Male Genital Tract

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16.3 Male Genital Tract

Overview (Table 68):

..............................................................................................................

Table 68.Abnormal findings in the male genital organs

yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy

Vesiculitis (p. 389)

Acute prostatitis (p. 389)

Benign prostatic hyperplasia (BPH, p. 390)

Prostatic carcinoma (p. 390)

Chronic prostatitis, prostatic calcifications (p. 391)

Orchitis, abscess, hematoma (p. 392)

Testicular tumors (p. 393)

Hydrocele, varicocele (p. 393)

Spermatocele (p. 394)

Epididymitis (p. 394)

Testicular torsion (p. 394)

Urethral strictures (p. 394)

Abnormal Findings

..............................................................................................................

Changes in the seminal vesicles (Fig. 577):

Focal echogenic areas: calcifications (Fig. 577a)

Hypoechoic swelling: purulent vesiculitis (Fig. 577b). Must be differentiated from invasion by prostatic carcinoma.

Urogenital Tract

Fig. 577a, b Abnormalities of the seminal vesicles. a Calcifications of the seminal vesicles (SV). B = bladder. b Purulent vesiculitis : bulky hypoechoic to anechoic seminal vesicles with ill-defined margins. Harmonic imaging

Acute prostatitis (Fig. 578):

Decreased echogenicity of the prostate

Slight enlargement

Smooth borders

Frequent purulent liquefaction

389

16.3 Male Genital Tract

Urogenital Tract

Benign prostatic hyperplasia (BPH, Fig. 579; see also Fig. 574, p. 387):

Fig. 578 Acute prostatitis: fluid collection (P, arrow) in the prostate. The echogenic area represents purulent liquefaction. R = rectum

Circumscribed or diffuse enlargement of the periurethral gland near the bladder floor (= enlarged middle lobe) Proliferation of the central paraurethral tissue may exert pressure on the other parts of the gland, inciting the formation of a “surgical capsule.” Smooth margins, intact capsule

Fig. 579a–c Benign prostatic hyperplasia (BPH). a Lower abdominal transverse scan: homogeneous echo pattern with fairly smooth borders. The bulging upper surface of the prostate has elevated the bladder floor.

b Lower abdominal longitudinal scan:

geneous due to numerous microcalcifications (amyloid bodies, arrows). R = rectum. c Benign nodular prostatic hyperplasia (P, cursors) with a hypoechoic benign prostatic hypertrophy, “middle lobe adenoma” (A, cursors) indenting the bladder floor (B)

Prostatic carcinoma (Figs. 580 and 581):

Early signs:

390

– Nonhomogeneous echo pattern – Hypoechoic areas

large prostate indenting the bladder floor (B). The echo pattern is nonhomo-

16.3 Male Genital Tract

Fig. 580a, b Prostatic carcinoma. a Early prostatic carcinoma (stage pT2b): intraprostatic hypoechoic mass (arrows). b Advanced prostatic carcinoma: nonhomogeneous hypoechoic lesion with ill-defined margins and peripheral extensions. B = bladder, P = prostatic carcinoma

Fig. 581a, b a Hypoechoic mass in the left lobe of the prostate, infiltrating the right lobe (PR). Histologically confirmed prostatic carcinoma, stage IIIa. B = bladder. T = prostatic carcinoma. b CDS: nonhomogeneous, markedly hypoechoic mass with extracapsular extension. Sparse, aberrant spot-like vessels

Urogenital Tract

Late signs:

– Irregular gland outline with discontinuities in the capsule – Infiltration of surrounding structures (bladder orifice, ureteral orifice, semi-

nal vesicles, lymph nodes) – CDS: sparse tumor vessels

Chronic prostatitis, prostatic calcifications:

Small prostate

Hyperechoic or heterogeneous internal echo pattern

Echogenic = scar tissue

Intensely echogenic calcifications with acoustic shadows (secondary to inspissated secretions or inflammation, Fig.

582)

391

16.3 Male Genital Tract

Urogenital Tract

Orchitis, abscess, hemat oma (Figs. 583, 584 and 413; see also Fig. 586a, p. 393):

Fig. 582 Prostate stones (calculi, arrow) in a patient with presumed chronic prostatitis : very hyperechoic intraprostatic masses with distal acoustic shadows (S). B = bladder, P = prostate

Orchitis (Fig. 583): e.g., viral orchitis, mumps – Homogeneous hypoechoic pattern – Enlarged testis Abscess, hematoma (see Fig. 413): – Circumscribed mass of very low echogenicity – CDS: absence of internal vessels

Fig. 583a, b Bacterial orchitis of the right testis with abscess formation (FL). a Slightly decreased echogenicity and inflammatory hypervascularity. Inflammatory

edema of the scrotum (SC). EP = epididymiy, TE = testis b Compare with the normal echogenicity and vascularity of the left testis

Fig. 584a, b Posttraumatic testicular hematoma. a B-mode image: anechoic mass. b CDS: absence of blood vessels in the hematoma. LE = left testis

392

16.3 Male Genital Tract

Testicular tumors (Fig. 585):

Nonhomogeneous, predominantly hypoechoic mass

Possible fine calcifications (“starry sky” appearance = testicular microlithiasis, may be caused by neoplasia, inflammation or chemotherapy)

CDS: tumor vessels

a b

Fig. 585a, b Testicular tumors. a Testicular carcinoma (TU). CDS shows peripheral hypervascularity. b “Starry sky” appearance of right testicular calcifications following left orchiectomy for a germ cell tumor

Hydrocele (Fig. 586a):

Anechoic fluid collection around the testis

Frequently accompanied by epididymitis

Varicocele (Fig. 586b, c):

Visible and palpable dilatation of the pampiniform plexus

Tortuous, anechoic tubular structures

CDS: color signals in response to a Valsalva maneuver

Urogenital Tract

Fig. 586a–c a Hydrocele in orchitis (balloon-like enlargement of the testis). b Varicocele : multiple anechoic sites of vascular ectasia around the epididymis. c CDS of varicocele: a Valsalva maneuver evokes color flow signals due to increased venous flow velocity

393

16.3 Male Genital Tract

Spermatocele (Fig. 587a):

Anechoic mass in the region of the epididymis

Typical cystic criteria

Highly variable in size

Epididymitis (Fig. 587b):

Enlargement of the epididymis (head, body, tail)

Variable echo pattern, predominantly hyperechoic to heterogeneous

Urogenital Tract

Fig. 587a, b a Left spermatocele: fluid collection (FL) with a cystic area (C) around the upper part of the testis. b Epididymitis: swollen, hypoechoic epididymis (EP) with an accompanying hydrocele. TE = testis

Testicular torsion (see p. 80):

Testicular enlargement in the acute stage, no significant alteration of echo pattern

Later: hypoechoic or anechoic areas and a decrease in testicular size

CDS: decreased or absent blood flow

Urethral strictures: The corpora cavernosa are easily distinguished by their fine

echo texture from the corpus spongiosum and thus from the urethra. Urethral strictures due to scarring can be diagnosed with a high-resolution scanner after fluid instillation.

Evaluation and Further Testing

..............................................................................................................

Sonography: Genital tract abnormalities are often detected incidentally on ultra-

sound examination, and frequently they are difficult to interpret. For this reason the essential findings should at least be classified as requiring follow-up and/or requiring further, specific investigation.

Further testing

Caution: Any indeterminate hypoechoic lesion of the prostate requires further

investigation.

Digital rectal examination (DRE), possible urological follow-up

Prostate-specific antigen test: Normal PSA ranges are age-dependent, and today carcinoma is being detected even in younger men (positive family history is linked to increased risk). Combining PSA with DRE increases the positive predictive value to 49 %.

Transrectal ultrasound (TRUS): Because of its low specificity and sensitivity as a screening modality, TRUS alone is generally relegated to a role in the diagnostic work-up of other abnormal screening tests like DRE and PSA and follow up after therapeutic modalities.

394

Core biopsy

16.4 Female Genital Tract

Overview (Table 69):

..............................................................................................................

Table 69.Abnormal findings in the female genital organs

yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy

Uterine myoma (p. 395)

Endometrial carcinoma (p. 395)

Cervical carcinoma (p. 396)

Foreign bodies (p. 396)

Ovarian or adnexal cysts (p. 396)

Serous cystadenoma (p. 397)

Mucinous cystoma (p. 397)

Cystadenocarcinoma (p. 397)

Meigs tumor (p. 398)

Endometriosis (p. 398)

Abnormal Findings

..............................................................................................................

Uterine myoma (Fig. 588):

Submucous: polypoid mass projecting into the uterine cavity

Subserous: bulge in the uterine contour

Intramural: hypoechoic mass in the uterine wall

All: frequent regressive changes (cystic areas, calcifications)

Urogenital Tract

Fig. 588a, b Uterine myoma. a Subserous uterine myoma (arrow): isoechoic or slightly hypoechoic mass causing a bulge in the uterine contour. b Intramural uterine myoma (T) with an anechoic center due to regressive liquefaction. UT = uterus, CE = cervix, B = bladder. Lower abdominal longitudinal scan

Uterine carcinoma (Fig. 589):

Endometrial carcinoma (Fig. 589a): – Endometrial thickness i 15 mm (or i 5–8 mm after menopause) – Nonhomogeneous echo pattern with micro- or macrocystic masses – Indistinct endometrial–myometrial boundary – Distention of the uterine cavity by exophytic tumor growth – Abnormal thickening of the endometrial echo with irregular boundaries

395

16.4 Female Genital Tract

Urogenital Tract

Fig. 589a, b Uterine carcinoma. a Endometrial carcinoma (D2), just distinguishable from the myometrium by its greater echogenicity (postmenopausal patient). UT = uterus. b Cervical carcinoma (arrows): heterogeneous mass with echogenic areas, located posterior to the uterus (UT) and infiltrating the bladder (B). FL = fluid

Cervical carcinoma (Fig. 589b): – Cervix is thickened or shows barrel-shaped distention – Heterogeneous echo pattern – Anechoic to hyperechoic areas

Foreign bodies (Fig. 590):

Coils (Fig. 590a): intensely hyperechoic intrauterine echo (new plastic coils may be difficult to detect)

Tampon (Fig. 590b): smooth, elongated echo (in longitudinal section) or a bean-shaped echo with a distal shadow in the vagina

Fig. 590a, b Intrauterine foreign bodies. a IUD coil. Posterior to the bladder (B) is the distended cervix (CE) with hypoechoic foci consistent with microabscesses. The IUD is visible in the uterine cavity (UT). b Tampon: echogenic band in the vagina (arrows) with a distal acoustic shadow (S). B = bladder, UT = uterus

Ovarian and adnexal cysts: simple cysts (Figs. 591 and 592):

Functional cysts such as follicular and corpus luteum cysts (dependent on the menstrual cycle, Fig.

Premenopausal cysts I 3 cm (to 5 cm) = theca-lutein cysts (correspond to follicular cysts; multiple bilateral)

Paraovarian cysts : intraligamentous, well delineated from the ovary (independent of the menstrual cycle)

Polycystic ovary (Stein–Leventhal syndrome, Fig. 592): caused by unphysiologi- cal stimulation; enlarged ovaries with multiple cysts up to 5–10 cm in size and

396

an echogenic center.

591)

Fig. 591a–c Simple cysts. a Mature graafian follicle. B = bladder,

UT = uterus, C = cystic-appearing follicle. b Follicular remnant (C) after ovulation. FL = free fluid, IV = iliac vein, UT = uterus, B = bladder. c Simple ovarian cyst with septation and internal echoes in a 29-year-old woman (functional cyst? theca-lutein cyst?). The lesion should be extirpated if it does not regress and shows enlargement

16.4 Female Genital Tract

Urogenital Tract

Fig. 592 Bilateral polycystic ovaries during menarche

Cystic ovarian tumors (Figs. 593 and 594):

Serous cystadenoma (Fig. 593): benign – Unilocular – Sharply circumscribed, relatively small anechoic mass with echogenic (solid)

components

Mucinous cystadenoma: septated or loculated ovarian cyst, sometimes quite large – Usually unilateral – Large, bilateral lesions are more likely to be malignant (20 % of cases).

Caution: Percutaneous biopsy is contraindicated because of the risk of intra-

abdominal spread.

Cystadenocarcinoma (Fig. 594): A cystic mass with solid components is always suspicious for carcinoma. Ascites can often be detected because of peritoneal carcinomatosis. – Cyst walls show echogenic foci of tumor thickening – Polypoid structures projecting into the cyst

397

16.4 Female Genital Tract

Urogenital Tract

Fig. 593a, b Serous cystadenoma. a Hypoechoic mass (C) in the enlarged ovary (T). A = ascites, UT = uterus, B = bladder. b Ovarian cyst (approximately anechoic mass) in menopause, 10 cm in diameter (cysts greater than 5 cm in menopause are indications for operative treatment)

Fig. 594a, b Cystadenocarcinoma. a Cystic tumor (T) with fine septations and subtle tumor vessels by CDS. Serous cysts are a more common finding than mucinous cysts. B = bladder. b Solid (T) and cystic (C) tumor components (characteristic finding), detected incidentally at ultrasound. B = bladder

Ovarian tumor in Meigs syndrome: benign ovarian fibroma with ascites and/or

pleural effusion

Solid tumor mass projected over the ovary (see Fig. 210, p. 162)

Endometriosis (Fig. 595):

Endometriosis interna (= intramyometrial adenomyosis of the uterus): illdefined cystic mass located in the myometrium. Requires differentiation from true endometriosis

Fig. 595 Endometriosis externa with intralesional hemorrhage: hypoechoic mass, hematomas (H) due to bleeding endometriotic foci

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