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A.Epidermis
B.Subcutaneousfat
C.Tunicaalbuginea
D.Penileurethra
AnswersandExplanations
1.AnswerD.Imagesoftheleft testisshowawell-circumscribedsolidmasswithmultipleconcentric
hypo-andhyperechogenicringsgivingitan“onionring”appearance.Thereislackofvascularflow on
color Doppler,and thesurroundingtesticularparenchymaisnormal. The findingsare pathognomonicof
epidermoidcystofthetestis,whichisararebutbenignlesion.
Alternating hypo- and hyperechogenic concentric rings are considered to be characteristic of an
epidermoid cyst and correspond to its natural evolution. The lining of the cyst produces keratin in
successivelayersbydesquamatingepitheliumfromthecystwall,resultingintheonionringappearance.
References:HertzbergBS,MiddletonWD.Ultrasound:therequisites,3rded.Philadelphia,PA:Elsevier,2016:153.
LoyaAG,SaidJW,GrantEG.Epidermoidcystofthetestis:radiologic-pathologiccorrelation.RadioGraphics2004;24(Suppl1):S243–S246.
RumackCM,WilsonSR,CharboneauWJ.Diagnosticultrasound,4thed.Philadelphia,PA:ElsevierHealthSciences,2011:853–854.
2. Answer D. The potential for higher ultrasound intensities to cause biologic injury has been
established in the laboratory. A theoretical risk exists that diagnostic ultrasound can also produce
unwanted biologic effects on humans, especially on intrauterine gestations as a result of thermal and
nonthermalbioeffects.However,diagnosticultrasoundhasanexcellentsafetyrecord,andtherehavebeen
no reportedincidents ofadversebioeffectson humansatdiagnosticultrasoundlevels inthe absenceof
contrastagents.Insituationsinwhichan ultrasoundisclinicallyindicated,thebenefitof the ultrasound
willoutweightherisks.
Reference:AmericanInstituteofUltrasoundinMedicine.Medicalultrasoundsafety,3rded.Laurel,MD:AmericanInstituteofUltrasound
inMedicine,2014:23–28.
3.AnswerC.Ultrasoundimagesaretypicallycomposedof640×480or512×512pixels.Eachpixel
hasadepthof8bits(1byte)ofdigitaldata,providingupto28,thatis,256levelsofgrayscale.
Reference: BushbergJT,SeibertJA,LeidholdtEM. Theessential physics of medicalimaging,3rded. Philadelphia, PA: Wolters Kluwer
Health/LippincottWilliams&Wilkins,2011:542.
4a.AnswerD.Imagesoftherighttesticleshowmultipleechogenicfociwith“dirty”shadowinginthe
scrotumposteriortotherighttesticleconsistentwith gas.Inthesettingofscrotal swelling,painandno
history of trauma, the findings are consistent with Fournier gangrene. The most common predisposing
factors for Fournier gangreneare diabetesmellitus and alcoholism.Therefore,choice Dis the correct
answer.
Coexistingdiabetesmellitushasbeenfoundinupto40%to60%ofpatientswithFourniergangrene.
OtherpredisposingfactorsincludeindwellingFoleycatheters,surgicalprocedures,malignancy,steroids,
chemotherapy, radiation therapy, prolonged hospitalization, and HIV. It occurs most frequently in men
aged 50 to 70 years. Multiple organisms are usually involved, including Klebsiella, Streptococcus,
Proteus,andStaphylococcus.
Congestive heartfailure (choice B) andpseudomembranous colitis (choice C) arenot risk factors.
Although malignancy can be associated with Fournier gangrene, lymphoma (choice A) is incorrect
becausediabetesmellitusisafarmorecommoncause.
4b.AnswerD.The treatmentofFourniergangreneincludesIV antibiotics,hemodynamicstabilization,
and immediate surgical debridement. Multiple debridements may be needed to remove all nonviable
tissue.Patients with incomplete debridement/drainage orwho aretreatedwithantibiotics alonehavea
poor prognosis. Thecause ofdeath includessevere sepsis, multipleorgan failure, coagulopathy, acute
renalfailure,anddiabeticketoacidosis.
References:LevensonR,SinghA,NovellineR.Fourniergangrene:roleofimaging.RadioGraphics2008;28(2):519–528.
RumackCM,WilsonSR,CharboneauWJ.Diagnosticultrasound,4thed.Philadelphia,PA:ElsevierHealthSciences,2011:869.
5.AnswerC.Images1and2showacontourabnormalityofthetesticleatthelowerendoftheimage.
Image 3 shows flow within the testicle, except for a peripheral hypoechoic area with no flow, and
geographic,non–mass-likemargins.Thereisdisruptionofthetunicaalbuginea,whichisfreefloatingin
image1.Thefindingsareconsistentwithtesticularrupture.
The tunica albuginea is a thin, echogenic curvilinear structure completely surrounding the testes.
Disruption ofthetunicaalong with extrusion oftheseminiferous tubules is a specificsignoftesticular
rupture. The contour abnormality at the lower end of the images represents the extruded seminiferous
tubules. In addition, there is a hydrocele containing low-level echoes consistent with a hematocele.
Therefore,bluntscrotaltrauma (choice C) isthecorrectanswer.Anintact tunica albugineais crucial,
because,ifintact,surgeryisusuallynotindicated.Ifdisrupted,testicularviabilitycanbemaintainedmore
than80%ofthetimeifsurgeryisperformedwithin72hours.Afterward,viabilitydropstobelow50%.A
disruption of the tunica albuginea is a definitive sign of rupture, but is often not detected. A contour
abnormalityindicatesextrusionoftheseminiferoustubulesandisareliablesecondarysign.
Patients with intrascrotal hematoma or hematocele will typically undergo surgical exploration
becauseofthedifficultyinexcludingruptureintheirpresence.Testicularfractureindicatestearingofthe
testicular parenchyma with or without disruption of the tunica albuginea.Itappears as anavascular or
hypovascularintratesticulardefect.Intratesticular hematomaisalsocommonintesticulartrauma.When
large,theycanleadtotesticularnecrosis,andsurgicalexplorationisnecessary.
Acute onset of testicular pain and swelling (choice A) can be seen in epididymitis–orchitis and
torsion. However, the contour abnormality and disrupted tunica would not be seen in either of these
entities.OnewouldexpecttoseeamasswithDopplerflow,andnodisruptionofthetunicaifthepatient
hadaneoplasticprocess (choice B).Feverandpyuria (choice D)wouldbeindicativeofaninfectious
process.Ofthechoices,theimagessupporttrauma,notinfection.
References:HertzbergBS,MiddletonWD.Ultrasound:therequisites,3rded.Philadelphia,PA:Elsevier,2016:164–167.
RumackCM,WilsonSR,CharboneauWJ.Diagnosticultrasound,4thed.Philadelphia,PA:ElsevierHealthSciences,2011:869–871.
6.AnswerC.Multipledilatedveinswithintherightscrotumarecompatiblewithascrotalvaricocele.
Varicocelesareusuallytheresultofincompetentorcongenitallyabsentvalveswithinthetesticularvein.
Theyarethemostcommoncorrectablecauseofmaleinfertility.Diagnosticcriteriaincludedilatedveins
ofthepampiniformplexusgreaterindiameterthan2to3mminstandingorsupinepositionsandvenous
refluxonDopplerimagingduringorwithoutaValsalvamaneuver.Themajorityofvaricoceles(85%)are
unilateralandleftsided.Bilateralvaricocelesconstitutethemajorityoftheremainderofcases.Unilateral
right-sided varicoceles rarely occur. When they do, compression of the right spermatic vein by a
retroperitonealmassorsitusinversusshouldbeconsidered.
Reference:HertzbergBS,MiddletonWD.Ultrasound:therequisites,3rded.Philadelphia,PA:Elsevier,2016:148–150.
7.AnswerA.Spermgranulomasarepresumedtobebecauseofanecrotizinggranulomatousresponseto
extravasatedspermatozoa.Theycanbepainfulorasymptomaticandaremostfrequentlyfoundinpatients
whohaveundergonevasectomy.Spermgranulomasaretypicallyhypoechoicorheterogeneousandoften
lackincreasedDopplerflow.Calcificationscanbeseeninchronicspermgranulomas.
Varicoceles(choiceB)areanechoicandtubularandcontainDopplerflow.Germcelltumors(choice
C)arisefromthetestisandnottheepididymis.Thelesionshownissolidandintheregionofepididymis.
Thereisnoperitesticularcollectiontosuggesthematocele(choiceD).
References:BlackJA,PatelA.Sonographyoftheabnormalextratesticularspace.AJRAmJRoentgenol1996;167(2):507–511.
RumackCM,WilsonSR,CharboneauWJ.Diagnosticultrasound,4thed.Philadelphia,PA:ElsevierHealthSciences,2011:872.
8a.AnswerD.Thefirstimageisoftherighttesticle,whichhasanormalappearanceandnormalcolor
Dopplersignal.Thesecondimageisofthelefttesticle,showingnodetectableDopplersignal.Thethird
image shows asymmetryof flow on a side-by-side view, andthefourth imagelabeled “leftspermatic
cord”showsawhirlpoolappearance ofthecord,theso-calledtorsionknot.Thisisacase oftesticular
torsion.Inadultspresentingwithacutescrotalpainintheabsenceoftrauma,thedistinctionmustbemade
between torsion and an inflammatory condition such as acute epididymitis. Testicular torsion usually
occursasa resultofa faultyattachmentofthe testistothescrotalwall,most commonlyresultinginthe
bell-clapperdeformity.Inthiscondition,thetunicavaginaliscompletelysurroundsthetestis,causingthe
testistobefreelysuspendedbythespermaticcordinthescrotalsac.Promptsurgicalintervention(choice
D)isnecessaryifthetestisistobesalvaged.
The salvage rateis80%to100% ifsurgeryisperformedwithin 6hoursafterthe onset ofpainbut
dropstoonly20%ifsurgeryisdelayedformorethan12hours.Inmostcasesoftorsion,asinthiscase,
therewillbenodetectableflow.Somecaseswillshowflowthatisasymmetric,whichiswhyside-bysideimagesaremandatory.Ifthetorsionisprolonged,theremaybehyperemiainthetissuessurrounding
the infarcted testis. Gray-scale findings in torsion are variable, and echogenicity may be normal,
increased, or decreased, and the parenchyma may be homogeneous or heterogeneous. If the testis is
hypoechoicorheterogeneous,itislikelynonviable.
ChoiceAisincorrectbecausethisisnota caseofepididymitis.Withepididymitisorepididymitis–
orchitis,onewouldexpecttoseeincreasedflowonthesideofpain,notdecreased/absentflowasinthis
case.Ifthiswasacaseoftumorinfiltrationofthelefttestis,onewouldexpecttoseeincreasedflowin
the affectedparenchyma. Tumor most oftenpresents as a painless mass, which is not how this patient
presented.Therefore,astagingCTscan(choiceB)isnotappropriate.ChoiceCisincorrectbecauseof
theneedforpromptsurgicalintervention,ideallywithin6hours,forsalvage.
8b.AnswerC.Approximately20%isthecorrectanswer,asdiscussedabove.
Reference:HertzbergBS,MiddletonWD.Ultrasound:therequisites,3rded.Philadelphia,PA:Elsevier,2016:159–162.
9.AnswerD.Thehistoryoflifelongsteroidsupplementationsuggestsadiagnosisofcongenitaladrenal
hyperplasia. Congenital adrenal hyperplasia (CAH) is an autosomal recessive disorder resulting inan
enzyme deficiency (usually 21-hydroxylase deficiency) involved in the production of cortisol and
aldosterone. Low levels of glucocorticoids and mineralocorticoids lead to elevated levels of
adrenocorticotropin(ACTH),whichinturnleadtoadrenalhyperplasia.Adrenalrestsareectopicfociof
adrenal tissue that can be found in up to 50% of normal neonates within the retroperitoneum, broad
ligaments,ovaries,inguinalregion,andtestes.Normally,adrenalrestsalmostalwaysregress.However,
elevatedACTHlevelsinthesettingofCAHcanmaintainandgrowtheectopicrests.Testicularadrenal
rests are usually bilateral and vary in size from 4 to 38 mm. They are usually sharply demarcated
hypoechoiclesionsonultrasound.Largelesionsarepalpable.Aslesionsenlarge,theymaycompressthe
surroundingtesticularparenchyma,leadingtoinfertilityorchronicpain.
Anincreaseinsizeandnumberoftesticularadrenalrestscanoccurifexogenoushormonetherapyis
inadequate. Increasing the dose of exogenous hormone therapy until endogenous ACTH levels are
suppressedcanresultinregressionofadrenalresttumors.Therefore,choiceD,increasedsteroiddosage,
iscorrect.
Testicular biopsy (choice B) and bilateral orchiectomy (choice C) are not the correct answers
because although the sonographic appearance of individual adrenal rests overlaps with testicular
carcinoma,thebilateralityofthelesions is veryunusual fortesticularcancer.Antibiotics (choiceA)is
alsoincorrectbecausethesonographicmass-likefindingswithoutpainorothersignsofinfectiondonot
indicateaninfectiousprocess.
Other differential considerations for bilateral testicular lesions include Leydig cell hyperplasia,
sarcoidosis,lymphoma,andmetastases.
References: Dogra V, Nathan J, Bhatt S. Sonographic appearance of testicular adrenal rest tissue in congenital adrenal hyperplasia. J
UltrasoundMed2004;23(7):979–981.
German-MenaE,ZibariG,LevineS.Adrenalmyelolipomasinpatientswithcongenitaladrenalhyperplasia:reviewoftheliteratureandacase
report.EndocrPract2011;17(3):441–447.
OlpinJD,WittB.Testicularadrenalresttumorsinapatientwithcongenitaladrenalhyperplasia.JRadiolCaseRep2014;8(2):46–52.
10.AnswerD.Tubularectasiaoftheretetestisisanincidentalfindingthatdoesnotwarrantanyfurther
evaluation, intervention, or follow-up. Multiple anechoic cystic or tubular spaces replacing the
mediastinumtestis,oftenbilaterally,arethe typicalsonographicappearanceandshouldnotbeconfused
withtesticulartumororabscess.
No further evaluation is required as tubular ectasia of the rete testis is a benign entity. Therefore,
choice A is incorrect. Tubular ectasia of the rete testis is a noninfectious entity and does not need
treatmentwithantibiotics(choiceB). Atesticularabscess hasthe appearanceofa more heterogeneous
complex fluidcollectionwithperipheral hyperemia.Tubularectasiaoftheretetestis isa benignentity
that does not require surgical intervention (choice C). Testicular malignancies often are solid or have
dominantsolidcomponents.
References:HertzbergBS,MiddletonWD.Ultrasound:therequisites,3rded.Philadelphia,PA:Elsevier,2016:151–154.
RumackCM,WilsonSR,CharboneauWJ.Diagnosticultrasound,4thed.Philadelphia,PA:ElsevierHealthSciences,2011:861–863.
11a.AnswerD.Imagesshowasmalltestiswiththickoverlyingtissuecompatiblewithanundescended
lefttestis.Althoughundescendedtestescanoccuranywherewithintheretroperitoneumfromthelevelof
thelowerpoleofthekidneytotheinguinalregion,approximately80%arelocatedintheinguinalregion.
Mostofthosearejustcaudaltotheexternalinguinalring.
11b. Answer A. Complications associated with undescended testes include infertility, carcinoma,
torsion,andincreasedsusceptibility totesticulartraumaticinjury. Althoughanundescended testishasa
significantlyincreasedriskofdevelopingcancer(usuallyseminoma),thenormaldescendedtestisisalso
placed at an elevated cancer risk. This increased risk does not completely disappear following
orchiopexyandpatientsrequirecontinuedsurveillancefortesticularcancer.
11c. Answer D. American Urological Association (AUA) guidelines recommend against the use of
imagingintheevaluationofboyswithcryptorchidism.Morethan70%ofcryptorchidtestesarepalpable
and require no imaging. Patients with nonpalpable cryptorchid testes should undergo a diagnostic
laparoscopytoidentifyandtreatthemalpositionedtestes.Theinvestigationcanendiftesticularabsence
isconfirmedatsurgery.
References: Kolon TF, Herndon CDA, Baker LA, et al. Evaluation and treatment of cryptorchidism: AUA guideline. J Urol
2014;192(2):337–345.
RumackCM,WilsonSR,CharboneauWJ.Diagnosticultrasound,4thed.Philadelphia,PA:ElsevierHealthSciences,2011:871–874.
12a. Answer C. Enlargement and decreased echogenicity of the epididymis and right testis with
hyperemia are classic features of acute epididymitis–orchitis. Most commonly, inflammation of the
scrotuminvolvestheepididymisasaresultofalowerurinarytractinfection.Wheninflammationspreads
into the testis, an epididymitis–orchitis results. Hence, isolated orchitis is much less common than
isolatedepididymitis. Inflammationoftheepididymismaybefocalordiffuse,whereasinflammationof
thetestisismuchmorefrequentlydiffuse.Whenafocalhypoechoichypervascularintratesticularlesionis
foundinthesettingofsuspectedinflammation,follow-upsonographyshouldbeperformedtoexcludean
occultmalignancy. Pain andtenderness of the abnormal testis withouta palpable mass or signs of an
inflamedepididymisonimagingwouldfavorafocalorchitis.Themostcommoncomplicationsoforchitis
includepyocele,testicularabscess,andtesticularinfarction.
12b. Answer C. Vascularity ofthe normal epididymis is less thanthetestis. Normally, flow maynot
necessarilybedetectableonDopplersonography.
References:HertzbergBS,MiddletonWD.Ultrasound:therequisites,3rded.Philadelphia,PA:Elsevier,2016:163–164.
RumackCM,WilsonSR,CharboneauWJ.Diagnosticultrasound,4thed.Philadelphia,PA:ElsevierHealthSciences,2011:869.
13a.AnswerC.Imagesshowanintratesticularmasswithcystic,solid,andcalcifiedcomponentsnearly
replacing the right testicle. A thin rim of normal testicular parenchyma surrounds the mass. Imaging
featuresareconsistentwithneoplasm.
Althoughacuteepididymitis–orchitismaycausetheaffectedsidetoappearenlargedandhyperemicas
inthiscase,orchitisisnotmass-likeandshouldalsoinvolvetheepididymis.Inthiscase,theepididymis
isnormal.Bothintratesticularhematomaandtesticularrupturemaycauseheterogeneousechogenicityof
the testicle. Hematomas should be avascular onDoppler imaging.Testicular rupture isalso associated
with irregular testicular contour or disruption of the tunica albuginea and is accompanied by a
hematocele.
13b.AnswerA.Imagesshowamasswithcystic,solid,andcalcifiedcomponentsnearlyreplacingthe
righttesticle.Thepresenceofcysticandcalcifiedcomponents, especially inthisagedemographic,are
mostconcerningforamixed germcell tumor. Pureseminomasaremost oftenuniformlyhypoechoicon
US. Although lymphoma and leukemia can be indistinguishable from mixed germ cell tumors, these
entitiesarelesscommonatthisage.
13c.AnswerA. Testicular tumorsspreadviathelymphaticchannels, whichaccompany the testicular
vessels.Forthisreason,theretroperitoneallymphnodesaretypicallythefirstsiteofspreadwithrightsidedtumorsspreadingtotherightparacaval,precaval,andrightretrocavalnodesandleft-sidedtumors
spreadingtotheleftpara-aorticandpreaorticnodes.Hematogenousspreadtothelungs,brain,bone,and
livercanalsooccur.
13d.AnswerA.Riskfactorsfortesticular cancerinclude personalhistory ofgermcell tumor,family
history,cryptorchidism,infertility,andtesticulardysgenesis.Althoughoncethoughttobeassociatedwith
cancer,microlithiasisisnolongerbelievedtobeariskfactor.
References: KreydinE,Barrisford G, Feldman A, et al. Testicular cancer: what the radiologist needs to know. AJR Am J Roentgenol
2013;200(6):1215–1225.
SohaibS,KohD,HusbandJ. The role of imaging in the diagnosis, staging,andmanagementoftesticular cancer. AJR. AmJ Roentgenol
2008;191(2):387–395.
WoodwardP,SohaeyR,O’DonoghueM,etal.FromthearchivesoftheAFIP:tumorsandtumorlikelesionsofthetestis:radiologic-pathologic
correlation.RadioGraphics2002;22(1):189–216.
14. Answer C. Gray-scale ultrasound image of the left testis shows heterogeneity of the testicular
parenchyma. Power Doppler fails to demonstrate vascular flow in a portion of the parenchyma. This
findingisconfirmedonscrotalMRI, whichshowslackofenhancementinasmallperipheralportionof
the left testis with enhancement of the overlying intact tunica albuginea. The imaging appearance is
consistentwithsegmentalinfarctionofthetestis.
Theupperpoleofthetestisismorepronetoinfarctionbecauseofdualsupplytothelowerpolefrom
theposteriorepididymalartery.Onultrasound,awedge-shapedareaofhypoechogenicityorheterogeneity
isusuallyseenwiththevertexdirectedtowardthemediastinumtestis.Thereislackofflowoncoloror
power Doppler imaging. Occasionally, the area of infarct may appear rounded on ultrasound with
surroundingmasseffect. In such cases,itmaybedifficulttodifferentiatefrom testiculartumor.MRI is
helpful in these cases and will show an area of nonenhancement sometimes surrounded by a rim of
perilesionalenhancement.
References:HarisinghaniM,RajeshA.Genitourinaryimaging:acasebasedapproach.London,UK:Springer,2014:260–262.
RumackCM,WilsonSR,CharboneauWJ.Diagnosticultrasound,4thed.Philadelphia,PA:ElsevierHealthSciences,2011:854.
15.AnswerC.Theimagesshowacalcifiedplaquewithposterioracousticshadowingandnointernal
bloodfloworperilesionalhyperemia.ThisimagingappearanceistypicalofPeyroniedisease,whichis
anidiopathicconditioncharacterizedbyformationoffibrousplaqueswithin thetunica albugineaofthe
corpora cavernosa.This canresultin penile deformity and curvature. Theplaquesare usuallyseen as
focalhyperechoicthickeningofthetunicaalbugineaandmaybecalcified.Theyareusuallyfoundonthe
dorsalsurfaceofthepenis,buttheycanalsooccurontheventralandlateralsurfaces.
Reference:HertzbergBS,MiddletonWD.Ultrasound:therequisites,3rded.Philadelphia,PA:Elsevier;2016:173.
6 Gynecology
Questions
1a.A33-year-oldfemalepresentsforevaluationofdysmenorrhea.Imagesoftheleftadnexaareshown.
An ultrasoundfrom 3 months agoshowed a similar finding.Beta-hCG was negative. Whatis themost
likelydiagnosis?
A.Hemorrhagiccyst
B.Maturecysticteratoma
C.Endometrioma
D.Tuboovarianabscess
1b.Whichofthefollowingisthestandardofreferenceinthediagnosisofendometriosis?
A.Hysterosalpingogram
B.CT
C.MRI
D.Laparoscopy
1c. Malignant transformation is a rare complication (<1% of cases) of endometriosis. Which of the
followingisthemostcommonmalignantneoplasmarisingfromendometriosis?
A.Clearcellcarcinoma
B.Clearcellsarcoma
C.Endometrioidcarcinoma
D.Endometrialcarcinoma
1d.Whichofthefollowingisthemostcommonlyaffectedgastrointestinaltractareabyendometriosis?
A.Cecum
B.Distalileum
C.Appendix
D.Rectosigmoidcolon
2a.A30-year-oldfemaleis undergoinginfertility workup. 3D coronal US image ofthemidto fundal
uterusandtransverseimagethroughtheloweruterinesegmentareshown.Theimagingfeaturesaremost
consistentwithwhichuterineanomaly?
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