THIEME E34 Review Common and Uncommon Presentation of Fluid within the Scrotal Spaces Authors V. Patil, S. M. C. Shetty, S. Das Affiliation Radiodiagnosis, JSS Medical College, Mysore, India Key words Abstract gin. US may suggest a specific diagnosis for a ●▶ US wide variety of intrascrotal cystic and fluid ▶ ▼ ● ultrasonography Ultrasonography(US) of the scrotum has been lesions and appropriately guide therapeutic ●▶ fluid demonstrated to be useful in the diagnosis of options. The paper reviews the current knowl- ●▶ testis ●▶ scrotum fluid in the scrotal sac. Grayscale US character- edge of ultrasound in conditions with fluid in the izes the lesions as testicular or extratesticular testis and scrotum. The review presents the and, with color Doppler, power Doppler and applications of ultrasonography in the diagnosis pulse Doppler, any perfusion can also be assessed. of hydrocele, testicular cysts, epididymal cysts, Cystic or encapsulated fluid collections are rela- spermatoceles, tubular ectasia, hernia and hema- tively common benign lesions that usually pre- toceles. The aim of this paper is to provide a pic- sent as palpable testicular lumps. Most cysts torial review of the common and uncommon arise in the epidydimis, but all anatomical struc- presentation of fluid within the scrotal spaces. tures of the scrotum can be the site of their ori- Introduction images with portions of each testis on the same ▼ image should be ideally acquired in grayscale and Scrotal conditions associated with fluid can be color Doppler modes. The structures within the received 21.01.2015 accepted 29.06.2015 broadly classified as fluid in scrotal sac, testicular scrotal sac are examined to detect extra testicu- cysts, epididymal cysts and inguinoscrotal hernia. lar masses or other abnormalities. In patients Bibliography with small palpable nodules, scans should DOI http://dx.doi.org/ include the area of clinical concern. It is helpful to 10.1055/s-0035-1555919 Examination Technique put a finger beneath the nodule and the trans- Published online: ducer placed directly over the nodule for scan- November 6, 2015 ▼ Scrotal US is performed with the patient in the ning, or a finger can be placed on the nodule and Ultrasound International Open 2015; 1: E34–E40 supine position and the scrotum supported by a the transducer opposite to confirm imaging of © Georg Thieme Verlag KG towel placed between the thighs. Optimal results the lesion. Stuttgart · New York are obtained with a high-frequency linear array ISSN 2199-7152 transducer above 10 MHz. Scanning is performed most often with the transducer in direct contact Sonographic Anatomy of Scrotum Correspondence with the skin, but if necessary a stand-off pad can ▼ Dr. Vikram Patil be used for evaluation of superficial lesions. The The normal adult testis is ovoid, measuring 3–5 cm Radiodiagnosis testes are examined in at least 2 planes along the in length and 2–3 cm in both transverse and anter- JSS Medical College 101, Gayathri Apartment long and transverse axes. The size and echo- oposterior dimensions. Its echo texture is homo- New Kantharj Urs Road, Mysore genicity of each testis and the epididymis are geneous, and its echogenicity is intermediate. 570004, Mysore compared with those on the opposite side. Scro- The epididymal head is rhomboid to triangular in India tal skin thickness is evaluated. Scrotal skin echo- shape, measures less than 1 cm, and is similar in Tel.: + 91/988/6896 511 genicity is also evaluated. echo texture and echogenicity to the testis. The [email protected] In patients being evaluated for an acute scrotum, epididymal head is positioned superolaterally to the asymptomatic side should be scanned ini- the testis with the body of the epididymis aligned License terms tially in order to set the gain settings to allow along the long axis posteriorly. Occasionally, tes- comparison with the affected side. Transverse ticular appendages such as the appendix testis, a Patil V et al. Common and Uncommon Presentation … Ultrasound International Open 2015; 1: E34–E40 Review E35 Table 1 Cystic/liquid lesions of the scrotum in adults. 1. Fluid in scrotal sac a. Congenital hydrocele b. Spermatic cord hydrocele c. Acquired hydrocele d. Hematocele e. Pyocele f. Lymphocele 2. Testicular lesions a. Tunica albuginea cysts b. Single or multiple cysts Fig. 1 a Normal closure of processus vaginalis. Straight arrows indicate c. Tubular ectasia funicular process and curved arrow indicates tunica vaginalis. b Com- d. Epidermoid cysts municating hydrocele – complete patency of tunica vaginalis. c Funicular e Testicular abscess hydrocele of the cord – diverticulum communicates with the cord only. f. Intratesticular varicocele d Encysted hydrocele of the cord – no communication to peritoneum or g. Post-traumatic cysts tunica vaginalis. 3. Cysts in the epididymis a. Epididymal cysts b. Spermatocele Fig. 2 Antenatal c. Tubular ectasia of the epididymis hydrocele shows the d. Cyst of the appendix testis and appendix epididymis fluid in the scrotal sac 4. Inguinoscrotal hernia with echogenic testis. mullerian duct remnant found at the superior aspect of the tes- tis, and the appendix epididymis, a mesonephric remnant located at the epididymal head, can also be seen. The appendix testis appears as an ovoid structure 5 mm in length in the groove between the testis and the epididymis. The appendix testis is isoechoic to the testis and may occasionally be cystic. The appendix epididymis is of the same approximate with only about 80 reported pediatric cases [3]. These are large dimensions as the appendix testis but is more often peduncu- inguinoscrotal hydroceles that protrude through the internal lated [1]. Normal structures of the scrotal canal (veins, artery) inguinal ring into the abdominal cavity and manifest clinically as can also be identified ●( ▶ Table 1). a communicating abdominal-scrotal mass. The exact mecha- nism by which peritoneal fluid is forced into the abdominal cav- ity remains speculative [4]. 1. Fluid in Scrotal Sac Most congenital hydroceles (80 %) resolve spontaneously before ▼ the age of 2 years. However, surgical treatment is usually applied Hydrocele in spermatic cord and abdominoscrotal hydroceles. Hydrocele is an abnormal collection of fluid between the vis- ceral and parietal layers of the tunica vaginalis and/or along the Spermatic cord hydrocele spermatic cord. In the normal scrotum, 1–2 mL of serous fluid Hydrocele of the spermatic cord is a rare anomaly that results may be observed in the potential tunica vaginalis cavity and from an aberration in the closure of the processus vaginalis. It is should not be mistaken for hydrocele. a loculated fluid collection along the spermatic cord, separate It may be congenital or acquired (primary/idiopathic and sec- from the testis and the epididymis and located above them. Clin- ondary). ically it manifests as groin swelling that is indistinguishable Hydrocele is the most common cause of painless scrotal swelling from a mass at palpation. in children. Virtually all hydroceles are congenital in neonates There are 3 types of spermatic cord hydrocele: communicating, and infants and associated with a patent processus vaginalis, funicular, and encysted. A communicating hydrocele is associ- which allows peritoneal fluid to enter the scrotal sac [2]. In older ated with complete patency of the processus vaginalis. On US, it children and adolescents, hydroceles are usually acquired and appears as a fluid collection that extends from the pelvis through are the result of an inflammatory process, testicular torsion, the deep inguinal ring to the scrotum. A funicular hydrocele is a trauma, or a tumor. result of abnormal obliteration of the deep inguinal ring, with At sonography, congenital hydrocele appears as an anechoic constriction just above the testis. On US, it resembles a perito- fluid collection surrounding the anterolateral aspects of the tes- neal diverticulum, appearing as a fluid collection that communi- tis and sometimes extending to the inguinal canal or as a fluid cates with the peritoneum at the deep inguinal ring and that collection with low-level swirling echoes, which are related to does not surround the testicle [5]. A funicular hydrocele may protein aggregation or deposition of cholesterol crystals [2] contain fibrous adhesions, the remnants of partial constrictions (● ▶ Fig. 1, 2). and inflammatory changes. The resultant beaded appearance of Closure of the processus vaginalis above the testis and below the the spermatic cord and thickened tunica vaginalis gave rise to internal inguinal ring leads to a less common type of hydrocele, the term pachyvaginalitis. Funicular hydroceles become larger also known as spermatic cord hydrocele, which appears as a with increased intraperitoneal pressure during straining and fluid collection in the spermatic cord [2]. Another type, referred smaller during relaxation [6]. They are prevalent in children and to as abdominoscrotal hydrocele, is a highly uncommon entity, premature infants. However, they may be incidentally discov- Patil V et al. Common and Uncommon Presentation … Ultrasound International Open 2015; 1: E34–E40 E36 Review Fig. 3 An ovoid Fig. 6 An increase anechoic mass is seen in the resistive index in the groin along the (RI) of the testicular spermatic cord – sper- artery is seen due to a matic cord hydrocele. compressive effect on the vessels. Fig. 4 Hydrocele Fig. 7 Low-level ech- noted with testicular oes seen in the scrotal appendage is well fluid collection indica- defined. tive of hematocele. flow within the testis. Vascular resistance in intratesticular arteries is increased (● ▶ Fig. 6), and color Doppler US may dem- onstrate an increase in the caliber of capsular arteries [8]. Aspi- ration of the fluid restores normal blood flow to the testis. Fig. 5 Chronic In patients with hydrocele, the volume of the homolateral testis hydrocele showing is increased and so are the RI and the pulsatility index (PI). Post- fluid having multiple operatively, both the volume and impedance indices decrease. thin septations in the scrotal sac. Hematocele In most of the patients, the injury will be solitary but may be associated with involvement of the penis or urethra.