A Review of Classification, Diagnosis, and Management of Hydrocele.

This article summarizes and updates a number of issues related to hydrocele including anatomy, embryology, classification, etiology, clinical manifestations, imaging findings, and management. Hydrocele is an abnormal collection of serous fluid between the parietal and visceral layers arising from the mesothelial lining of the tunica vaginalis that surrounds the testis and spermatic cord directly. Hydroceles result from an imbalance of secretion and reabsorption of fluid from the tunica vaginalis. Hydroceles can be divided into two types as primary and secondary. The diagnosis should be based on medical history, clinical manifestations, and imaging studies. Understanding the causes and types of hydroceles is useful for accurately diagnosing and treatment strategy. Hydroceles can be managed by conservative treatment, fluid aspiration, or hydrocelectomy.

Testicular quantitative ultrasound: A noninvasive monitoring method for evaluating spermatogenic function in busulfan-induced testicular injury mouse models.

Busulfan-induced testicular injury mouse models are commonly used for experiments on spermatogonial stem cell transplantation, treatments for azoospermia due to spermatogenic failure and preserving male fertility after chemotherapy. Here, we investigated the value of testicular quantitative ultrasound for evaluating spermatogenic function in this model. In this study, testicular ultrasound was performed on mice from day 0 to 126 after busulfan treatment (n = 48), and quantitative data, including the testicular volume, mean pixel intensity and pixel uniformity, were analysed. The results revealed that from day 0 to 36, the testicular volume was positively associated with the testicle-to-body weight ratio (r = .92). On day 63, the pixel uniformity, which remained stable from day 0 to 36, declined significantly compared with that on day 36 (p < .01). On day 126, when the whole progression of spermatogenesis could be observed in most tubules, the mean pixel intensity also returned to normal (p > .05). In conclusion, testicular quantitative ultrasound could be used as a noninvasive and accurate monitoring method for evaluating spermatogenic function in busulfan-induced testicular injury mouse models.

The prevalence of ultrasonographic abnormalities and histopathologic lesions is high in testes of yearling tropical hair rams.

Ultrasonography is commonly used to examine testes as part of a breeding soundness examination in sheep, especially, in cases of infertility or when gross testicular abnormalities are present. A descriptive, prospective, prevalence study was conducted to characterize the ultrasonographic, histopathologic, and spermatozoal morphology abnormalities present in a group of yearling tropic hair rams on the island of St. Kitts. Hyperechoic and shadowing abnormalities increased over a 6 month study period. Hyperechoic abnormalities were present in one or both testes in 89% (25/28) of yearling rams and 71% (40/56) of testes at castration. Shadowing abnormalities were present in one or both testes in 46% (13/28) of rams and 34% (19/56) of testes at castration. Shadowing was present more with moderate and severe hyperechoic abnormalities, with few testes in the mild category having any shadowing. As hyperechoic and shadowing abnormalities increased in severity, so did the severity of microscopic lesions including increased interstitial cellularity/fibrosis, interstitial mineralization, seminiferous tubules mineralization (hyperechoic only), and chronic lymphoplasmacytic orchitis. There were no spermatozoal morphologic abnormalities other than an increase in distal cytoplasmic droplets. The study findings detail a pathologic event in this group of yearling rams that has an unknown etiology. Potential causes may include scrotal insulation, trauma, infectious causes, immunity alterations, nutritional imbalances, and ingestion of a toxin. Further studies are required to elucidate the causative agent.

The use of ultrasonography in the reproductive evaluation of boars.

The objective was to study the use of ultrasound as a complementary test in the breeding soundness evaluation in male pigs and study the pattern of echogenicity of the testicular parenchyma in boars of different racial groups. Twenty-six adult boars from four different racial groups were used, 10 from the Piau breed (group 1), four from the commercial and finishing group (group 2), six Pietrain breed (group 3) and six from the Duroc breed (group 4). All animals were evaluated for breeding soundness evaluation and the ultrasound examination of the testicles. The groups of animals that were evaluated showed no difference in the main semen parameters that were evaluated, except for the sperm volume, concentration of the ejaculated sperm and the supravital staining; the lowest figures were for the animals from the Piau breed (group 1). In relation to the testicular biometrics, Duroc animals (group 4) had a greater scrotal width compared to the other groups. But when we assessed the intensity of pixels of the testicles, there was a difference between groups. The groups 2 (finishing animals), 3 (Pietrain) and 4 had no difference between themselves. Group 3 had greater pixel intensity in relation to group 1. Of the 26 animals studied, five showed an abnormality during ultrasound evaluation, like hydrocele, hyperechoic mass in the testicular parenchyma, cyst in the head of the epididymis and the presence of fluid in the head and tail of the epididymis. The various animal groups studied did not differ in the principal reproductive parameters evaluated, showing that despite the great variability of reproductive traits between breeds and within the same breed, the breeding soundness evaluation, the more complete it is, is essential for the selection of breeders and the ultrasonography of the reproductive system becomes an important addition in this examination.

Causes of Avascular Hypoechoic Testicular Lesions Detected at Scrotal Ultrasound: Can They Be Considered Benign?

OBJECTIVE: The purposes of this study were to determine the cause of avascular hypoechoic lesions detected at scrotal ultrasound and to assess usefulness of sonographic and clinical features in differentiating benign from malignant etiologic factors. MATERIALS AND METHODS: This retrospective study included 58 patients with avascular hypoechoic lesions detected at testicular ultrasound. The sonographic features recorded were lesion size and margins and presence of peripheral vascularity and focal calcifications. Also recorded were patient age, symptoms, risk factors, lesion palpability, and levels of serum tumor markers. The reference standard was pathologic results or at least 2-year stability documented with serial follow-up ultrasound studies. Features associated with malignant, including burnt-out, lesions and benign lesions were examined by Fisher exact test, Wilcox-on rank sum test, and the generalized estimating equations method for multivariable models. RESULTS: Sixty-three lesions were identified in 58 patients; 40 of the 63 (63.5%) were benign. Patients with malignant lesions had elevated serum tumor marker levels more often than patients who had benign lesions (26.1% versus 5.7%, p = 0.043). The clinical palpability of lesions and history of testicular cancer were not statistically significantly different between patients with malignant and those with benign lesions. Poorly defined margins of a lesion and focal calcification within the lesion were more often found in malignant lesions. Maximal size of a lesion and peripheral vascularity were not associated with either the benign or the malignant nature of a lesion. CONCLUSION: Although most avascular hypoechoic testicular lesions are benign, a substantial proportion are malignant. The ultrasound characteristics of a lesion, the patient's clinical presentation, and serum tumor marker status may be useful in differentiating malignant from benign lesions.

Testicular adrenal rest tumors in congenital adrenal hyperplasia-cross-sectional study of 51 Croatian male patients.

Testicular adrenal rest tumors (TARTs) are common cause of infertility in males with congenital adrenal hyperplasia (CAH). We studied the role of genotype and disease regulation on TART development, their impact on gonadal function, and frequency in 47 21-hydroxylase deficiency (21-OHD) and four 11-hydroxylase deficiency (11-OHD) male patients. Testicular ultrasound (TU), genotype, hormonal measurement in 51, and spermiogram in five patients were performed. TARTs were detected in 14 SW21-OHD and one 11-OHD patient: 1/8 patients aged <7 years (1.8 years old is the youngest), 1/8 patients aged <12 years, 5/17 patients aged <18 years, and in 8/18 adults. All 21-OHD TART patients had exclusively severe mutations of CYP21A2 gene. Poor hormonal control in 8/15 patients with and 12/36 patients without TART indicates correlation of tumor development with poor disease control. None of the TART patients fathered a child. Low inhibin-B was found in 7/15 TART patients. Azoospermia was found in four and oligoasthenozoospermia in one patient. CONCLUSION: TART was detected exclusively in patients with severe CYP21A2 mutations. Disease regulation plays a role in development of TART that impairs testicular function and increases the risk of infertility. Screening for TART by TU is indicated from early childhood. What is Known: • Due to improved diagnostic and therapeutic possibilities, majority of the male patients with congenital adrenal hyperplasia nowadays reach adulthood and screening for long-term complications is becoming more important. • Testicular adrenal rest tumors (TARTs) are common cause of infertility and impaired gonadal function in males with CAH. What is New: • A 1.8-year-old boy described in this paper is the youngest reported patient with TART. • Screening for TART by testicular ultrasound from early childhood, especially in patients with severe CYP21A mutations, is recommended.

[Long-term evolution of detorsion of the testes after acute scrotum]. / Evolución a largo plazo de la detorsión testicular tras escroto agudo.

OBJECTIVES: To assess the long-term evolution of the testicles preserved after testicular torsion (TT). MATERIAL AND METHODS: We realized a prospective study by ultrasound of patients diagnosed TT that underwent orchidopexy. We reviewed 85 patients treated for acute scrotum (2004-2014), finding 49TT. We excluded from the study 15 perinatal torsions, 14 orchiectomies and 5 patients who refused to participate. We analyzed 15 patients, comparing testicular volumes between affected and contralateral testes, and the difference in volume between the two testes of the 15 cases with 14 control patients (Mann-Whitney U test). RESULTS: 15 patients underwent surgery at a mean age of 10,7 years, with an average time of 6 hours evolution [0,7-24]. The control ultrasound was performed at a mean age of 14,7 years, after a mean time of 47 months after the episode, finding a medium volume of the affected and contralateral testicle of 9,3 cc and 12,6 cc, respectively (p = 0,683). The median of the difference between the volumes was 0'8 cc [0,1-12,80]. In the control group, ultrasounds were performed at a mean age of 16 years, with an average volume of 6,64 cc on right testicle and 6,26 cc on the left, and median volume difference of 0,34 cc [0,05-4,59]; with no statistically significant difference (p = 0,270) between testicular volume differences of cases and controls. CONCLUSION: Testicular orchidopexy in patients with TT with less than 6 hours of evolution does not affect the long-term testicular growth, compared with the contralateral testis growth and testes of the normal population.

OBJETIVOS: Valorar la evolución a largo plazo de los testículos preservados tras torsión testicular (TT). MATERIAL Y METODOS: Estudio prospectivo mediante ecografía de pacientes diagnosticados de TT a los que se les realizó detorsión y orquidopexia. Revisamos 85 pacientes intervenidos por escroto agudo (2004-2014), encontrando 49TT. Excluimos del estudio 15 torsiones perinatales, 14 orquiectomías y 5 pacientes que se negaron a participar. Analizamos 15 pacientes, comparando volúmenes testiculares entre testes afectos y contralaterales, y la diferencia de volúmenes entre ambos testes de los 15 casos con 14 pacientes control (prueba U de Mann-Whitney). RESULTADOS: Los 15 pacientes se intervinieron a una edad media de 10,7 años, con un tiempo medio de evolución de 6 horas [0,7-24]. La ecografía control se realizó a una edad media de 14,7 años, tras un tiempo medio de 47 meses después del episodio, encontrando unas medianas del volumen del teste torsionado y contralateral de 9,3 cc y 12,6 cc, respectivamente (p = 0,683). La mediana de la diferencia entre los volúmenes fue de 0,8 cc [0,1-12,80]. En el grupo control, las ecografías fueron realizadas a una edad media de 16 años, con media de volumen de teste izquierdo de 6,26 cc y derecho de 6,64 cc, y mediana de diferencia de volúmenes de 0,34 cc [0,05-4,59]; no encontrándose diferencias estadísticamente significativas (p = 0,270) entre las diferencias de volúmenes de los testículos de casos y controles. CONCLUSION: La detorsión testicular en pacientes con TT con un tiempo de evolución inferior a 6 horas no influye en el crecimiento testicular a largo plazo, comparado con el crecimiento del teste contralateral y de los testículos de la población normal.

Intra- and Interobserver Variability in Ultrasound Measurement of Testicular Volumes in Pubertal Boys.

Accurate measurement of testicular volume (TV) in boys is an important tool in clinical practice, e.g., in varicocele treatment. This study aims to assess the degree of intra- and interobserver variability of testicular volume measurements. In a prospective study, boys between 11 and 17 years of age without testicular pathology were enrolled. Testicular ultrasound was performed by three investigators (A: pediatric radiologist; B: pediatric surgery/urology resident; C: pediatric urologist). Intraobserver variability was calculated in investigators B and C and interobserver variability between all three investigators. A total of 30 boys were enrolled. Mean intraobserver variability in both observers was +0.3% with a range of -39.6 to 51.5%. The proportion of measurements with a difference >20% was 18.6%. The mean interobserver variability was -1.0% (range: -74.1% to 62.8%). The overall proportion of measurements with a difference >20% was 35%. A lower testicular size of < 4 mL showed a significantly higher rate of >20% difference in both the intraobserver group (31.1% vs. 14.4%; p = 0.035) and the interobserver group (63.2% vs. 26.2%; p = 0.000031). Furthermore, the rate of >20% difference was significantly lower in obese compared to non-obese patients in both the intraobserver (2.8% vs. 22.4%; p = 0.0084) and the interobserver group (24% vs. 40.8%, p = 0.0427). Both intraobserver and interobserver variability in ultrasound-based TV measurements in pubertal boys contain a relevant degree of uncertainty that renders them unsuitable for individualized follow-up care. At the cohort level, however, mean differences in ultrasound-based TV measurements are low enough to make ultrasound comparisons reasonable.

Testicular ultrasonographic features predict future risk for bilateral testicular germ cell tumour: A long-term single centre follow-up study.

BACKGROUND: Bilateral testicular germ cell tumours (B-GCT) are rare, with an incidence of 2-5%, and can be classified as synchronous (sB-GCT) or metachronous (mB-GCT). Our study aimed to identify clinical, biochemical, and radiological risk factors for mB-GCT in a cohort of patients with GCT at a single tertiary referral centre. METHODS: This retrospective case-control study included patients with GCT referred to Policlinico Umberto I-Sapienza University of Rome, from 2005 to 2023. We evaluated clinical history, testicular ultrasound features, hormone levels, semen analysis, histological characteristics, staging, and treatments. mB-GCTs were compared with unilateral GCT patients with a follow-up longer than the median time-to-onset of the second tumour. RESULTS: Of 319 patients, 52 experienced B-GCT, with a median time-to-onset of the second tumour of 62 months (range: 8-229). The mB-GCT group showed higher gonadotropin levels (FSH 13.6mUI/mL vs. 7.4mUI/mL, p < 0.001; LH 6.6mUI/mL vs. 3.9mUI/mL, p = 0.004), lower sperm concentration (27 × 106/ejaculate vs. 78 × 106/ejaculate, p = 0.009), smaller residual testis volume (10.4 mL vs. 16.3 mL, p < 0.001), more inhomogeneous echotexture [57.5% vs. 14%, p < 0.001], and presence of microlithiasis (75% vs. 19.5%, p < 0.001). Kaplan-Meier curves confirmed that ultrasound features of the residual testis increased the cumulative risk of developing a second tumour. Microlithiasis was a strong independent predictor (OR 30.712, 95% CI 3.357-280.942, p = 0.002). CONCLUSIONS: Histological features of the first tumour or its treatment do not influence the onset of a second tumour. However, low residual testis volume, inhomogeneous echotexture, and microlithiasis significantly increase this risk. A comprehensive evaluation of the residual testis at baseline is essential for developing a personalised surveillance programme in GCT survivors, with regular ultrasound follow-up recommended beyond the conventional 5-year limit.

Contrast-enhanced ultrasound (CEUS) for the characterization of intra-scrotal lesions.

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.

Testicular adrenal rest tumors (TART) secondary to congenital adrenal hyperplasia: A case report emphasizing early detection and management.

This study highlights the significance of testicular adrenal rest tumors (TARTs) in the context of congenital adrenal hyperplasia (CAH). The case report of an 11-year-old male with bilateral scrotal enlargement underscores the diagnostic challenges and complexities involved. Through thorough clinical, radiological, and hormonal assessments, we elucidate the pathophysiology, prevalence, and potential impact on fertility. Early detection and management of TARTs are crucial for preserving testicular function. Regular scrotal ultrasound screenings are recommended to avert long-term complications in male CAH patients.

Testicular Dysfunction in 47,XXY Boys: When It All Begins. A Semilongitudinal Study.

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.

From subjective to objective: A pilot study on testicular radiomics analysis as a measure of gonadal function.

BACKGROUND: The connection between testicular ultrasound (US) parameters and testicular function, including both spermato- and steroidogenesis has been largely suggested, but their predictive properties are not routinely applied. Radiomics, a new engineering approach to radiological imaging, could overcome the visual limit of the sonographer. OBJECTIVES: This study is aimed at extracting objective testicular US features, correlating with testicular function, including both spermato- and steroidogenesis, using an engineering approach, in order to overcome the operator-dependent subjectivity. MATERIALS AND METHODS: Prospective observational pilot study from December 2019 to December 2020 on normozoospermic subjects and patients with semen variables alterations, excluding azoospermia. All patients underwent conventional semen analysis, pituitary-gonadal hormones assessment, and testicular US, performed by the same operator. US images were analyzed by Biolab (Turin) throughout image segmentation, image pre-processing, and texture features extraction. RESULTS: One hundred seventy US testicular images were collected from 85 patients (age 38.6 ± 9.1 years). A total of 44 first-order and advanced features were extracted. US inhomogeneity defined by radiomics significantly correlates with the andrologist definition, showing for the first time a mathematical quantification of a subjective US evaluation. Thirteen US texture features correlated with semen parameters, predicting sperm concentration, total sperm number, progressive motility, total motility and morphology, and with gonadotropins serum levels, but not with total testosterone serum levels. Classification analyses confirmed that US textural features predicted patients' classification according to semen parameters alterations. CONCLUSIONS: Radiomics texture features qualitatively describe the testicular parenchyma with objective and reliable quantitative parameters, reflecting both the testicular spermatogenic capability and the action of pituitary gonadotropins. This is an innovative model in which US texture features represent a mirror of the pituitary-gonadal homeostasis in terms of reproductive function.

Testicular Adrenal Rest Tumors in a Patient With Congenital Adrenal Hyperplasia.

Ultrasound is the imaging examination of choice for evaluation of suspected testicular pathology. The differential diagnosis of bilateral testicular lesions includes malignancy such as lymphoma and metastases, infection, and, uncommonly, adrenal rest tumors. We present a patient who developed bilateral testicular adrenal rest tumors after years of poorly controlled congenital adrenal hyperplasia, possibly due to chronically elevated adrenocorticotropic hormone stimulating the growth of testicular stem cells. Our patient also has a testicular ultrasound appearance that is hyperechogenic, rather than hypoechogenic as commonly described in the literature. Treatment adherence is important in the management of congenital adrenal hyperplasia, as testicular adrenal rest tumors may eventually lead to infertility.

Traumatic testicular rupture: Multimodality imaging with intraoperative correlate.

Traumatic testicular rupture is a rare yet serious condition most commonly seen in penetrating trauma victims (e.g. gunshot wounds or motorcycle collisions) that requires immediate surgical management given its potential complications of hypogonadism and infertility. While ultrasound is the most established modality for diagnosing testicular rupture, trauma patients are usually first evaluated with a trauma protocol computed tomography (CT) exam including the chest, abdomen, and pelvis upon presentation, so it is important to recognize CT findings of testicular injury. We present a novel case in which the suspicion for testicular injury was initially raised based upon CT findings of scrotal hematoma/fluid. These findings were then further characterized with ultrasound and confirmed at surgery. In this case, we provide intraoperative imaging that corresponds clearly to findings seen on both CT and ultrasound.

The prognostic value of testicular microlithiasis as an incidental finding for the risk of testicular malignancy in children and the adult population: A systematic review. On behalf of the EAU pediatric urology guidelines panel.

INTRODUCTION: The exact correlation of testicular microlithiasis (TM) with benign and malignant conditions remains unknown, especially in the paediatric population. The potential association of TM with testicular malignancy in adulthood has led to controversy regarding management and follow-up. OBJECTIVE: To determine the prognostic importance of TM in children in correlation to the risk of testicular malignancy or infertility and compare the differences between the paediatric and adult population. STUDY DESIGN: We performed a literature review of the Medline, Embase and Cochrane controlled trials databases until November 2020 according to the Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) Statement. Twenty-six publications were included in the analysis. RESULTS: During the follow-up of 595 children with TM only one patient with TM developed a testicular malignancy during puberty. In the other 594 no testicular malignancy was found, even in the presence of risk factors. In the adult population, an increased risk for testicular malignancy in the presence of TM was found in patients with history of cryptorchidism (6% vs 0%), testicular malignancy (22% vs 2%) or sub/infertility (11-23% vs 1.7%) compared to TM-free. The difference between paediatric and adult population might be explained by the short duration of follow-up, varying between six months and three years. With an average age at inclusion of 10 years and testicular malignancies are expected to develop from puberty on, testicular malignancies might not yet have developed. CONCLUSION: TM is a common incidental finding that does not seem to be associated with testicular malignancy during childhood, but in the presence of risk factors is associated with testicular malignancy in the adult population. Routine monthly self-examination of the testes is recommended in children with contributing risk factors from puberty onwards. When TM is still present during transition to adulthood a more intensive follow-up could be considered.

Testicular Torsion in the Absence of Severe Pain: Considerations for the Pediatric Surgeon.

Testicular torsion is a surgical emergency. Early diagnosis and surgical treatment are vital in order to preserve the affected gonad. Current surgical teaching emphasizes sudden, severe, persistent, unilateral scrotal pain as a cardinal symptom of testicular torsion. We present the case of unilateral testicular torsion in a 14-year-old patient who presented with the absence of severe pain. Despite a delayed presentation to the emergency department, the gonad could be salvaged successfully. Literature on the topic of testicular torsion presenting with minimal pain is limited. Nevertheless, pediatric surgeons might be faced with cases similar to the one we describe. Underestimating this phenomenon might lead to a delay of treatment. In such cases, ultrasound can be a beneficial addition in the diagnosis and accelerate definitive operative treatment. The presented case clearly demonstrates that, although we do not include testicular torsion without severe pain in our surgical teaching algorithms, we might encounter it in our clinical practice.

Historical trends for the standards in scrotal ultrasonography: What was, what is and what will be normal.

BACKGROUND: Ultrasonography is the gold standard imaging method for scrotal investigation. Colour Doppler ultrasonography, contrast-enhanced ultrasonography and sonoelastography allow sonographers to assess size, echotexture, vascular features and stiffness of the scrotal organs and abnormalities. Scrotal ultrasonography has been used to investigate male reproductive health, scrotal pain, masses and trauma. However, ultrasonography thresholds/classifications used to distinguish normal and pathologic features of the scrotal organs have changed over time, and have not yet been fully standardized. OBJECTIVES: To evaluate historical trends for the standards in scrotal ultrasonography: what was, what is and what will be normal. METHODS: An extensive Medline search was performed identifying the most relevant studies in the English language from inception to date. RESULTS: We provide here (i) a brief overview of the history of ultrasonography, (ii) current indications for scrotal ultrasonography and (iii) previous and current normal values, cut-offs and classifications of the main colour-Doppler ultrasonography parameters/characteristics of the scrotal organs, as derived from recent guidelines and evidence-based studies. In addition, we report recommendations and the clinical utility of contrast-enhanced ultrasonography and sonoelastography. Finally, we discuss critical issues needing further evidence and future directions to fill in the current gaps. DISCUSSION: Several studies on scrotal ultrasonography are available. However, guidelines/recommendations dealing with specific ultrasonography applications have been published only in recent years. More recently, the European Academy of Andrology published evidence-based scrotal colour-Doppler ultrasonography reference ranges/normative parameters derived from a cohort of healthy, fertile men. In addition, a standardization of the methodology to evaluate qualitative and quantitative colour-Doppler ultrasonography parameters was reported. Other international societies reported indications, methodological standards, clinical utility and limitations of contrast-enhanced ultrasonography and sonoelastography. CONCLUSIONS: To date, colour-Doppler ultrasonography normative values for the scrotal organs are available. However, a wide international consensus on assessment and classification of several ultrasonography parameters is still lacking. An alignment of the world societies on these issues is advocated.

The role of contrast enhanced ultrasound in the differential diagnosis of segmental testicular infarction.

A 43-year-old male presented to the emergency department with acute left testicular pain. Physical exam showed a tender left testicle and epididymis with mild swelling. Doppler and contrast enhanced ultrasound revealed a heterogeneous, avascular lesion with hyper vascularized surrounding. Follow-up contrast enhanced ultrasound performed a few days later showed persistence of the sparsely vascularized lesion with more hypoechoic echo structure. Despite the tumor markers being negative, a necrotic tumor could not be ruled out and a left orchiectomy was performed. Pathology report described an extensive segmental testicular infarction with no evidence of malignant tissue. We present the ultrasound and pathology findings, differential diagnostic pearls and clinical perspective of segmental testicular infarction.

Testicular microlithiasis on scrotal ultrasound in 4850 young men from the general population: associations with semen quality.

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.