 ; 32 : E51 – E56.
Low flow
High resistance
Cremasteric artery
High flow
Low resistance
Epididymal arteryIntra-testicular artery
High flow
Low resistance
Normal RI: 0.54 0.08 2
32. Color & power Doppler US in normal testis
68 normal children – 6 weeks to 13 years
Barth RA & Shortliffe LD. Radiology 1997 ; 204 : 389 – 393.
Power Doppler more sensitive than color Doppler
for detection of intra-testicular blood flow in children
• Color Doppler Intra-testicular blood flow in 88%
• Power Doppler Intra-testicular blood flow in 97%
• Combined Intra-testicular blood flow in 100%
33. Doppler ultrasound of acute scrotum
• Normal anatomy of scrotum
• Normal US of scrotum
• Normal Doppler US of scrotum
• Doppler US of acute scrotum
35. Acute scrotum
Inflammatory conditions
– Acute epididymitis Most common cause
– Acute orchitis
– Testicular abscess
– Cellulitis
– Fournier gangrene
Turgut AT et al. Ultrasound Clin 2008 ; 3 : 93 – 107.
36. Doppler US findings in epididymo-orchitis
Ultrasound
Direct signs Enlarged heterogenous epididymis
Enlarged heterogeneous testis
Indirect signs Reactive hydrocele or pyocele
Scrotal wall thickening
Doppler
Epididymal or testicular hypervascularity
High flow PSV > 15 cm/sec
Low resistance RI < 0.5
Easily detectable venous flow
Turgut AT et al. Ultrasound Clin 2008 ; 3 : 93 – 107.
37. Acute epididymo-orchitis
Turgut AT et al. Ultrasound Clin 2008 ; 3 : 93 – 107.
Increased vascularity of both
testis & epididymis
Heterogeneous epididymis & testis
Enlargement of epididymal head
Reactive hydrocele
38. Epididymo-orchitis / pyocele
Low-level echoes – Multiple septations
Thickening of overlying scrotal skin
Sidhu PS et al. European Course Book – Ultrasound of the scrotum – 2011.
European Foundation of Societies of Ultrasound in Medicine & Biology.
39. Epididymo-orchitis / Epididymal abscess
Sidhu PS et al. European Course Book – Ultrasound of the scrotum – 2011.
European Foundation of Societies of Ultrasound in Medicine & Biology.
Acute epididymitis not responding to anti-bacterial therapy
Focal area of mixed reflectivity containing debris
in epididymal head
40. Orchitis
• Causes Usually in patients with epididymitis
Primary orchitis (rare): mumps – HIV
• US 1. Edema: diffuse low reflectivity
2. Striated pattern
3. Venous infarction (hemorrhage)
Areas of mixed or increased reflectivity
• Complications Abscess – Infarction – Necrosis
• Evolution Resolve completely
Small testis with fibrosis: heterogeneous
Stewart VR & Sidhu PS. Clin Radiology 2007 ; 62 : 289 – 302.
41. Orchitis / Striated testis
Striated appearance
Small complex hydrocele
Gray-scale ultrasound
Significant hyperemia
Color Doppler US
Loberant N et al. Ultrasound Quarterly 2010 ; 26 : 37 – 44.
42. Complicated orchitis
Sidhu PS et al. European Course Book – Ultrasound of the scrotum – 2011.
European Foundation of Societies of Ultrasound in Medicine & Biology.
Predominantly low reflective testis
Multiple areas of high reflectivity
43. Causes of striated testis
• Prominent rete testis
• Orchitis
• Torsion
• Testicular fibrosis
• Trauma
• Neoplasm (lymphoma – leukemia)
Striated pattern without clinical findings & normal
color Doppler has no clinical importance
Loberant N et al. Ultrasound Quarterly 2010 ; 26 : 37 – 44.
44. Striated testis / Senile fibrosis
First described in 1996 1
1 Cohn EL et al. J Urol 1996 ; 156 : 180 – 181.
2 Loberant N et al. Ultrasound Quarterly 2010 ; 26 : 37 – 44.
Striated pattern without clinical findings & normal
color Doppler has no clinical importance
Striated atrophic right testis
Spectacle view US
Normal vascularity
Color Doppler image
45. Testicular abscess
• Cause Usually secondary to epididymo-orchitis
• Suspicion Testicular swelling persists after treatment
• US Irregular walls
Low level internal echoes
Hypervascular margins of lesion
Turgut AT et al. Ultrasound Clin 2008 ; 3 : 93 – 107.
Not distinguished from acute epididymitis at early stage
46. Testicular abscess
Hypervascular margin of lesion
No flow within lesion
Color Doppler USGray-scale ultrasound
Heterogeneous hypoechoic complex
collection within enlarged testicle
Wittenberg AF et al. Curr Probl Diagn Radiol 2006 ; 35 : 12 – 21.
70-year-old diabetic patient with acute epididymo-orchitis
47. Brucellosis
Genitourinary complications: 2 – 10% of patients
Lee JC et al. Ultrasound Quarterly 2008 ; 24 : 3 – 16.
Hypoechoic nodules within testis & epididymis
Small hydrocele
Gradual onset, longer duration, no leukocytosis, & positive serology
48. Cellulitis
4 day-old male with swollen penis & scrotum after circumcision
Skin thickening
Hyperemia of scrotal skin
Peri-testicular fluid collection
Sagittal sonogram
Bilateral scrotal abscesses incised & drained at surgery
Transverse sonogram
Increased flow around testis
Adjacent complex fluid collection
Sung T et al. Am J Roentgenol 2006; 186 : 483 – 490.
49. Fournier’s gangrene
Aggressive necrotizing fasciitis of perineum
• Presentation Males 50-70 years – Diabetes 50%
Soft-tissue gas detected as “crepitus”
• Delay of dg Onset of symptoms to diagnosis: 5 days
• US Scrotal wall thickening
Multiple pockets of gas: “dirty shadow”
Normal underlying testes
• Treatment Surgical resection of devitalized tissues
• Prognosis High morbidity & mortality rate
Stewart VR & Sidhu PS. Clin Radiology 2007 ; 62 : 289 – 302.
50. Fournier gangrene
Emergency – Prompt medical & surgical treatment
McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
Thickening
of scrotal skin Foci with dirty
shadowing (air)
US detects gas before it becomes clinically palpable
Normal testis
52. Presentation of acute testicular torsion
• Young patients: almost all under age of 20
• Sudden pain followed by nausea, vomiting, & low-grade fever
• Pain cannot be relieved by elevating the scrotum
• Swollen, tender, & inflamed hemi-scrotum
• Cremasteric reflex usually absent
• Transverse location of testis instead of vertical position
Dogra et al. Ultrasound Clin 2006 ; 1 : 55 – 66.
53. Salvage rate in acute torsion
• Within first 6 hours 100% salvage rate
• Within 6 to 12 hours 70% salvage rate
• Within 12 to 24 hours 20% salvage rate
Patriquin HB et al. Radiology 1993 ; 188 : 781 – 5.
54. Normal anatomy
Tunica vaginalis attached to posterior lateral aspect of scrotal wall
Prando D. Ultrasound Quarterly 2002 ; 18 : 41 – 57.
Extra-vaginal torsion
Less frequent
Peri-pubertal
56. Doppler US of acute testicular torsion
• US Enlarged testis
Normal or decreased echogenicity of testis
Multifocal hyperechogenicity of testis: infarction
Enlargement & nodularization of epididymis
Reactive hydrocele
Thickening of scrotal skin
• Doppler Complete (≥ 360 ) Absence of flow
Partial (< 360 ) Decreased flow& elevated RI
Prando D. Ultrasound Quarterly 2002 ; 18 : 41 – 57.
57. Acute torsion / less than 6 hours
Longitudinal view of left testis
Power Doppler
No flow to left testis
Spectacle US view
No abnormalities
Longitudinal view of right testis
Power & pulsed Doppler
Blood flow to right testis
58. Acute torsion / more than 6 hours
Heterogeneous echotexture
Areas of increased echogenicity
“hemorrhage”
Side-by-side image
Lack of flow within left testis
Color Doppler US of left testis
Stengel JW et al. Am J Roentgenol 2008 ; 190 : S35 – S41.
59. Acute torsion / Bell-clapper anomaly
Bilateral in most cases
Dogra et al. Ultrasound Clin 2006 ; 1 : 55 – 66.
Diagnosed by US in presence of moderate hydrocele
Hydrocele encircling distal third of spermatic cord
Testis
Hydrocele
Spermatic cord
60. Acute torsion / whirlpool sign of spermatic cord
Aso C et al. RadioGraphics 2005 ; 25 : 1197 – 1214.
Absence of color flow
Reactive hydrocele
Scrotal wall thickening
Right testis
Normal color flow
Left testis
Edematous spermatic cord
with anechoic structures
“dilated lymphatic vessels”
Right spermatic cord
61. Acute torsion / Incomplete or partial (< 360°)
Mernagh JR et al. Curr Probl Diagn Radiol 2004 ; 33 : 60 – 73.
Two weeks later
62. Acute torsion / Incomplete or partial (< 360°)
Prando D et al. Abdom Imaging 2009 ; 34 : 648 – 661.
Pulsed Doppler US
Increased RI Absent diastolic flow Reversed diastolic flow
Absent or reversed diastolic flow:
Severe epididymo-orchitis (venous infarction)
Scrotal trauma (venous occlusion)
63. Acute torsion / Torsion-detorsion syndrome
Intermittent left scrotal pain - Asymptomatic at examination
Dogra et al. Ultrasound Clin 2006 ; 1 : 55 – 66.
Increased blood flow to left testis
Left testis
Hyperemia with resolution of pain is highly suggestive
Right testis
Normal blood flow to right testis
64. Doppler US in acute testicular torsion
Normal color Doppler US does not exclude:
1. Early torsion
2. Partial torsion
3. Torsion/detorsion syndrome
If high clinical suspicion: repeat Doppler US in 1 – 4 hours
Datta V et al. Ultrasound Quarterly 2011 ; 27 : 127 – 128.
65. Conditions with decreased blood flow in testes
• Poor technical parameters
• Pediatric population: small testicular volume
• Large hydrocele & hematoma
• Marked scrotal edema: poor penetration of US
• Epididymo-orchitis resulting in testicular infarction (rare)
• Idiopathic testicular infarct (rare)
• Vasculitis: Polyarteritis nodosa – Lupus
• Protein S & antithrombin III deficiency
Dogra et al. Ultrasound Clin 2006 ; 1 : 55 – 66.
66. Testicular torsion mimic
Large hydrocele
Decreased blood flow to right testis
Pressure on testis from large hydrocele
Dogra et al. Ultrasound Clin 2006 ; 1 : 55 – 66.
Normal blood flow of
left testis
67. • Causes Idiopathic – Acute epididymitis – Trauma
Sickle cell disease – Hypercoagulable states
• Presentation Testicular pain
• US Low reflective area may be wedge-shaped
• Doppler Poor or absent color Doppler flow
• DD Malignant lesion: ↑ color Doppler flow
Segmental testicular infarction
dg made following orchidectomy for suspected tumor
Stewart VR & Sidhu PS. Clin Radiology 2007 ; 62 : 289 – 302.
68. Segmental testicular infarction / Round shape
Stewart VR & Sidhu PS. Clin Radiology 2007 ; 62 : 289 – 302.
Negative tumor markers – Regression in size on follow-up US
Focal mixed reflective area No color Doppler within lesion
Patient with underlying epididymitis
69. Segmental testicular infarction / Wedged shape
Saxon P et al. Emerg Radiol 2012 in press.
MRI or CEUS when Doppler US findings are equivocal
Gray-scale US
Low reflective wedged shape area
Color Doppler US
No power Doppler flow
70. Testicular appendigeal torsion
7 to 14 years old boys – Appendix testis (95%)
• Examination Firm nodule on upper testis
Bluish discoloration: “blue dot sign”
Cremasteric reflex still be elicited
• US Iso, hypo or hyperechoic appendix ≥ 5 mm
Peri-appendiceal blood flow
Reactive hydrocele (common)
Skin thickening (common)
Dogra et al. Ultrasound Clin 2006 ; 1 : 55 – 66.
Role of US: exclude torsion or acute epididymo-orchitis
72. Testicular appendigeal torsion
Hypoechoic extra-testicular mass
Peripheral hyperemia separate from epididymis
Resolved on follow-up
Dogra et al. Ultrasound Clin 2006 ; 1 : 55 – 66.
10-year-old boy with testicular pain
73. • CDU imaging is now the gold standard for diagnosis
• CDU imaging highly operator dependent
• Cut-off values Vein diameter 2 2.4 mm at rest
2.9 mm Valsalva
Reflux duration 1 sec – 2 sec
• Classifications Sarteschi Supine & standing
Dubin Supine
Idiopathic varicocele
15% of adult – Almost always on left – Bilateral in 30%
1 Liguori G et al. World J Urol 2004 ; 22 : 378 – 381.
2 Pilatz A et al. World J Urol 2011 ; 29 : 645 – 650.
74. Idiopathic varicocele
Reversed flow lasting longer than 1 - 2 seconds
Detected during Valsalva maneuver & resolved with its release
Turgut AT et al. Ultrasound Clin 2008 ; 3 : 93 – 107.
75. Sarteschi’s classification of varicocele
Supine & standing positions
Sarteschi LM. G Ital Ultrasonologia 1993 ; 4 : 43 – 9.
Examinations done in supine & standing positionsGrade 1 Reflux in inguinal channel only during Valsalva
Scrotal varicosity not evident in standard US study
Grade 2 Small varicosities extend to superior pole of testis
Diameters increase & venous reflux seen only during Valsalva
Grade 3 Vessels enlarged at inferior pole of testis only in standing position
No enlargement detected in supine position
Reflux observed only during Valsalva
Grade 4 Vessels appear enlarged in supine position
Dilatation increased in upright position & during Valsalva
Testicular hypotrophy common at this stage
Grade 5 Venous ectasia even in prone decubitus and supine positions
Reflux at rest & does not increase during Valsalva
76. Sarteschi’s classification/Grade 1
Pauroso S et al. J Ultrasound 2011 ; 14 : 199 – 204.
Reflux in vessels seen
only during Valsalva
Valsalva’s maneuver
No varicosity in inguinal channel
on standard US examination
Relaxing condition
77. Sarteschi’s classification/Grade 2
Pauroso S et al. J Ultrasound 2011 ; 14 : 199 – 204.
Small varicosities exhibiting
reflux only during Valsalva
Valsalva’s maneuverRelaxing condition
Small varicosities extend to
superior pole of testis
78. Sarteschi’s classification/Grade 4
Pauroso S et al. J Ultrasound 2011 ; 14 : 199 – 204.
Relaxing condition
Venous reflux evident in
basal condition
Venous diameter increases
during Valsalva
Valsalva’s maneuver
79. Sarteschi’s classification/Grade 5
Pauroso S et al. J Ultrasound 2011 ; 14 : 199 – 204.
Venous diameter does not
increases during Valsalva
Valsalva’s maneuverRelaxing condition
Venous reflux evident in
basal condition
80. • Presentation Testicular pain
• Association Extra-testicular varicocele: common – left
• US Anechoic structures from mediastinum testis
Involvement of sub-capsular veins described
• Doppler Vascular flow of venous type
• DD Cystic structures: Prominent rete testis
Intra-testicular cyst
Intra-testicular varicocele
Uncommon (< 2% in symptomatic population)
Stewart VR & Sidhu PS. Clin Radiology 2007 ; 62 : 289 – 302.
81. Intra-testicular varicocele
Color Doppler US
Valsalva maneuver
demonstrating color Doppler flow
Stewart VR & Sidhu PS. Clin Radiology 2007 ; 62 : 289 – 302.
Serpiginous structure in center of
testis with „„tumbling‟‟ echoes within
Gray-scale US
82. Secondary varicocele
Increased pressure on abdominal spermatic vein
Dogra VS et al. Radiology 2003 ; 227 : 18 – 36.
Non-compressible varicoceles on left or right:
Retroperitoneal evaluation for retroperitoneal mass
LRV evaluation for thrombus or tumor extension
• Hydronephrosis
• Cirrhosis with PHT
• Nutcracker phenomenon
• Abdominal & retroperitoneal neoplasm
83. Henoch-Schönlein purpura
Aso CE et al. RadioGraphics 2005 ; 25 : 1197 – 1214.
Scrotal wall thickening
Scrotal tunica thickening
Epididymal enlargement
Reactive hydrocele
Two days later
Typical purpuric lesions on both legs
84. Thrombosis of pampiniform plexus veins / rare
Turgut AT et al. Ultrasound Clin 2008 ; 3 : 93 – 107.
Thrombus within veins of
pampiniform plexus
Hypoechoic & thickened
vessel walls
34-year-old man presenting with acute scrotum
86. • Scrotal or testicular edema
• Testicular fracture or rupture
• Scrotal hematoma
• Scrotal hydrocele
• Scrotal hematocele
Most common findings of scrotal trauma
Turgut AT et al. Ultrasound Clin 2008 ; 3 : 93 – 107.
Several of which are usually concurrent
87. Testicular Trauma / Intra-testicular hematoma
Stewart VR & Sidhu PS. Clin Radiology 2007 ; 62 : 289 – 302.
2 hypoechoic lesions in right testis
Areas of rounded high reflectivity
Patient involved in motorcycle accident
Gray-scale US Color Doppler US
Absence of vascularity
Traumatic intra-testicular hematoma
88. Testicular Trauma / Tunica albuginea rupture
Turgut AT et al. Ultrasound Clin 2008 ; 3 : 93 – 107.
Discontinuation of tunica albuginea (arrows)
Protrusion of testicular contents from ruptured tunica (arrowheads)
Associated scrotal wall hematoma (asterisk)
Necessitates emergent surgery
89. Testicular Trauma / Fracture line
Fracture line through mid-aspect of testis
Sidhu PS et al. European Course Book – Ultrasound of the scrotum – 2011.
European Foundation of Societies of Ultrasound in Medicine & Biology.
90. Testicular trauma / Hematocele
Kurian R & de Bruyn R. Ultrasound 2006 ; 14 : 216 – 222.
Turgut AT et al. Ultrasound Clin 2008 ; 3 : 93 – 107.
Large left hydrocele
Containing multiple echoes within
Acute hematocele Chronic hematocele
Complex peritesticular collection
Thick internal septations
Compressing ipsilateral testis
91. Evolution of testicular hematoma
Longitudinal view 2 weeks later
Hematoma has largely resolved
Poorly defined hypoechoic area
representing hematoma
McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
Longitudinal US view Longitudinal US two weeks later
95. Doppler US of testicular tumors
• Usual appearance
Homogenous & low reflectivity
• Wide range of appearances
High reflectivity
Heterogeneous with calcification & cystic changes
• Doppler US
Increased vascularity even in small tumor (new transducers)
Sidhu PS et al. European course book: Ultrasound of the scrotum.
European Foundation of Societies of Ultrasound in Medicine & Biology, 2011.
Distinguishing various cell types not practical
Any suspected mass prompts orchiectomy or surgical biopsy
96. Classic testicular seminoma
Hypoechoic – Homogeneous
Gray-scale US
Hypoechoic lobulated lesion
Power Doppler US
Mildly increased flow
Wittenberg AF et al. Curr Probl Diagn Radiol 2006 ; 35 : 12 – 21.
97. Testicular teratoma
Dogra VS et al. RadioGraphics 2001 ; 21 : S273 – S281.
Multiple cystic areas (2 - 15 mm)
Process involves nearly whole testis
dd: testicular tubular ectasia
Immature teratoma
Septated cystic lesion
Two solid nodules within
Mature teratoma
98. Burned-out germ cell tumor / Azzopardi scars
McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
Coarse calcification in lower pole
Longitudinal view of left testis
Retroperitoneal mass
Axial color view of abdomen
Grown quickly outstripping their blood supply
Appear as anything from small echogenic foci to hypoechoic masses
99. Sertoli cell tumor
Sidhu PS et al. European Course Book – Ultrasound of the scrotum – 2011.
European Foundation of Societies of Ultrasound in Medicine & Biology.
Well defined tumor with linear wall calcification
100. Peutz-Jeghers syndrome
Aso C Eet al. RadioGraphics 2005 ; 25 : 1197 – 1214.
Melanin pigmentation of lips
Characteristic of Peutz-Jeghers
Several echogenic lesions
Burned-out Sertoli cell tumors
Bilateral
101. Para-aortic lymph node in testicular cancer
Enlarged para-aortic lymph node with cystic degeneration
Cokkinos DD et al. Curr Probl Diagn Radiol 2011 ; 40 : 1 – 14.
102. Testicular macro-calcification
• Benign lesion Intra-testicular cyst
Epidermoid cyst
Sertoli cell tumor
Granulomatous disease of testes
• Malignant lesion “burnt-out” tumor
Primary testicular tumor
Sidhu PS et al. European Course Book – Ultrasound of the scrotum – 2011.
European Foundation of Societies of Ultrasound in Medicine & Biology.
103. Testicular microlithiasis
Bright foci of 1 – 2 mm without acoustic shadowing
Stengel JW et al. Am J Roentgenol 2008 ; 190 : S35 – S41.
Limited: < 5 microliths per US field
Classical: > 5 microliths per US field
Relative risk of concurrent neoplasm 20 fold
Annual sonographic examination
105. Non-Hodgkin lymphoma
< 1% of patients with lymphoma
Hypoechoic mass replacing
most of testis
Longitudinal view of right testis
Blood flow in tumor
Color Doppler US
106. Testicular metastases
Malignant melanoma
Robertson E & Baxter G. Ultrasound 2010 ; 18 : 86 – 88.
Hypervascularity of hypoechoic areas
Blood flow of tumor deposits
Color Doppler imageGray-scale image
Multiple hypoechoic lesions
Highly suspicious of tumor deposits
107. • Presentation Mass which may be painful
• Involvement Most commonly involves epididymis
Solitary testicular involvement uncommon
• US Low reflective focal lesions
• DD Primary testicular malignancy
Clinical evidence of sarcoid elsewhere
Multiple focal lesions
Epididymal involvement
Stewart VR & Sidhu PS. Clin Radiology 2007 ; 62 : 289 – 302.
Genital sarcoidosis
Multi-system disorder – Non-caseating epitheloid granulomas
108. Testicular sarcoidosis
Recent diagnosis of sarcoidosis from skin lesion biopsy
Multiple hypoechoic areas within testis & epididymis
Lee JC et al. Ultrasound Quarterly 2008 ; 24 : 3 – 16.
109. Testicular adrenal rests
Essential to recognize (avoid unnecessary orchidectomy)
• Cause Congenital adrenal hyperplasia
More commonly 21-hydroxylase deficiency
• US Multiple hypoechoic areas near mediastinum
Usually bilateral
Frequent epididymal involvement
• Doppler Hypervascular: vessels course without θ changes
• DD Bilateral malignant tumors: rare (2 – 3%)
110. Adrenal rest / Adrenal remnants
Aso CE et al. RadioGraphics 2005 ; 25 : 1197 – 1214.
Nodule in epididymal head
Several hypoechoic lesions in upper pole of testis
111. • Presentation Painless lump – Most common on left
• US Homogeneous hypoechoic mass
Difficult to separate from testis
• Doppler Central vascular pattern toward periphery
Disorganized pattern in primary tumor
• DD Testicular tumor
99mTc-sulphur colloid scan diagnostic
Spleno-gonadal fusion
Accessory spleen in pelvis or scrotum fused to gonadal organs
Stewart VR & Sidhu PS. Clin Radiology 2007 ; 62 : 289 – 302.
112. Spleno-gonadal fusion
Stewart VR & Sidhu PS. Clin Radiology 2007 ; 62 : 289 – 302.
Color Doppler US
Ordered vessels at central aspect
Splenic tissue at histology
Iso-echoic lesion at upper pole
Simulating primary testicular tumor
Gray-scale US of left testis
114. Cyst of tunica albuginea
Ma OJ et al. Emergency ultrasound, 2nd edition.
Bhatt S et al. Diagn Interv Radiol 2011 ; 17 : 52 – 63.
Alvarez DM et al. J Clin Imaging Sci 2011 ; 1 : 5 -
Partially calcified cyst
of tunica albuginea
Well defined cyst
Posterior enhancement
Tunica albuginea cyst
with milk of calcium
115. Cyst of tunica vaginalis
Tunica vaginalis cyst visible in presence of hydrocele
Sidhu PS et al. European Course Book – Ultrasound of the scrotum – 2011.
European Foundation of Societies of Ultrasound in Medicine & Biology.
116. Intra-testicular simple cyst
≥ 40 years – Solitary – Near mediatinum
• Causes Congenital, post-trauma, post-inflammatory
• Size 2 – 20 mm in diameter
• Association Extra-testicular spermatocele
• Examination Usually not palpable – Not firm even if large
• US Anechoic, thin wall, posterior enhancement
• Treatment No treatment
Palapable cyst should be removed 2
1 Dogra VS et al. RadioGraphics 2001 ; 21 : S273 – S281.
2 Hamm B et al. Radiology 1988; 168 : 19 – 23.
117. Intra-testicular cyst
Anechoic lesion – Imperceptible wall – Posterior enhancement
Surrounding thin rim of testicular parenchyma → intratesticular cyst
Search for wall irregularity which may suggest cystic tumor
Kim W et al. RadioGraphics 2007 ; 27 : 1239 – 1253.
118. Epidermoid cyst
Mistaken for malignancy if absence of classic US findings
• Manifestation Painless mass in 20 – 40 year old patient
• US features Varies with degree of maturation
Type 1 „„Onion-ring‟‟ – Suggestive – Teratoma
Type 2 Densely calcified mass
Type 3 Cyst with rim & peripheral/central calcification
Type 4 Mixed pattern: heterogeneous & poorly defined
Suggestive No color Doppler flow - Negative tumor markers
• Treatment Enucleation – Orchidectomy (often performed)
Stewart VR & Sidhu PS. Clin Radiology 2007 ; 62 : 289 – 302.
119. Intra-testicular epidermoid cyst
Stewart VR & Sidhu PS. Clin Radiology 2007 ; 62 : 289 – 302.
Stengel JW et al. AJR 2008 ; 190 : S35 – S41.
“Onion-ring‟‟appearance
Layers of compacted keratin
Well-circumscribed mass
Thick hyperechogenic wall
Heterogeneous with sonolucent center
120. Tubular ectasia of rete testis
Benign – Very common – > 50 years – Bilateral in 1/3
• Causes Epididymal obstruction (infection – trauma)
Post-vasectomy patients
• US Multiple hypoechoic oval structures
Located in mediastinum testes
Absence of color Doppler flow
• DD Intra-testicular varicocele
Cystic dysplasia of testes: congenital
Cystic malignant tumor: Teratoma
Stewart VR & Sidhu PS. Clin Radiology 2007 ; 62 : 289 – 302.
121. Tubular ectasia of rete testis
Frequent association with spermatocele or epididymal cyst
Turgut AT et al. Ultrasound Clin 2008 ; 3 : 93 – 107.
Fluid-filled dilated tubular structures
Nearby intra-testicular cyst
Sagittal gray-scale US
122. Cystic dysplasia of testes
Rare – Congenital – Renal malformation
Enlarged testis
Multiple irregular anechoic areas
measuring few millimeters each
Pathology specimen
showing multiple cysts
McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
123. Epididymal cyst
Common (20 – 40% of asymptomatic men)
Lee JC et al. Ultrasound Quarterly 2008 ; 24 : 3 – 16.
Epididymal tailEpididymal bodyEpididymal head
Indistinguishable
from spermatocele
124. Spermatocele
Cystic dilatations of efferent ductules
Well defined cyst in epididymal head – Fluid debris level
Typical of spermatocele
Lee JC et al. Ultrasound Quarterly 2008 ; 24 : 3 – 16.
Differentiate spermatocele from epididymal cyst by US not possible
126. Inguinal hernia
Turgut AT et al. Ultrasound Clin 2008 ; 3 : 93 – 107.
Bowel loop herniation into scrotum
Increased tunical fluid surrounding the testis
Diagnosis supported by visualization of peristaltic activity
Fluid
Hernia Testis
127. Complications of inguinal herniorrhaphy
• Hernia recurrence
• Epididymo-orchitis
• Hematoma Inguinal canal & scrotum
• Testicular ischemia Rare - more in recurrent hernia repair
McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
128. Scrotal wall edema
Marked thickening of scrotal wall
Following inguinal hernia repair
Sidhu PS et al. European Course Book – Ultrasound of the scrotum – 2011.
European Foundation of Societies of Ultrasound in Medicine & Biology.
129. Testicular ischemia
after inguinal hernia repair
Dellabianca C et al. J Ultrasound 2011 ; 14 : 205 – 207.
No intra-testicular vascular signal
Cremasteric vessel hypertrophy
Inhomogeneous hypoechoic testis
Bowel loop in scrotum
(recurrence of hernia)
131. Acute idiopathic scrotal edema
• Etiology Possible allergic origin
• Presentation From 4 months to 18 years
Sudden onset of non-hemorrhagic edema
Redness of scrotal wall
• US Scrotal walls thickening & hypervascularity
Characteristic findings
• Evolution Resolves spontaneously in 3 – 4 days
One or more relapses in next years
• Treatment Conservative
Aso CE et al. RadioGraphics 2005 ; 25 : 1197 – 1214.
Halb C et al. Ann Dermatol Vénéréol 2010 ; 137 : 775 – 781.
132. Acute idiopathic scrotal edema
Aso C Eet al. RadioGraphics 2005 ; 25 : 1197 – 1214.
Marked thickening of scrotal walls
Normal testes & tunicae
Increased vascularity seen at color Doppler imaging
1-year-old boy
Testes are ovoid in shape with medium-level echoes and measure 5×3×2 cm each. Tunica albugineais the fibrous covering of the testicle and is covered by the tunica vaginalis. The tunica albuginea can be seen with a high-frequency transducer as an echogenic line. Septa extend from the tunica albuginea into the testicle, dividing the testis into 250 to 400 lobules. The posterior surface of the tunica albuginea is reflected into the interior of the testis, forming the incomplete septum known as the mediastinum testis. Sonographically, the mediastinum testis is seen as an echogenic band running in a cephalocaudal direction. Each lobule consists of one to three seminiferous tubules supporting the Sertoli cells, Leydig cells sceretingtestesterone and the spermatocytes that give rise to sperm. The seminiferous tubules open through the tubulirectiinto dilated spaces called the rete testis within the mediastinum.
The rete testis drains into the epididymis through 10 to 15 efferent ductules. The epididymis, consisting of a head, body, and tail, is located superior to and is contiguous with the posterior aspect of the testis.The tail of the epididymis continues as the vas deferens.
Testicular artery Arise from aorta Supply testis High flow – Low resistanceDeferential artery Arise from vesical artery Supply epididymis & vas deferens High flow – Low resistance Cremasteric artery Arise from inferior epigastric artery Supply wall of scrotum Low-flow – high-resistancePampiniform venous plexus is the draining vein of the testicle, which forms around the upper half of the epididymis and continues into the testicular vein through the inguinal ring.The right testicular vein empties into the IVC and the left testicular vein drains into the left renal vein.
Anterior & posterior epididymal artery arise from testicular artery.
The scrotum is divided into right and left halves by a fibrous septum called the “median raphe”. Each testis is able to move in the scrotum by the presence of the tunica vaginalis, which has two layers, a visceral layer attached to the surface of the testis and a parietal layer attached to the scrotal wall. A minute amount of fluid is interposed between the two layers. This is similar to the visceral and parietal pleura. The tunica vaginalis does not cover the posterior aspect of the testis at its attachment to the scrotal wall.
Even if infection and torsion are not clinically suspected, a sonographic evaluation of testicular blood flow must be routinely included.
Each testis is able to move in the scrotum by the presence of the tunica vaginalis, which has two layers, a visceral layer attached to the surface of the testis and a parietal layer attached to the scrotal wall. A minute amount of fluid is interposed between the two layers. This is similar to the visceral and parietal pleura. The tunica vaginalis does not cover the posterior aspect of the testis at its attachment to the scrotal wall.
Low resistance flow in the epididymis because anterior & posterior epididymal arteries originate from testicular artery.
One study demonstrated that the resistive index of testes of healthy volunteers is rarely less than 0.5More than half of patients with epididymo-orchitis, the resistive index is less than 0.5.Use of a peak systolic velocity threshold of 15 cm/s results in a diagnostic accuracy of 90% for orchitis & 93% for epididymitis.
Sexually transmitted Chlamydia trachomatisand Neisseria gonorrhea are frequent pathogens in men younger than age 35. In prepubertal boys and men older than age 35, the disease is most frequently caused by Escherichia coli and Proteus mirabilis.Acute epididymitis first affects the tail of the epididymis in retrograde spread of infection from the bladder and prostate via vas deferens.If there is continued progression, it involves the body and head of the epididymis and, eventually, the testes. Orchitis develops in 20% to 40% of cases of epididymo-orchitis by direct spread of infection. Isolated orchitis is rare and is generally due to viral causes such as mumps, human immunodeficiency virus (HIV) or due to post-traumatic inflammation.
Linear bands of varying appearance radiate within the testis perpendicular to its long axis, in a similar orientation to the testicularfibrous septae. These striations may be hypoechoic against normal background of low-level echoes or may appear as hypoechoic & hyperechoic bands. First described in 1996, striated testis may be unilateral or bilateral, may involve a portion or the entire testis, and may be seen in a symptomatic or asymptomatic testis.
Scrotal wall cellulitis can develop in obese, diabetic, or immunocompromised patients. Clinically, the scrotum is swollen, tense, warm, and red. Sonographic features: increased scrotal wall thickness & hypoechoic areas showing hypervascularity on color Doppler US.Scrotal wall cellulitis may progress to form scrotal abscess that usually is identified by presence of irregular walls & low-level internal echoes
Differential diagnosis: 1- scrotal hernia with gas-containing bowel2- penetrating trauma to the scrotum
Degree of torsion can vary from one-quarter twist (90°) to up to three complete turns (1,080°) of the vascular pedicle.
Diffuse hypoechogenicity and enlargement when compared with the contralateral side.
The bell-clapper deformityThe tunica vaginalis completely encircles distal spermatic cord, epididymis & testis rather than attaching to posterolateral aspect of testis.
Arterial flow need not be absent for torsion to be present.Since venous obstruction usually precedes arterial obstruction (veins have thinner walls than the arteries and consequently are more sensitive to the compression), the early manifestation of the testicular torsion can be a diminished arterial velocity and a decreased diastolic flow with a consequently increased resistive index, indicating severe obstruction or occlusion to the outflow of blood.Evaluation of the Doppler waveform obtained in normal testicular arteries yielded an RI of 0.67 ± 0.07(range 0.50–0.80) [35] or a mean RI of 0.62 (range, 0.48–0.75).Reference: Siegel MJ (1997) The acute scrotum. RadiolClin North Am 35:959–976.
Firm palpable nodule on superior aspect of testisBluish discoloration on overlying skinCremasteric reflex still be elicited
Idiopathic varicoceles are more common on the left side where the left spermatic vein enters perpendicular to the left renal vein.The right spermatic vein enters obliquely into the inferior vena cava and this appears to have some protective effect on the right side.
Several classification systems have been proposed. The most widely used are the ones developed by Sarteschi which involves examinations done with the patient lying down and standing and distinguishes five different stages and by Dubin which requires examination of patients in supine position & includes three stages. Sarteschi classification: Grade 4:enhancement of venous reflux after Valsalva’smanoeuvre is the criteria that allows the distinction between this grade from the previous and the next one.
Nutcracker phenomenon: Compression of left renal vein between superior mesenteric artery and aorta.
Several systemic diseases can occur with scrotal involvement. The testes are affected in 15%–37% of patients with Henoch-Schoinleinpurpura. In this disease, scrotal symptoms may precede other manifestations. US findings include scrotal wall thickening, epididymal enlargement, and reactive hydrocele. Involvement is bilateral in the vast majority of cases; hence, this entity should be considered when bilateral US findings similar to those of inflammatory epididymitisare visualized.
The venous return of the left testicle may be impaired for various reasons, including the longer course of left spermatic vein & ‘‘nutcracker phenomenon’’ corresponding to entrapment of the left renal vein by the superior mesenteric artery anteriorly andthe aorta posteriorly. Theoretically this condition may, in turn, be a predisposing factor for stasis and thrombosis.
Potential complications of delayed diagnosisTesticular ischemic necrosisAbscessLoss of spermatogenesis
Discontinuity of the echogenic tunica albuginea is indicative of testicular rupture and necessitates emergent surgery
Scrotal massTwo important questions to answer.Is the mass intratesticular or extratesticular?Is the mass cystic or solid?A good rule of thumb is that intratesticular masses are malignant until proven otherwise, whereas extratesticularintrascrotal masses are generally benign.A second rule of thumb is that a solid lesion is malignant until proven otherwise,whereas cystic lesion is generally benign.
Ten percent of patients with testicular tumors present with acute scrotum, most likely from intratumoral hemorrhage.
Seminomatous is the most common tumor type accounting for approximately 50% of germ cell tumors. Seminomatoustumours occur almost exclusively in men in their 40s and rarely in younger men/boys.They have one of the best prognoses as they are sensitive to radiotherapy and chemotherapy. They are often associated with elevated b-human chorionic gonadotrophin hormone (bHCG). A large amount of the testis can be replaced by tumor; necrosis is common histologically and 10% have been shown to have cystic areas.Lymphatic spread to retroperitoneal lymph nodes and/or haematogenous spread to the lungs and/or brain can occur.
Much has been written about the sonographic appearance of the various malignant testicular tumors. Although of intellectual and academic interest, diagnosing and distinguishing among the various cell types is rarely of practical import to general radiologist because the finding of any potentially malignant mass within testicle generally prompts orchiectomy or at least biopsy.Percutaneous testicular biopsy should never be performed in the setting of intratesticular mass. Rare exception being the young leukemia patient with probable testicular leukemia.
Cystic teratomas may manifest as cystic massUsual appearance: inhomogeneous mass containing cystic & solid areas of various sizes which helps differentiate them from simple cysts.
Azzopardi:
First a brief word on testicular biopsy. Percutaneous testicular biopsy is technically feasible and is often performed in the evaluation of male infertility.However, percutaneous testicular biopsy should never be performed in the setting of an intratesticular massA rare exception being the young leukemia patient with probable testicular leukemia. Requests for percutaneous biopsy of a focal testicular mass generally arise from young trainees in academic centers (usually in the month of July). These requests should be courteously but emphatically denied, and the patient should be scheduled for an open biopsy in theoperating room. There, the urologist delivers the testicle via an inguinal approach before bivalve, random or ultrasound guidedbiopsy of the gland on a sterile towel. This way, if the testicular lesion is malignant, any potential tumor spillage occurs on the towel rather than into the patient, and long-term prognosis is significantly improved. Of note, recent reports from outside the United States state that percutaneous biopsy of focal testicular masses may be safe, but this should be avoided until further data are available and the standard of care allows this practice
Limited testicular microlithasis (LTM): < 5 microliths on one US image.Testicular microlithiasis can be associated with several conditions such as: CryptorchidismAlveolar microlithiasiscongenital urethroperineal fistulaKlinefelter syndromeGerm cell neoplasm.In our series, associated cryptorchidism was the most common (four of eight cases [50%]).
Testicular adrenal rests are hyperplastic adrenal cortical tissue originating from aberrant adrenal tissue that adheres to the gonads anddescends with the testes or ovary during the developmental stages.
Testicular adrenal remnants grow under adrenocorticotropic hormonesLeading to “adrenal rest tumors”Essential to recognize this association to avoid unnecessary orchidectomy.
Hamm et al stress the importance of palpability and claim that palpable intratesticular cysts should be removed.This recommendation would include simple cysts if they were palpable. However, Hamm et al reported that all of their cystic neoplasms (13 of 16, excluding three epidermoid cysts) except one had US features of complicated cyst. They did not encounter a cyst that appeared simple at US, was palpable, and turned out to be a neoplasm. Reference: Hamm B, Fobbe F, Loy V. Testicular cysts: differentiation with US and clinical findings. Radiology 1988; 168:19–23.
Epidermoid cysts are the commonest benign tumours arising from the testis though accounting for only 1-2% of all resected testicular masses.As the ultrasound findings are frequently non-specific, orchidectomy is often performed.
Also known as cystic transformation of rete testis.
Cystic dysplasia of the testis is a rare congenital malformation, usually found in children and occasionally in young adults, that consists of multiple small cysts, affecting part or the whole testis and originating in the mediastinal area. This disorder results in enlargement of the testis and atrophy of the remaining parenchyma. The dysplasia has been explained on the basis of an embryologic defect that prevented connection of the tubules of the rete testis with the efferent ducts. Of interest is the association of cystic dysplasia with renal agenesis, bilateral renal dysplasia, and duplication of the renal collecting systems. On ultrasound, it appears as an enlarged testis with multiple irregular anechoic areas measuring a few millimeters each.
Epididymal cysts contain clear serous fluid. The etiology of cyst formation is unclear. Trauma and epididymitis are implicated as possible contributory factors.
Almost always arise in the epididymal head.Low level echo within it. Indistinguishable from epididymal cysts when present within the epididymal head.
Causes of testicular ischemia: 1- Spermatic cord torsion: most common cause 2- Secondary to severe epididymitis with vessel compression3- Inguinal hernia repair4- Spontaneous thrombosis of funicular vessels5- Xanthogranulomatous or filarialfuniculitis