Search

Purpose: Contrast-enhanced ultrasound (CEUS) has been increasingly used for the diagnostic identification of neoplasms due to its ability to visualize the microvascularization of lesions. In the study of testicular abnormalities, the appropriate use of CEUS can improve the diagnostic accuracy of conventional gray-scale ultrasound and color Doppler ultrasound (CDUS). The purpose of this study is to comprehensively evaluate the diagnostic performance of CEUS in testicular space-occupying lesions., Methods: A comprehensive search of PubMed, Embase, Cochrane Library, and Web of Science databases was conducted from the inception of each database to November 16, 2022 for relevant studies. The required data were extracted, and the methodological quality of the studies was assessed using the QUADAS-2 tool. The diagnostic value of CEUS was assessed by calculating the combined sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio, and a summary receiver operating characteristic (SROC) curve was used to conduct this meta-analysis., Results: A total of six studies with 354 testicular space-occupying lesions were included in the analysis. The results showed that CEUS could provide additional useful information for the diagnosis of testicular space-occupying lesions, with a sensitivity of 0.92 (95% CI:0.82, 0.97), specificity of 0.91 (95% CI:0.80, 0.96), diagnostic odds ratio of 114 (95% CI:25, 528), respectively, and an overall diagnostic accuracy expressed as area under the SROC curve (AUC) of 0.97 (95% CI:0.95-0.98). Significant heterogeneity was seen in the sensitivity with I 2 = 82.53% (95% CI:69.44-95.61). Subgroup analysis revealed that the proportion of infertile patients selected may be the source of heterogeneity., Conclusion: CEUS can be used to diagnose testicular space-occupying lesions more accurately and improve diagnostic accuracy when the conventional US cannot accurately differentiate the type of lesion. In particular, CEUS should be recommended for the identification of microscopic lesions so that physicians can provide patients with more appropriate interventions to avoid unnecessary orchiectomy., (Copyright © 2024 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved.)

Scrotoliths, or "scrotal pearls," are calcified fibrous loose bodies found within the tunica vaginalis, often seen during radiological evaluation or autopsies. Chronic inflammation due to trauma, parasitic infestations, and torsion and subsequent detachment of the appendices of the testis or epididymis are postulated mechanisms suggested for their formation. They are benign but can mimic a tumor. Scrotoliths can be diagnosed with high-resolution ultrasonography. Here, we report a case in which, during routine dissection, two scrotoliths were found within the tunica vaginalis of the left testis in an elderly male cadaver. Histologically, the central portion of the scrotoliths exhibited concentric collagen lamellae that enclosed calcified remains of tissue debris. There were no arterioles, venules, or microfilarial larvae seen within them. Awareness about the histological findings can help understand the mechanism that led to their formation., (This is an open access article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

This report describes a boy in his early adolescence who was referred to a urologist with a large, painless right scrotal mass. Following a thorough workup, the patient underwent surgical removal of the mass, which was revealed to be a paratesticular fibrous pseudotumour (PFP) on histopathological analysis. This diagnosis is rare and can often prove difficult to distinguish from a malignant lesion within the scrotum. We have conducted a review of the current literature surrounding PFP to compliment the case discussion., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: This study aims to examine the clinical characteristics and surgical management of pediatric testicular epidermoid cysts, thereby contributing to the existing body of knowledge pertinent to the diagnosis and therapeutic intervention s for this condition., Methods: A retrospective analysis was conducted on the clinical records of 23 pediatric patients diagnosed with testicular epidermoid cysts, who were admitted to our institution between April 2013 and February 2024. Concurrently, a comprehensive review and analysis of pertinent literature were undertaken to augment the findings., Results: The mean age at which the onset of epidermoid cysts was observed was 6.0 years. All cases were singular and unilateral. B-ultrasound diagnosis categorized 6 cases as epidermoid cysts, 11 as teratomas, and 6 as indeterminate, yielding a diagnostic sensitivity of 26.1%. All patients underwent testicle-sparing mass resection, and nine patients underwent rapid intraoperative frozen section analysis, revealing eight cases of testicular epidermoid cysts and one teratoma, with a diagnostic sensitivity of 88.89%. Postoperative histopathological examination confirmed the diagnosis of testicular epidermoid cyst., Conclusions: Pediatric testicular epidermoid cysts are an uncommon occurrence, primarily presenting as a painless scrotal mass, which can mimic the clinical features of malignant testicular tumors. Imaging modalities and histopathological assessment are pivotal in the diagnostic process for pediatric testicular epidermoid cysts. For cases where B-ultrasound is inconclusive, rapid intraoperative pathological examination should be considered., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Testicular microlithiasis (TM) is thought to be associated with testicular tumors and impaired spermatogenesis; however, its etiology remains unclear., Objectives: To identify factors, other than testicular function, that are associated with testicular microlithiasis., Materials and Methods: We enrolled males who underwent ultrasound examination of the scrotum at Tokyo Dental College Ichikawa General Hospital. The patients were categorized into two groups: those with or those without testicular microlithiasis. Background and blood test data were compared between the groups., Results: Testicular microlithiasis was observed in 72 of the 828 (8.7%) patients enrolled. Ages ranged from 15 to 87 years (mean age, 40.0 years). A history of germ cell tumor was significantly more prevalent in patients with testicular microlithiasis than in those without (1.3 vs. 16.7%; p < 0.001). Blood test data showed that, patients with testicular microlithiasis had significantly higher serum creatinine levels (0.91 vs. 1.04 mg/dL; p = 0.046) and lower calcium levels (9.4 vs. 9.3 mg/dL; p = 0.031) than those without. Serum creatinine levels (> 1.00 mg/dL) and germ cell tumors were significantly associated with testicular microlithiasis in both univariate and multivariate analyses. The prevalence of testicular microlithiasis increased in patients older than 50 years. Age (> 50 years) was associated with testicular microlithiasis in univariate analysis. The mean body weight tended to be heavier (70.7 vs. 72.2 kg; p = 0.051) and epididymitis was observed more frequently (3.2 vs. 8.3%; p = 0.056) in patients with testicular microlithiasis than in those without., Discussion and Conclusion: A history of testicular tumors and elevated serum creatinine levels were associated with testicular microlithiasis. Testicular microlithiasis was observed across all age groups, with a tendency to increase in patients older than 50 years. Patients with testicular microlithiasis were slightly heavier and had a higher prevalence of epididymitis than those without. Our findings suggest that, in addition to testicular dysgenesis, other factors are involved in the development of testicular microlithiasis., (© 2023 American Society of Andrology and European Academy of Andrology.)

Contrast-enhanced ultrasound (CEUS) has emerged as a promising imaging modality for the characterization of hepatic and renal lesions. However, there is a paucity of data describing the use of CEUS for the evaluation of intra-scrotal pathology. In the following review, we describe the clinical utility of CEUS for the characterization and differentiation of common and uncommon intra-scrotal conditions, including testicular torsion, infection, trauma, and benign and malignant intratesticular and extratesticular neoplasms. In addition, we outline key principles of CEUS and provide case examples from our institution., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Objective: Klinefelter syndrome is the most common chromosomal disorder in males and the most common cause of hypergonadotropic hypogonadism. We describe the natural history of testicular dysfunction in patients with Klinefelter syndrome through the integration of clinical, hormonal, and quantitative ultrasound data in a life-course perspective., Design: Prospective semilongitudinal study., Methods: We included 155 subjects with 47,XXY karyotype (age range: 7 months-55 years) naïve to testosterone replacement therapy. Subjects were divided according to pubertal stage and age group (transition age and adults). Serial clinical, hormonal, and testicular ultrasound (US) assessments were performed., Results: Testicular development progresses until Tanner stage 4, with subsequent regression, whereas Sertoli and germ cell impairment is not hormonally detected before Tanner stages 3-4, as reflected by normal inhibin B values until stage 4 and the fall in the inhibin B/follicle-stimulating hormone ratio thereafter. The testosterone/luteinizing hormone ratio peaks during Tanner stages 2-3 and declines from Tanner stage 4 onward, preceding the development of overt hypogonadism. US echotexture progressively worsens until transition age, reflecting ongoing gonadal compromise, whereas quantitative US echotexture measures and the presence of both hypoechoic lesions and microlithiasis independently and significantly predict a lower circulating testosterone level., Conclusions: The findings from this large prospective study contribute to our understanding of the natural history of testicular dysfunction in Klinefelter syndrome, underlining the importance of quantitative testicular US in infancy and childhood, as well as during pubertal development and transition age, for the optimal care of Klinefelter syndrome patients., (© The Author(s) 2023. Published by Oxford University Press on behalf of the Endocrine Society.)

Background: Spontaneous idiopathic testicular hemorrhage is an extremely rare entity with few published reports in the literature., Case Presentation: We report a case of a 15-year-old boy who had been experiencing intense, left scrotal pain for the previous twelve hours. No previous history of trauma or bleeding disorders. The left testis was enlarged and tender. Left orchiectomy was performed. The entire testis was dusty and dark grossly. Microscopic sections show diffuse intratesticular bleeding with intact seminiferous tubules and spermatogenesis., Conclusions: Spontaneous idiopathic testicular hemorrhage should be considered when evaluating patients with acute scrotal pain. Clinical and ultrasonographic findings and histopathologic evaluation are mandatory to diagnose it., (© 2023. The Author(s).)

To present the results of testicular ultrasonography supported by clinical and hormonal aspects in paediatric patients with Klinefelter syndrome (KS). Prospective analysis of medical files of 20 patients diagnosed with KS between 2016 and 2022. Assessed data included analysis of causes of referral, ultrasound, and clinical characterisation with hormonal evaluation of serum FSH, LH, testosterone, inhibin B, and anti-Müllerian hormone. Non-mosaic Klinefelter syndrome (47, XXY) was diagnosed in 65% of cases (13/20) by the geneticist (including 7 cases prenatally), in 25% (5/20) by the endocrinologist and in 10% (2/20) by the hematologist. Ultrasound assessment revealed bilateral testicular microlithiasis (TM) in all patients. The youngest KS patient with TM was 3 months old. TM patterns have not changed during follow-ups of up to 6 years in any of the patients. In all KS patients markedly reduced echogenicity and in pubertal KS patients, also irregular echostructure of the testes was observed. The hormonal patterns observed in the study group were typical for those already described in KS. Sertoli and Leydig cell function was intact in prepubertal patients and deteriorated after the start of puberty., Conclusion: Although the degenerative process in the testicular tissue starts very early in the testes in KS and is reflected in morphological changes seen in ultrasonography, Sertoli and Leydig cell hormonal function is normal in prepubertal KS patients., What Is Known: • So far, normal Leydig and Sertoli cell function was observed in infants and prepubertal KS patients., What Is New: • The morphological changes in the testes in KS may already be seen in early infancy., (© 2022. The Author(s).)

Background: Testicular infiltration is infrequent in pediatric patients with leukemia and can be confused with other testicular conditions., Objective: To analyze the presence of clinical and radiological features suggestive of testicular disease and its histological association with leukemia infiltration., Method: Retrospective and analytical observational study that included patients with diagnosis of leukemia who underwent biopsy for suspected testicular infiltration. The relationship with the variables analyzed were diagnosis, reason for taking the biopsy, ultrasound findings, stage of treatment, induration, increased volume and pain, with testicular infiltration., Results: Eighteen patients were included; 11 of them with microlithiasis, of which one 1 reported infiltration (odds ratio: 0.075; p = 0.026), no association was found between ultrasound findings and the presence of infiltration. Clinical findings were significantly associated with positive biopsies., Conclusions: No risk association was found with the ultrasound findings such as microlithiasis and hypoechoic imaging. The clinically evident testicular disease (testicular enlargement and testicular induration) has a significant statistic association with the presence of leukemia infiltration., (Copyright: © 2023 Permanyer.)

Online supplemental material is available for this article.

Purpose: To analyze the association of testicular pathologies with TM., Method: The retrospective study included pediatric patients who underwent scrotal ultrasonography (US) due to complaints, including testicular pain, discomfort, swelling, scrotal redness in our clinic between June 2020 and January 2022. The patients were divided into two groups. Group 1; patients were diagnosed with testicular pathology or presented with testicular pain. Group 2; patients without testicular pathology or complaints. Patients were also classified as having undescended testis, epididymo-orchitis, varicocele and testicular pain without testicular pathology in group 1. Group 1 and subgroups of group 1 were compared with group 2 for the presence of TM., Results: A total of 516 patients were included in the study. Median age at the time of US examination was 24 months (range 1 month-17 years). There was no significant difference between groups 1 and 2, and boys with undescended testis and group 2 with regard to the presence of TM (p = 0.85, p = 0.55, respectively). TM was significantly higher in patients who had undergone orchiopexy and presented with testicular pain compared to group 2 (p = 0. 013, p = 0.03, respectively). TM was not detected in patients with epididymo-orchitis, varicocele., Conclusion: We found no association between TM and testicular pathologies. Testicular pain may be a symptom of microlithiasis., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Abstract: Polyorchidism, a very rare congenital anomaly, refers to the presence of more than 2 testes. It is often associated with many other pathologies including cryptorchidism, varicocele, testicular malignancy, and inguinal hernias.In this report, we describe a 40-year-old man who presented with an intermittently painful left groin, initially appearing as inguinal hernia. On ultrasound examination, a supernumerary testes and epididymis were found in the inguinal canal. The testes appeared sonographically normal with no evidence of associated pathologies. There was no evidence of an inguinal hernia containing fat or bowel.Ultrasound is essential in first-line diagnosis and classification of polyorchidism. Color Doppler ultrasound and magnetic resonance imaging can be used to clarify findings if sonographic images are inconclusive. We also review relevant literature as it pertains to classification, embryology, and treatment options. Patient treatment is based on imaging findings; if associated pathologies or malignancy is suspected, aggressive treatment such as surgical excision may be necessary. Otherwise, conservative treatment may be all that is needed., Competing Interests: The authors declare no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

A 28-year-old patient was admitted to radiology department due to a painless left-sided extra scrotal lump and discomfort in the ipsilateral lower inguinal region. Scrotal ultrasound revealed an oval circumscribed soft tissue mass, located in the proximity of the distal part of spermatic cord, without visible flow at Color Doppler. Scrotal MRI depicted T2 hyperintense, T1 hypo- to isointense oval mass with diffusion restriction and no fat suppression, surrounded by T1/T2 hypointense rim, located close to the spermatic cord. Additionally, MRI revealed coma-shaped T1 iso-/T2 hypointense related to the testicle formation. Following the intravenous administration of gadolinium-based contrast agent, both previously described structures enhanced. Taking into account that malignancy could be the potential complication of polyorchidism our patient was operated and histopathology confirmed supernumerary testicle with cribriform epididymal hyperplasia., (© 2021. Società Italiana di Ultrasonologia in Medicina e Biologia (SIUMB).)

Chronic orchialgia is a common disease in department of urology and andrology. The etiology is complex, and the treatment is difficult. In severe cases, orchiectomy is even necessary. In recent years, microsurgical denervation of the spermatic cord (MDSC) is a minimally invasive and effective surgical method for the treatment of chronic orchialgia. Its greatest advantage is to preserve the testis and epididymis, avoid the possible organ resection. The key of the operation is to dissect all the fibrous tissues in the spermatic cord, while protecting the arteries (especially the testicular arteries) and several lymphatic vessels. Combined with the use of microvascular doppler in the operation, when separating the structure of spermatic cord under the microscope, the testicular arteries can be objectively and accurately protected (pulse "whistle" sound can be heard when the microvascular doppler probes the arterial surface), while artery injury and venous missed ligation can be avoided. The postoperative blood supply of the testis is also maximumly safeguarded. At the same time, we can be more fearless to cut the cremaster muscle, fatty and connective tissues surrounding the spermatic cord blood vessels and vas deferens after the arteries and lymphatic vessels being accurately protected under the microscope, finally achieve the spermatic cord completely "skeletonized" (only the testicular arteries, lymphatic vessels and vas deferens remained after the surgery). Thus we can better ensure the clinical curative effect (denervation thoroughly), avoid serious complications (testicular atrophy), and achieve better surgical results.

A wide range of benign and malignant processes can affect the spermatic cord (SC). Familiarity with and recognition of the characteristic imaging features of these entities are imperative for accurate diagnosis and optimal clinical care. While some SC diseases are self-limiting, others can result in infertility and potentially life-threatening infection or bleeding if they are left untreated. Therefore, correct diagnosis is important for life-saving treatment and preservation of fertility. Disorders including anomalies of the vas deferens and the processus vaginalis, arterial and venous diseases (torsion of the SC and varicoceles), infection, trauma, and neoplasms are the most pertinent entities with which radiologists should be familiar when assessing the SC. Knowing what to expect in a patient who has undergone SC interventions is imperative. US has a fundamental role in the initial examination of patients who present with symptoms that indicate abnormalities of the SC, such as suspected posttraumatic testicular retraction or SC torsion. Other imaging techniques including abdominal and pelvic MRI and CT have their own importance. For correct interpretation of the findings and to establish an accurate diagnosis, it is crucial to have a thorough knowledge of the anatomy, the utility and limitations of various imaging modalities, optimal imaging and scanning techniques, and the imaging features of various benign and malignant pathologic conditions that can involve the SC. Online supplemental material is available for this article. © RSNA, 2022.

Testicular epidermoid cysts are relatively rare, accounting for about 1% of all testicular tumors, and are often treated by high orchiectomy. We describe here the case of a testicular epidermoid cyst treated by testicle-sparing surgery due to a preoperative diagnosis. A 23-year-old man complained of a painless mass in the right scrotum. Physical examination revealed a firm little fingertip-sized smooth-surfaced mass in the right testis. Ultrasonography showed a hypoechoic lesion with an echogenic rim in the right testis. A T2-weighted magnetic resonance image showed a well-demarcated mass with a low signal outline. On the basis of a preoperative diagnosis of epidermoid cyst, intraoperative testicular frozen section was performed, and the mass was resected surgically while preserving the testis.

We have encountered a lesion of the pediatric testis, termed "nodular maturation," that clinically mimics a testicular neoplasm causing ultrasound abnormalities that may lead to surgical excision. To our knowledge, it has only been described anecdotally in textbooks without a series or description in the literature. We, therefore, report 8 cases in pediatric patients emphasizing the clinical presentation, ultrasound findings, histologic features, and clinical follow-up information. Patients ranged in age from 5 to 11 years (mean: 7.9 y). Precocious puberty was identified in 1 patient as isolated penile enlargement without other signs; another had a history of McCune-Albright syndrome, but did not have signs of precocious puberty; others had no clinical manifestations. All patients had testicular abnormalities on ultrasound; 6 had a discrete lesion and 2 showed diffuse testicular enlargement. In the 6 cases with available data, mean size of the lesion on ultrasound was 0.9 cm (range: 0.4 to 1.7 cm). In the 3 cases for which macroscopic descriptions were available, no gross abnormalities were noted in the testicular parenchyma, despite the ultrasound findings. Histologically, nodular maturation occurred as a zone of more mature testicular parenchyma having larger, lumen-bearing seminiferous tubules that contrasted with the smaller, immature cords of the remaining parenchyma. The mature tubules showed germ cell maturation (to the level of late spermatids/spermatozoa in 6 cases), mature Sertoli cells, and, in 4 cases, admixed nodules of mature Leydig cells. Of the 6 patients with available follow-up information, none developed a testicular neoplasm. Given its ability to cause a lesion on ultrasound leading to surgical intervention, pathologists, radiologists, and urologists should be aware of nodular maturation., Competing Interests: Conflicts of Interest and Source of Funding: The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective To explore the preliminary application method and diagnostic value of virtual touch tissue imaging quantification (VTIQ) in diffuse testicular diseases of male infertility. A total of 70 male examiners in our hospital from June 2019 to March 2020 were selected as the research objects. According to whether the subjects are sick (testicular microlithiasis, varicocele), all subjects are divided into three groups: normal group, testicular microlithiasis group, and varicocele group. Whether there is a difference between the groups, and analyze whether there is a correlation between the index reflecting the quality of the semen and the testicular shear wave velocity. The measurement of different positions in the testis will affect the magnitude of the shear wave velocity (P < 0.05). The shear wave velocities of the testes of different diseases are obviously different from the normal side. At the same time, postural changes will have a certain impact on the shear wave velocities of both testes (all P < 0.05). There is a certain correlation between the testicular shear wave velocity and the conventional semen quality index (total sperm motility (P < 0.05)) of the subjects. Acoustic palpation tissue imaging quantitative technology can be applied to the diagnosis of male testes and testicular-related diseases (especially diffuse testicular diseases), and is more suitable for male infertility, which can provide clinical diagnosis and treatment options certain imaging basis., (Copyright © 2022 The Authors. Published by Elsevier GmbH.. All rights reserved.)

Objective: To investigate the prevalence of testicular microlithiasis and its association with sperm retrieval rates and histopathology in men with non-obstructive azoospermia., Methods: A total of 120 men underwent scrotal ultrasonography prior to microsurgical testicular sperm extraction. Sperm retrieval rate, testicular histopathology, testicular size, reproductive hormones, karyotyping, Y chromosome microdeletion analyses, and presence of varicoceles and hydroceles were compared between men with and without testicular microlithiasis., Results: The total sperm retrieval rate was 40%. Ten men with normal spermatogenesis were excluded. The remaining 110 men with non-obstructive azoospermia were analyzed and testicular microlithiasis was detected in 16 of them (14.5%). The sperm retrieval rate in that subgroup was only 6.2% (1/16) as opposed to 39.4% (37/94) in men with non-obstructive azoospermia and no evidence of microlithiasis (P = 0.009). The mean right and left testicular diameters were significantly lower in the microlithiasis group (P = 0.04). On multivariate logistic regression analysis, the presence of mictolithiasis (odds ratio 7.4, 95% confidence interval 2.3, 12.2; P = 0.01) was the only independent predictor of unsuccessful sperm retrieval. The 15 patients with microlithiasis and without successful sperm extraction were diagnosed by histopathology as having Sertoli cells only. The 16th patient with successful sperm retrieval had a histopathology of mixed atrophy and was diagnosed with Klinefelter syndrome., Conclusion: The presence of testicular microlithiasis is associated with low sperm retrieval rates among our cohort of men with non-obstructive azoospermia undergoing scrotal ultrasonography prior to microsurgical testicular sperm extraction. Larger, prospective studies should be conducted to confirm these findings., (© 2021 The Japanese Urological Association.)

Contrast-enhanced ultrasound (CEUS) utilization is expanding rapidly, particularly in children, in whom the modality offers the important advantages of dynamic evaluation of the vasculature, portability, lack of ionizing radiation, and lack of need for sedation. Accumulating data establish an excellent safety profile of ultrasound contrast agents (UCAs) in children. Although UCAs have been FDA-approved only for IV use in children for characterizing focal liver lesions and for use in children during echocardiography, off-label applications are expanding the diagnostic potential of ultrasound. Focal liver lesion evaluation is the most common use of CEUS, and the American College of Radiology Pediatric LI-RADS Working Group recommends including CEUS for evaluation of a newly discovered focal liver lesion in many circumstances. Data also support the role of CEUS in hemodynamically stable children with blunt abdominal trauma, and CEUS is becoming a potential alternative to CT in this setting. Additional potential applications that require further study include evaluation of pathology in the lung, spleen, brain, pancreas, bowel, kidney, female pelvis, and scrotum. This article explores the implementation of CEUS in children, describing basic principles of UCAs and CEUS technique and summarizing current and potential IV diagnostic applications based on pediatric-specific supporting evidence.

Abstract: Understanding a variety of scrotal diseases is essential to developing an accurate differential diagnosis and is critical in providing optimal patient care. Ultrasound is the imaging modality of choice when evaluating for scrotal pathology, with the major purpose of locating such pathology to either the testis, or epididymis, or other intrascrotal structures, as well as characterizing lesions as solid or cystic. It is generally assumed that most solid intratesticular masses are more likely malignant, whereas most extratesticular ones are benign, although some exceptions to that rule exist. This pictorial essay will focus on rare and less commonly encountered benign and malignant testicular and paratesticular pathologies, which may pose a diagnostic dilemma for interpreting radiologists and treating physicians. Knowledge of their imaging characteristics will help narrow the differential diagnosis and assist in proper patient management and care., Competing Interests: The authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Multiparametric MRI (mpMRI) of the scrotum has been established as a useful second-line diagnostic tool for the investigation of scrotal diseases. Recently, recommendations on clinical indications for scrotal MRI were issued by the Scrotal and Penile Imaging Working Group of the European Society of Urogenital Radiology., Objective: To update current research on when to ask for an MRI of the scrotum., Methods: PubMed database was searched for original articles and reviews published during 2010-2021., Results: Eighty-three articles fulfilled the search criteria. Scrotal MRI is mainly recommended after inconclusive US findings or inconsistent with the clinical examination and should be asked in the following cases: differentiation between intratesticular and paratesticular lesions (in rare cases of uncertain US findings), characterization of paratesticular and intratesticular lesions (when US findings are indeterminate), discrimination between germ cell and sex cord-stromal testicular tumors, local staging of testicular malignancies (in patients planned for testis-sparing surgery), differentiation between seminomas and non-seminomatous tumors (when immediate chemotherapy is planned and orchiectomy is delayed), assessment of acute scrotum and scrotal trauma (rarely needed, in cases of non-diagnostic US findings) and detection and localization of undescended testes (in cases of inconlusive US findings). Although preliminary data show promising results in the evaluation of male infertility, no established role for mpMRI still exists., Conclusion: Multiparametric MRI of the scrotum, by assessing morphologic and functional data represents a valuable problem-solving tool, helping to improve our understanding on the nature of scrotal pathology and the process of spermatogenesis. The technique may improve patient care and reduce the number of unnecessary surgical procedures., (© 2021 The Authors. Andrology published by Wiley Periodicals LLC on behalf of American Society of Andrology and European Academy of Andrology.)

An 18-month-old Angus bull presented to Auburn University College of Veterinary Medicine for a routine breeding soundness evaluation and lameness evaluation. He was classified as deferred potential breeder due to a lameness and was donated to the university. Following treatment, the bull's lameness resolved. He passed the breeding soundness examination in accordance with the Society for Theriogenology standards. However, avascular dilated areas at the level of the mediastinum testis of the right testicle were detected via Doppler ultrasonography. A high level of vascularity is routinely seen with neoplasia, such as teratomas. Due to the lack of vascularity, a presumptive diagnosis of tubular ectasia of the rete testis was made. The bull was castrated. The right testicle was submitted for histopathology revealing a definitive diagnosis of tubular ectasia of the rete testis., (© 2021 Wiley-VCH GmbH.)

Background: Ultrasound (US) is the primary modality for the investigation of scrotal pathology, including both intra- and paratesticular abnormalities., Objective: To describe the abnormalities of the paratesticular space., Materials/methods: The paratesticular space contains the epididymis, spermatic cord and the tunica vaginalis cavity and is affected by a variety of inflammatory or tumoral entities. Differential diagnosis based on US criteria is frequently problematic, as the findings are non-specific., Results: Some general rules apply: (i) unlike testicular lesions, extra-testicular entities are usually benign in the adult, (ii) the first steps to accurate diagnosis include careful localization of the lesion and assessment of its consistency (solid or cystic) and (iii) magnetic resonance imaging can be useful for further tissue characterization of lesions suspected to contain fat, but surgical biopsy will often provide the definite diagnosis. Contrast-enhanced ultrasound (CEUS) has been applied with limited experience indicating a narrow role, primarily for the differential diagnosis of echogenic cystic entities and the delineation of a necrotic abscess from a solid neoplasm., Discussion: The various abnormalities are discussed and illustrated., Conclusion: This manuscript summarizes the literature on paratesticular lesions and the value of US in diagnosis., (© 2021 The Authors. Andrology published by Wiley Periodicals LLC on behalf of American Society of Andrology and European Academy of Andrology.)

Background: Contrast-enhanced ultrasound (CEUS) is a sonographic technique that increases the diagnostic accuracy of ultrasound and color Doppler ultrasound (CDUS) when studying testicular abnormalities. However, its role in clinical practice is still debatable because there are no accepted standards regarding how and when this technique should be used for patients with testicular disease., Objectives: To perform a nonsystematic review of the current literature to highlight the strength and flaws of performing CEUS and to provide a critical overview of current research evidence on this topic., Materials and Methods: A thorough search of published peer-reviewed studies in PubMed was performed using proper keywords., Results: Strong enhancement of neoplastic lesions (both benign and malignant) during CEUS aids in differential diagnosis with non-neoplastic lesions, which usually appears either nonenhanced or enhanced in a manner similar to that of the surrounding parenchyma. CEUS enhancement has a high predictive value in the identification of neoplastic lesions, whereas a similar or complete absence of enhancement may be interpreted as strong evidence of benignity, although there are exceptions. Literature on quantitative analysis is still scarce, though promising, particularly in distinguishing benign from malignant neoplasms. Furthermore, CEUS may be useful in many emergency situations, such as acute scrotum, blunt scrotal trauma, and focal infarction of the testis. Finally, CEUS can help increase the probability of sperm recovery in azoospermic males., Discussion and Conclusion: CEUS is a safe, easy-to-perform, and cost-effective diagnostic tool that can provide a more accurate diagnosis in testicular lesions and acute scrotal disease. However, further studies with larger cohorts are required to refine the differential diagnosis between benign and malignant neoplasms. Finally, these preliminary results can instigate the development of innovative research on pre-testicular sperm extraction to increase the chances of sperm recovery., (© 2021 American Society of Andrology and European Academy of Andrology.)

Greyscale and color doppler ultrasound are the standard when investigating testicular lesions. However, they cannot provide information on the microvasculature. As such, differentiating benign from malignant tumors is challenging. Contrast-enhanced ultrasound (CEUS) uses ultrasound contrast agents that are exclusively intravascular to image the microvasculature. This review assessed CEUS outcomes in investigating intratesticular lesions and concluded that qualitative CEUS provides the most advantage by confirming vascularity, thus differentiating non-neoplastic from neoplastic lesions with added confidence, allowing for appropriate management. Whilst results for quantitative CEUS are promising in distinguishing malignant from benign neoplasms, further research on its benefits is required., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: To discuss the clinical application value of contrast-enhanced ultrasound (CEUS) in testicular occupied lesions., Methods: Nine conventional-ultrasound-found testicular occupied lesions which underwent CEUS meantime were analyzed retrospectively. The CEUS perfusion pattern was compared with the surgical pathological result or follow-up findings., Results: Among all the 9 testicular occupied lesions, there were 5 testicular malignant tumors, 1 testicular benign tumor, 1 testicular tuberculosis, and 2 testicular hematomas. CEUS diagnosed 6 testicular malignant tumors, 1 testicular benign tumor, and 2 testicular hematomas, and its diagnostic accuracy was about 88.9%., Conclusion: CEUS has high clinical application value in the differential diagnoses of benign and malignant testicular occupied lesions., Competing Interests: The authors declare no competing financial interests., (Copyright © 2021 Qiping Liu et al.)

Study Question: Is there an association of testicular microlithiasis (TM) and its severity with testicular dysfunction in men from infertile couples?, Summary Answer: The presence of ≥5 testis microcalcifications per sonogram at the scrotal ultrasonography (US) of infertile males was associated with a more severe testicular dysfunction as compared to males with limited, or without, TM., What Is Known Already: TM, representing an incidental finding in the scrotal US, is associated with male infertility and a higher risk for testicular cancer as compared to that in infertile males without TM. Still, there are unresolved questions on the relation between TM severity and testicular dysfunction in infertile men, as well as on the identification of risk factors for TM., Study Design, Size, Duration: This study was an observational, retrospective, case-control investigation involving males who underwent clinical evaluation, measurement of reproductive hormones, seminal analysis and scrotal US as part of diagnostic work-up for couple infertility at an andrology clinic, between January 2004 and December 2018. One hundred patients, out of the 2112 scored men, were found to have TM during the US evaluation. One hundred male partners from 100 infertile couples without TM, comprising the control group, were selected through a matched analysis by age and date of evaluation to reduce the confounding effect of both age and technique variability all along the long period of observation., Participants/materials, Setting, Methods: TM was defined as limited TM (LTM) or classical TM (CTM), when the maximum number of hyperecogenic spots per sonogram was <5 or ≥5, respectively. CTM, LTM and control groups were compared for clinical variables, serum levels of FSH, LH, and total testosterone, as well for semen parameters and scrotal US features., Main Results and the Role of Chance: After the exclusion of cases with testicular nodules to eliminate the possible confounding effect of testis cancer on testicular dysfunction, cases with CTM showed a lower mean testis volume (P = 0.03) and a lower sperm concentration (P = 0.03) as compared to the other two groups. A higher FSH level was observed in the CTM group compared to the LTM group (P = 0.02) and in controls (P = 0.009). The multiple logistic regression analysis showed that only a smaller testicle volume exhibited an independent significant association with a higher odds of detecting CTM (odds ratio = 0.84, 95% CI: 0.75-0.94; P = 0.02). No significant differences were observed between groups in the prevalence of risk factors for testicular cancer, or in the prevalence of conditions associated with TM., Limitations, Reasons for Caution: The retrospective design of the study did not allow conclusions to be drawn about the possible underlying links in the associations of TM with defective spermatogenesis., Wider Implications of the Findings: Males from infertile couples who exhibit a reduced testicular volume should undergo scrotal US, independent of sperm parameters, to exclude CTM and, eventually, testis cancer, although the association of CTM and current or future testis cancer risk is not yet clear. Evidence is provided here demonstrating that the presence of LTM has no clinical relevance in males from infertile couples., Study Funding/competing Interest(s): Investigation was funded by Ministero dell'Università e della Ricerca, PRIN 2018, Italy. The authors have not declared any competing interests., Trial Registration Number: N/A., (© The Author(s) 2021. Published by Oxford University Press on behalf of European Society of Human Reproduction and Embryology. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Cystic dysplasia of the rete testis (CDT) is a rare cause of scrotal swelling in children. It is a congenital disorder and it can be associated with other genitourinary abnormalities. At present, there is no clear consensus on treatment. Surgical approach has traditionally been the treatment of choice, while, more recently, conservative approach has been applied, justified by the benign nature of the lesion and after few cases of spontaneous regression have been documented. Ultrasonography, supported by negative tumor markers, plays a key role in the diagnostic work up and during observational follow-up. We report a further case of spontaneous regression of suspected CDT in an 18-month-old boy, who has been followed with clinic and ultrasonographic checks.

Immunoglobin-G4 related disease (IgG4-RD) is an auto-immune inflammatory condition where patients present with a tumour-like mass that shows infiltration by plasma cell and subsequent fibrosis. It is a systemic condition that primarily involves the salivary glands, pancreas, kidneys, aorta, and retroperitoneum amongst other organs. Testicular involvement is a rare occurrence in this disease entity. A 55-year old male patient presented with the complaints of pain and swelling in the right scrotal region. Right-sided orchidectomy was carried out which on histopathology showed features suggestive of IgG4-RD which was later confirmed on immunohistochemistry. Whole body MRI revealed that no other organ was involved in the disease process in this patient. IgG4-RD has a variable clinical course and considerable overlap with its differentials. Imaging studies and serum IgG4 levels are neither confirmatory nor customarily diagnostic in every case. The only confirmatory diagnostic investigation is histopathological examination, which shows infiltration of IgG4+ plasma cells and fibrosis in the involved tissue. Whenever a mass-forming lesion with typical histomorphological features is encountered with involvement of multiple organs/anatomic sites, IgG4-related disease should be considered among the differentials, and clinicians of all disciplines should be familiar with this disease entity.

Background: To systematically evaluate the incidence characteristics of testicular microlithiasis (TM) in children and its association with primary testicular tumors (PTT)., Methods: A systematic review and meta-analysis were conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement. A priori protocol was registered in the PROSPERO database (CRD42018111119), and a literature search of all relevant studies published until February 2019 was performed. Prospective, retrospective cohort, or cross-sectional studies containing ultrasonography (US) data on the incidence of TM or the association between TM and PTT were eligible for inclusion., Results: Of the 102 identified articles, 18 studies involving 58,195 children were included in the final analysis. The overall incidence of TM in children with additional risk factors for PTT was 2.7%. In children, the proportion of left TM in unilateral cases was 55.7%, the frequency of bilateral TM was 69.0%, and proportion of classic TM was 71.8% [95% confidence interval (CI) 62.4-81.1%, P = 0.0, I 2  = 0.0%]. About 93.5% of TM remained unchanged, and newly detected PTT rate was very low (4/296) during follow-up. The overall risk ratio of TM in children with a concurrent diagnosis of PTT was 15.46 (95% CI 6.93-34.47, P < 0.00001)., Conclusions: The incidence of TM in children is highly variable. Nonetheless, TM is usually bilateral, of the classic type, and remains stable or unchanged at follow-up. Pediatric patients with TM and contributing factors for PTT have an increased risk for PTT; however, there is no evidence to support mandatory US surveillance of children with TM.

The aim of this study is to assess the additional benefit of contrast-enhanced ultrasound (CEUS) over conventional ultrasonography (US) in identifying intra-testicular abnormalities among observers of different experiences. In this study, 91 focal testicular lesions (46 neoplastic, 45 non-neoplastic) imaged with gray-scale US/Doppler US and CEUS were classified using a 5-point scale. Three experienced and four inexperienced observers rated each lesion using gray-scale/color Doppler US alone and then with the addition of CEUS. Improved diagnostic specificity and accuracy with the addition of CEUS was observed for both experienced (specificity: 71.1% vs. 59.3%, p = 0.005; accuracy: 83.5% vs. 76.9%, p = 0.003) and inexperienced observers (specificity: 75.6% vs. 51.7%, p = 0.005; accuracy: 80.2% vs. 72.0%, p < 0.001). Significant inter-observer variability between the experienced and inexperienced observers when assessing conventional US alone was eliminated with the addition of CEUS. CEUS improves diagnostic accuracy of focal intra-testicular lesions for both experienced and inexperienced observers and reduces inter-observer variability in inexperienced operators., (Copyright © 2020 World Federation for Ultrasound in Medicine & Biology. All rights reserved.)

Background: Testicular microlithiasis (TM) is sometimes found on scrotal ultrasound. The prevalence seems higher in populations of men with testicular dysfunction, and TM may be a risk factor for testicular germ cell neoplasia in situ in men with additional risk factors. The association between TM and testicular function is controversial, especially in incidentally found TM., Objectives: To determine the frequency of TM in young men from the general population, and associations between TM, semen quality, and reproductive hormones., Materials and Methods: A cross-sectional study of 4850 Danish men, median age 19 years. Testicular pattern, including the presence of TM, was assessed by ultrasound examination. Participants provided a questionnaire, one semen sample, and one blood sample. Semen variables and serum reproductive hormones were analyzed as outcomes using multivariable regression analysis to determine associations with TM., Results: TM was detected in 53 men (1%), of which 19 (36%) were unilateral and 34 (64%) were bilateral cases. A history of cryptorchidism was associated with presence of TM. Bilateral TM was associated with slightly lower testicular volume, sperm concentration, and total sperm count. TM was not significantly associated with serum testosterone or other reproductive hormones., Discussion and Conclusion: TM is rare in men from the general population and is associated with lower sperm count if bilateral, although effect sizes were small. Current European guidelines do not recommend any follow-up in cases of TM with no other risk factors for testicular cancer. We suggest that men with incidentally found bilateral TM may be offered a semen analysis, but analysis of reproductive hormones seems unnecessary., (© 2020 American Society of Andrology and European Academy of Andrology.)

Objectives: To investigate the prevalence of testicular microlithiasis and the relationship between testicular microlithiasis, semen parameters and endocrinological profiles in healthy newlywed men trying for first-time pregnancy., Methods: Men visiting Juntendo University Urayasu Hospital, Urayasu, Chiba, Japan, or D Clinic Tokyo, Chiyoda-ku, Tokyo, Japan, for a first-time examination of fertility underwent scrotal examination, semen analysis and blood tests. Testicular volume measured by orchidometer, semen parameters measured by the Makler counting chamber and endocrinological profiles were compared between men with testicular microlithiasis and without testicular microlithiasis. The correlation between sperm concentration and the number of calcifications, and sperm motility and the number of calcifications, were investigated., Results: Of 739 men, 60 (8.1%) were diagnosed as having testicular microlithiasis. Among them, testicular volume, semen volume and motility were lower than those in the men without testicular microlithiasis. Luteinizing hormone and follicle-stimulating hormone levels were higher in those with than those without testicular microlithiasis. The sperm concentration correlated negatively with the number of calcifications. There was no significant correlation between sperm motility and the number of calcifications., Conclusion: Herein, we report the prevalence of testicular microlithiasis in healthy newlywed men. Furthermore, our findings suggest that semen parameters in men with severe testicular microlithiasis tend to be worse., (© 2020 The Japanese Urological Association.)

This is a case of an 8-year-old boy with a chief complaint of left-lower-quadrate abdominal pain for 3 days. Examination revealed swollen left hemi-scrotum and scrotal ultrasound showed a para-testicular cystic mass, which was later proven to be a torsion of a benign scrotal tunica cyst during emergent scrotal exploration. Torsion of the tunica vaginalis cyst is a rare cause of acute scrotum, and we present this case to share our experience of diagnosis and management of this peculiar disease., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Genitourinary sarcoidosis is an uncommon entity, and testicular sarcoidosis is even rarer. We present a case of 66-year-old man who presented to our hospital as PUO (pyrexia of unknown origin) and later diagnosed as testicular sarcoidosis with the help of FDG PET/CT.

Cystic dysplasia of the rete testis (CDT) is a rare, benign, cause of testicular mass in the pediatric population. The mass appears on sonography as multiple small cysts of varying size surrounded by normal or compressed testicular tissue. CDT is often associated with other genitourinary anomalies, commonly presenting with agenesis or dysplasia of the ipsilateral kidney. The pathophysiology and the management remains controversial. We report a case of a 3-year-old presenting with an enlarged testicular mass later presumed to be CDT associated with ipsilateral renal agenesis, review the literature, and propose an evaluation and management algorithm., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Introduction: Spermatic vein thrombosis is a rare entity with poor clinical distinctive signs for the differential diagnosis, which raises numerous controversies about the appropriate management. Case report: A 55 years old man presents at the emergency room for left scrotal pain and swelling evolving for two weeks. The patient denied any recent local traumatic event. Physical examination revealed an approximately 15 to 20 cm length mass from the posterior scrotum to the external inguinal orifice. The other genitals had a healthy appearance at the moment of the examination. An incarcerated hernia couldn't be excluded. The Doppler ultrasound evaluation of the scrotum con firmed the suspicion of left testicular vein thrombosis with complete cessation of blood flow. Both testicles appeared to have regular blood flow. CT scan established that the thrombus extended up to the left external inguinal orifice. Surgical treatment was preferred to address an eventually incarcerated hernia. The left testicular vein was excised from the external orifice. Postoperative management consisted of apixaban for 30 days, and the cardiology department thus conducted the treatment. Conclusions: Doppler ultrasound evaluation of the scrotum represents the gold standard diagnostic test for spermatic vein thrombosis. There are still controversies about the management approach of this pathology, conservative or surgical., (Celsius.)

Aim: To assess the value and efficacy of real-time shear-wave elastography (SWE) of normal testicular parenchyma and various common testicular diseases in clinical practice., Materials and Methods: SWE was undertaken in 338 patients (mean age: 43.2±17.2 years, range 17-78 years) comprising normal testicles (n = 358), testicular microlithiasis (n = 40), and various testicular diseases (n = 208) and the stiffness was recorded. The final diagnosis was correlated with the clinical context, long-term follow-up, or histopathology. Statistical evaluation was performed to provide a stiffness threshold for pathological diagnosis., Results: The mean size of testicular lesions was 2.6±1.5 cm (range: 10-42 mm). The mean Young's modulus value for normal testis was recorded at 4.55±2.54 kPa. Whatever the stage of microlithiasis, a higher statistically significant stiffness value was recorded. For acute orchitis, the mean stiffness value was slightly higher, but not statistically significantly. The testicular tumoural processes presented a median stiffness value of 21.02 kPa with a cut-off of 16.1 kPa. Fibrosis presented the highest median stiffness value of 30.03 kPa with a cut-off of 26.3 kPa. By analysing the distribution of the different pathological groups, the difference was statistically significant between fibrosis and tumoural processes (p = 0.001)., Conclusion: SWE is a feasible technique in the exploration of the testicular parenchyma. SWE values can be used to differentiate testicular fibrosis from a tumoural process with confidence., (Copyright © 2020 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)