Ultrasound of the Testis for the Andrologist: Morphological and Functional Atlas

276 Pages·2017·57.327 MB·English

by  Andrea M. Isidori,Andrea Lenzi (auth.)

Trends in Andrology and Sexual Medicine
Series Editors: E.A. Jannini, C. Foresta, A. Lenzi, M. Maggi
Andrea M. Isidori
Andrea Lenzi
Ultrasound of
the Testis for the
Andrologist
Morphological and Functional Atlas
Trends in Andrology and Sexual Medicine
Series Editors
Emmanuele A. Jannini
Chair of Endocrinology and Medical Sexology (Endosex)
Department of Systems Medicine
University of Rome Tor Vergata
Rome, Italy
Carlo Foresta
Chair of Endocrinology
Department of Medicine, Unit of Andrology and Reproductive Medicine
University of Padua
Padua, Italy
Andrea Lenzi
Chair of Endocrinology
Department of Experimental Medicine, Section of Medical Pathophysiology
Food Science and Endocrinology
Sapienza University of Rome
Rome, Italy
Mario Maggi
Chair of Endocrinology
Department of Experimental, Clinical and Biomedical Sciences
Unit of Andrology and Sexual Medicine
University of Florence
Florence, Italy
This series will serve as a comprehensive and authoritative resource that presents state of the art
knowledge and practice within the fields of Andrology and Sexual Medicine, covering basic
science and clinical and psychological aspects. Each volume will focus on a specific topic
relating to reproductive or sexual health, such as male and female sexual disorders (from
erectile dysfunction to vaginismus, and from hypoactive desire to ejaculatory disturbances),
diagnostic issues in infertility and sexual dysfunction, and current and emerging therapies
(from assisted reproduction techniques to testosterone supplementation, and from PDE5i to
SSRIs for premature ejaculation). In addition, selected new topics not previously covered in a
single monograph will be addressed, examples including male osteoporosis and the approach
of traditional Chinese medicine to sexual medicine. Against the background of rapid progress
in Andrology and Sexual Medicine, the series will meet the need of readers for detailed updates
on new discoveries in physiology and pathophysiology and in the therapy of human sexual and
reproductive disorders.
More information about this series at http://www.springer.com/series/13846
Andrea M. Isidori • Andrea Lenzi
Ultrasound of the Testis for
the Andrologist
Morphological and Functional Atlas
Andrea M. Isidori Andrea Lenzi
Department of Experimental Medicine Department of Experimental Medicine
Endocrinology and Andrology Unit, Endocrinology and Andrology Unit,
Sapienza University of Rome Sapienza University of Rome
Rome Rome
Italy Italy
Partially based on the volume "Scrotal Ultrasound: Morphological and Functional Atlas",
ISBN 9788889620465
ISSN 2367-0088 ISSN 2367-0096 (electronic)
Trends in Andrology and Sexual Medicine
ISBN 978-3-319-51825-1 ISBN 978-3-319-51826-8 (eBook)
https://doi.org/10.1007/978-3-319-51826-8
Library of Congress Control Number: 2017955845
© Springer International Publishing AG 2017
This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is
concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction
on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation,
computer software, or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not
imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and
regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed
to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty,
express or implied, with respect to the material contained herein or for any errors or omissions that may have been
made.The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Printed on acid-free paper
This Springer imprint is published by Springer Nature
The registered company is Springer International Publishing AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
Foreword
Over the last 10 years, ultrasound examination of the scrotum has become established as a
convenient extension of the andrological examination of patients presenting with a complaint
of reproductive function. A well-performed ultrasound examination is probably the single
most informative diagnostic procedure to facilitate the correct diagnosis of any intra-scrotal
abnormality. Pertinently, for the correct interpretation of imaging features, a full clinical his-
tory and clinical examination must be integrated with imaging findings, giving a comprehen-
sive overview of the patient’s healthcare. Importantly, hormonal assessment and sperm analysis
findings are most useful in the presence of any scrotal pathology.
Since 2002, the Department of Experimental Medicine at the “Sapienza” University of
Rome has established an ultrasonography unit dedicated solely to andrological cases, equipped
with the very latest and technically advanced ultrasound machines. Over this period of time,
the unit has performed over 10,000 testicular ultrasound examinations in patients investigated
for a variety of conditions. All the images of these examinations have been saved, with a mul-
titude of abnormalities forming the basis of this new atlas-textbook. This core experience has
been augmented by contributions of extremely valuable material from a number of interna-
tional experts to form probably the largest collection in the world, constituting over 1000
ultrasound images, many in full colour, of scrotal pathology.
This unique new reference text for scrotal ultrasonography is also notable for its main
emphasis on functional interpretation of the images supplemented by clinical data, thus ensur-
ing that the information will be helpful for clinical management. This approach is intended to
increasingly familiarise clinicians with the potential of ultrasonography and, in doing so,
encourage incorporation of ultrasound into a central position of the diagnostic pathway in
daily clinical practice. Moreover, all the specialists that deal with scrotal pathologies should
know the diagnostic potentials offered by the newest imaging modalities (contrast-enhanced
ultrasound, elastography), the so-called multiparametric ultrasound examination aiding further
development of this modality in the assessment of the scrotal contents.
Paul S. Sidhu
King’s College London
London, UK
v
Acknowledgments
We are grateful to Dr. Carlotta Pozza and Dr. Daniele Gianfrilli for their pivotal contribution
in assisting patients, discussing cases and helping write this book.
We thank our colleagues Prof. Cristiano Cristini, Dr. Giorgio Fattorini, Prof. Giorgio
Franco, Prof. Ermanno Greco, Prof. Francesco Lombardo, Prof. Giovanni Martino and Prof.
Antonio Radicioni, who constantly refer their most complex cases to our testis unit.
We are grateful to all the international collaborators who actively helped assembling this
unique collection of cases sending useful pictures of rare conditions: Prof. Amaya Basta, Prof.
Demosthenes Cokkinos, Prof. Monica Epelman, Prof. Alex Kirkham, Prof. Malai Muttarak,
Prof. Raymond Oyen, Prof. Paul S. Sidhu, Prof. S Boopathy Vijayaraghavan, Prof. Edward
Bluth, Prof. Ronald O. Bude, Prof. Kyoung-Sik Cho, Prof. K.C. Dewbury, Prof. Rahul Gupta,
Prof. David C. Howlett, Prof. John R. Mernagh, Prof. Martha M. Munden, Prof. Matilde Nino-
Murcia, Prof. P. Perimenis, Prof. Osmar De Cassio Saito, Prof. J. Smart, Prof. Simon Strauss,
Prof. Krishna M. Surti, Prof. Kunjie Wang, Prof. Neil F. Wasserman and Prof. Aaron F. Wittemberg.
vii
Contents
1 Scrotal and Testicular Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.2 Layers of the Scrotum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.3 The Testis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1.4 The Epididymis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
1.5 The Spermatic Cord . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
1.6 Arteries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
1.7 Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
1.8 Examination Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
2 Non-neoplastic Intratesticular Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
2.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
2.2 Cysts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
2.2.1 Intratesticular Cysts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
2.2.2 Tunica Albuginea Cyst . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
2.2.3 Tunica Vaginalis Cyst . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
2.2.4 Dilation of Rete Testis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
2.2.5 Epidermoid Cysts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
2.2.6 Dermoid Cyst . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
2.3 Calcifications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
2.4 Global and Segmental Ischaemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
2.5 Others . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
2.5.1 Abscess . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
2.5.2 Adrenal Rest. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
2.5.3 Sarcoidosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
2.5.4 Atrophy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
2.5.5 Orchitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
2.5.6 Post-biopsy Scars . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
2.5.7 Intratesticular Varicocele . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
2.5.8 Fibrosis of the Tunica Albuginea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
2.5.9 Testicular Gummas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
2.5.10 Splenogonadal Fusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
2.5.11 Intratesticular Haematoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
3 Neoplastic Intratesticular Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
3.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
3.2 Germ Cell Tumours . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
3.2.1 Seminomatous Germ Cell Tumours . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
3.2.2 Non-seminomatous Germ Cell Tumours . . . . . . . . . . . . . . . . . . . . . . . . 97
ix
x Contents
3.3 Stromal Cell Tumours . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
3.3.1 Leydig Cell Tumours . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
3.3.2 Sertoli Cell Tumours . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
3.4 Other Malignant Tumours . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
3.4.1 Lymphoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
3.4.2 Leukaemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
3.4.3 Plasmacytoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
3.4.4 Testicular Carcinoid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
3.4.5 Metastases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
3.5 Non-palpable Testicular Lesions: Benignity vs. Malignancy . . . . . . . . . . . . . . 127
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
4 Extratesticular Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
4.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
4.2 Epididymal Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
4.2.1 Epididymal Cysts and Spermatoceles . . . . . . . . . . . . . . . . . . . . . . . . . . 137
4.2.2 Inflammation and Infections of the Epididymis. . . . . . . . . . . . . . . . . . . 145
4.2.3 Epididymal Tumours . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
4.3 Spermatic Cord Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156
4.3.1 Funiculitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156
4.3.2 Spermatic Cord Tumours . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
4.4 Tunica Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
4.4.1 Fibrous Pseudotumour . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
4.4.2 Mesothelioma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
4.5 Extratesticular Calcifications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
4.6 Fluid Collections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
4.7 Hernias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173
5 Acute Scrotum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
5.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
5.2 Testicular Torsion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
5.3 Torsion of the Testicular Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
5.4 Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186
5.5 Epididymo-orchitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192
5.6 Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
5.6.1 Acute Idiopathic Scrotal Oedema . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
5.6.2 Thrombophlebitis of the Pampiniform Plexus . . . . . . . . . . . . . . . . . . . . 203
5.6.3 Vasculitis and Henoch-Schönlein Purpura . . . . . . . . . . . . . . . . . . . . . . . 203
5.6.4 Fournier’s Gangrene . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
6 Testicular Varicocele . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
6.1 Testicular Varicocele . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
6.1.1 Definition and Aetiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
6.2 Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
6.3 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212
6.4 Classification of Varicocele . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213
6.5 Intratesticular Varicocele . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225
6.6 Adolescent Varicocele . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229
Contents xi
7 Cryptorchidism, Pubertal Development, Hypogonadism
and Other Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231
7.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231
7.2 Cryptorchidism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231
7.2.1 Inguinal-Scrotal Hernia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237
7.2.2 Hydrocele in the Neonatal Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237
7.3 Pubertal Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238
7.4 Varicocele in Puberty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
7.5 Hypogonadism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252
8 Advanced Ultrasonographic Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253
8.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253
8.2 Contrast-Enhanced Ultrasound (CEUS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253
8.3 Elastosonography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254
8.4 A Selection of CEUS and Elastography Applications
in Testicular Pathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 256
8.4.1 Seminoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 256
8.4.2 Non Seminomatous Germ Cell Tumours . . . . . . . . . . . . . . . . . . . . . . . . 256
8.4.3 Sex Cord: Stromal Tumours . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 256
8.4.4 Epidermoid Cysts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257
8.4.5 Acute Scrotum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 270