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10.8 US of Male Genitals
377
10.7.3.3 Cystic Perivesical Structures
DDx: ventral meningocele, cysts from internal genitalia (e.g., (para-) ovarian cyst,
hydrosalpinx, paravaginal cysts and vaginal atresia, cystic seminal vesicles), mesenteric cyst, cystic venolymphatic vascular malformation, focal ascites collection,
abscess, seroma, dublication cysts, etc.
10.7.4 Role of US
Ideal for assessing bladder pathology and depicting all paravesical formations:
• Often origin may be depicted – use full bladder and meticulous scanning technique
with additional perineal access, fi lling of bladder/rectum, graded compression, etc.
• Differentiate solid from cystic structures.
NOTE : In suspected malignancy, additional cross-sectional imaging for initial preoperative assessment, anatomic information, and staging are often necessary.
10.8 US of Male Genitals
US used for external genitalia (scrotum, testis, inguinal canal), seminal vesicles:
• Prostate usually only seen in older children – unless in major pathology
(e.g. cystic dysplastic seminal vesicles, ectopic ureteral insertion, prostate
calcifi cations after infections, tumour/rhabdomyosarcoma).
10.8.1 US Technique
Scrotum / Testis
High-resolution linear transducers with highest feasible frequency.
NOTE : Avoid high sound pressure by reducing output gain.
Always assess testis in longitudinal and axial sections, compare both sides, fol-
lowing structure towards inguinal canal. Use of stand-off pad can be cumbersome;
plenty US gel advised.
TIP : Respect privacy of patients even if they are not adults!
Volume calculation: ellipsoid equation – depth (cm) × length × width × 0.5 = vol-
ume (ml).
Dynamic investigation of mobility of the testis, reducibility in case of inguinal
position can be assessed; the same for herniated material (reducibility of herniated
bowel/mesentery?).
Prostate / Seminal Vesicle
Commonly curved linear array; (phased) linear transducer preferred if size/bladder
fi lling allows. Apply age-adapted frequencies. Access area through fi lled bladder or
by perineal access.
( a)CDS
CDS essential for assessing infl ammatory conditions and torsion. Spectral analysis
comparing both sides mandatory. Vascular supply assessed by following main vessels into inguinal area/canal.
378
10 Ultrasound of the Urogenital Tract
ab
Fig. 10.45 Hydrocele. ( a ) Axial section – both testes/scrotum: right-sided hydrocele; the minimal
fl uid on left side is physiologic in neonates. ( b ) Longitudinal section: fl uid confi ned to scrotum, no
funiculocele. Note small cyst of epididymis
NOTE : Always assess both testes; vessels have to be documented in scrotal wall,
testicular capsule and within parenchyma as well as in epididymis.
Penile US
Rarely necessary in childhood unless for ureteral problems (see chapter urinary
tract/bladder).
However, haematoma/injury, cysts/diverticula, duplications, postoperative prob-
lems can be assessed/visualised.
NOTE : Urethra always best assessable during voiding. Penile US should be com-
plemented by perineal/urinary tract US.
10.8.2 Normal Findings
Testis: ellipsoid with homogeneous echogenicity, with spleen-like appearance,
some increased echogenicity at hilus.
Above testis: cape-like or nodular epididymis, testicular appendices better visible
with some hydrocele. Some minor fl uid around testis is physiologic.
Size in neonates ~2 ml, during childhood increasing with growth, mostly during
early puberty when testicular size reaches ~15 ml. Volume claculated by elipsoid
equation as for kidney.
Depiction of intratesticular vessels depends on equipment and patient maturity.
In neonates intratesticular vessels more diffi cult to see, whereas during puberty
intratesticular vessels must always be visible.
10.8.3 Common Pathologic Findings
10.8.3.1 Hydrocele
Defi ned as some fl uid in scrotum around testis and/or in processus vaginalis, common in neonates – not to be confused with normal minor fl uid formation (Fig. 10.45 ).
Fluid anechoic, some sedimented echoes may exist particularly in/after chronic
conditions.
Giant hydroceles (even if reactive) may impair testicular perfusion – need to be
relieved.
NOTE : In older patients secondary to underlying condition (e.g. tumour, torsion,
trauma – haematocele, infl ammatory process, varicocele).
10.8 US of Male Genitals
379
ab
Fig. 10.46 Undescended testis. Testis seen in inguinal canal ( a , + +) or intra-abdominal
+....+) lateral to empty, thick-walled urinary bladder
( b ,
1
DDx
Fluid in scrotum secondary to inguinal hernia/ascites; sonographic key – continuity
of fl uid through inguinal canal into abdominal space.
10.8.3.2 Undescended Testes
Common fi nding in early infancy; may be associated with unstable testicular position. Physiological delay of testicular descend may spontaneously mature/resolve.
US Findings
Testes not located in scrotum:
• Carefully assess inguinal canal, region next to abdominal wall, near internal
orifi ce of inguinal canal for testicular structures (Fig. 10.46 ). Non-descended
testis may be smaller and dysplastic, prone to malignant conversion.
• Intra-abdominal testicular position (often adjacent to bladder or psoas muscle)
more diffi cult to depict, particularly as undescended testes may be dysplastic and
small, exhibit somewhat altered echogenicity – thus defi nite identifi cation
sometimes impossible. May even be found at lower pole of spleen or kidney.
NOTE : This also applies for MRI where typical testicular signal may be lost in
small dysplastic testes.
Role of US
• To fi nd position of testes.
• Potentially to assess for reducibility/mobility.
• Assess size, parenchymal structure, perfusion for depiction of (hypo-)
dysplasia.
NOTE : Always perform a basic assessment of the urinary tract, as there may be
associated conditions.
10.8.3.3 Varicocele
Venous impairment, leading to dilatation and tortuosity of veins of pampiniform
plexus, most commonly found in peripubertal boys. Commonly on left side:
• May cause hydrocele, eventually infertility.
If in untypical age, on right side, recurrence after treatment: always assess
for potential underlying abdominal tumours causing congestion of testicular
draining vein (particularly Wilms’ tumour, adenopathy, retroperitoneal tumours
such as neuroblastoma/ganglioneuroma or metastases) – perform abdominal
survey.
380
10 Ultrasound of the Urogenital Tract
ab
Fig. 10.47 Varicocele. ( a ) “Sack of worms”-like appearance of dilated veins entering into scro-
tum (inguinal cross section). ( b ) Vivid colour signals with venous fl ow profi le on valsalva manoeu-
vre (similar section as a )
US Findings
“Sack of worms”-like appearance of tubular/circular anechoic structures that may
change size during valsalva manoeuvre.
Accompanying hydrocele, potentially asymmetric testicular size (Fig. 10.47 ).
CDS
Particularly with valsalva manoeuvre bidirectional/undulating venous fl ow/retrograde fl ow direction visualised (Fig. 10.47 ). Depending on amount of fl ow/fl ow
direction, US can grade varicocele (used for follow-up/indication for surgery):
• Grade I: clinically normal, slight increase of venous plexus structures during
valsalva.
• Grade II: palpable dilatation of externally visible enlarged veins that can be
sonographically seen even without valsalva; change of fl ow direction during
valsalva.
• Grade III: huge dilatation and tortuosity of veins are obvious on clinical inspection (sack of worms), constant inverted fl ow, even without valsalva manoeuvres.
10.8.3.4 Cystic Dysplasia of Rete Testis and Seminal Vesicles
Cystic dysplasia of rete testis : rare condition, associated with urogenital
malformation.
NOTE : Not tubular ectasia as in adults resulting from obstruction but congenital
malformation deriving from failure of fusion of afferent ducts.
US Findings
Multiple, particularly pseudo-confl uent cysts/cystic dilatation of rete testis/afferent
ducts, associated with parenchymal atrophy/dysplasia. Cysts often located at testicular mediastinum, may compress surrounding parenchyma.
NOTE : Cysts may contain mucoid material causing atypical US appearance – can
be mistaken for tumour, abscess, microlithiasis (if with speckled echogenicity), can
cause pseudofl ow on CDS (if high output power is applied).
Cystic dysplasia of seminal vesicles :
Rare condition, associated with other urogenital malformations (e.g. ipsilateral
MCDK, renal agenesis).
10.8 US of Male Genitals
381
US Findings
Multicystic, often confl uent mass at site of seminal vesicle – usually without echoes,
sometimes diffi cult to differentiate from residual remnant of MCDK in ectopic
position (if no kidney seen further up and large).
10.8.3.5 Testicular and Paratesticular/Epididymal Cysts/
Spermatocele
Rare, present with painless scrotal enlargement.
Appears on US like all cysts, usually anechoic mass = uncomplicated cyst.
Spermatoceles extremely rare in childhood.
Cysts may enlarge, compromise testicular parenchymal growth if large.
Differentiation against cystic tumour (teratoma) or ectatic vascular malformation
may be diffi cult.
Role of US
To depict reason for scrotal enlargement.
• Differentiate from rare venolymphatic vascular malformations (have echogenic
septations that may also exhibit some fl ow on CDS, can mimic complex
haematocele/hydrocele).
• Differentiate against paratesticular cystic masses (e.g. dermoids – often contain
some debris/sedimentations, epididymal cysts, spermatoceles (commonly seen
only in teenagers), tunical cysts, other causes of enlargement, particularly tumours).
10.8.3.6 Microlithiasis
Yet undefi ned entity with multiple calcifi cations within testis. Consists of debris
with calcifi c core in seminiferous tubules. Said to be sometimes precancerous
(under discussion), associated with infertility:
• Some centres recommend follow-up/screening. During course calcifi cation may
increase or decrease.
• Maybe associated with number of conditions (e.g. cryptorchidism, pseudoxanthoma elasticum, cystic fi brosis, chromosomal anomalies, but also after insult to
testis). Not to be confused with focal calcifi cation after trauma/infection/surgery,
in tumours, or paratesticular calcifi cations (e.g., after torsion of testicular appendices and meconium peritonitis).
US Finding
Multiple stippled small calcifi cations within testis causing blip-like echogenic spots
throughout testis (twinkling sign on CDS) (Fig. 10.48 ). Often bilateral.
In future elastography may be helpful for fi nding early tumurous changes (see
Fig. 1.22 ).
10.8.4 Inflammation – Orchitis, Ependymitis
Often clinically evident by increased size, reddish skin, pain, with typical laboratory
fi ndings.
US used to differentiate from torsion or detect abscess/necrosis.
382
10 Ultrasound of the Urogenital Tract
ab
Fig. 10.48 Microlithiasis. ( a ) Diffuse microlithiasis. ( b ) Bicolour mode conspicuously enhances
testicular calcifi cations
Fig. 10.49 (Epididymo-)orchitis. Asymmetrically enlarged swollen testis with vivid hypervascu-
larity of testis (and epididymis) on CDS
US / CDS Finding
Orchitis : unilateral increase of size of affected scrotum, may be hyperechoic.
• Reactive hydrocele, scrotal wall thickening. Secondary abscess/necrosis
possible.
• Hypervascularisation with hyperemic diastolic fl ow on spectral analysis (low RI)
(Fig. 10.49 ).
Epididymitis : Epididymis enlarged, more or less echogenic, potentially
inhomogeneous.
Exhibits signifi cant hypervascularisation without hyperperfusion of testis itself.
Often associated complex hydrocele:
• May also manifest combined with orchitis (epididymo-orchitis).
NOTE : Rarer in children, always think of associated urological problems/ascend-
ing infections from prostatic ducts, particularly in urethral obstruction.
Paratesticular infl ammation may arise from descending infection from peritoneal
cavity (peritonitis) or septicemic involvement. Similar fi ndings seen after inguinal
surgery with haemorrhage/secondary infection:
• Typical paediatric entity: echogenic complex material in scrotum around testis
– potentially with calcifi cation after meconium peritonitis in newborn
Complications
Particularly in orchitis: abscess, necrosis, segmental infarction – can be depicted on
US.
NOTE : Differentiation of necrosis versus abscess may be diffi cult, particularly in
early phases.
10.8 US of Male Genitals
Fig. 10.50 Scrotal trauma. Testicular trauma with haemorrhage into scrotal sack and injured,
partially destroyed testis – obviously with disrupted tunica and irregular contour
10.8.5 Scrotal Trauma
US used to assess contusion versus haematoma versus rupture.
• Contusion : focal inhomogeneous parenchyma seen with swelling of testis, but no
parenchymal disruption; continuity of outer border maintained.
• Haematoma : (intra- or extratesticular) easily depicted – CDS allows assessment
of viable testicular parenchyma (Fig. 10.50 ).
• Testicular rupture : defi ned by discontinuity of tunica and intrascrotal haema-
toma. Viability of different testicular components assessed by CDS, helping to
decide on surgery.
383
10.8.6 Torsion
Clinically typical acute onset of pain, swelling.
Two different types: neonatal extra-/supravaginal torsion; intravaginal torsion common
during puberty – usually no impact on therapy except for delayed diagnosis in neonates
(often has happened much earlier, e.g. during birth/fetally – then no emergency surgery!).
NOTE : Often adolescent presents delayed because of shyness about seeking care.
Thus “missed torsion” with completely necrotic testis not uncommon.
US Finding
Superiorly positioned, swollen, homogeneously hyperechoic testis, in peracute
phase. Some accompanying hydrocele, swelling of scrotal wall (Fig. 10.51 ).
In longer duration/late torsion, echogenicity of testis decreases, may become
more inhomogeneous – eventually anechoic when necrotic; secondary abscess
formation possible. More complex appearance of associated hydrocele fl uid.
CDS
Asymmetric lack of intratesticular vessels.
Twist of vascular pedicle when following it into inguinal canal (“whirl pool”
appearence as in volvulus):
• Partial torsion may exhibit residual but asymmetric perfusion – fi rstly affecting
veins (haemorrhagic infarction).
• After (spontaneous) detorsion, transient hyperaemia may be seen.
NOTE : Mandatory to depict intratesticular fl ow and prove symmetry with spectral
analysis – torsion can only be excluded when symmetric intraparenchymal fl ow
profi le in arterial and venous compartment is depictable. In every suspicion of torsion on US, emergent surgical exploration mandatory.
384
ab c
Fig. 10.51 Testicular and hydatid torsion. ( a ) Enlarged testis with hypoechoic (necrotic) paren-
chyma – no perfusion on CDS in older testicular torsion. ( b , c ) Echogenic testicular appendix ( b )
without fl ow on CDS ( c ), consistent with hydatid torsion
10 Ultrasound of the Urogenital Tract
US - guided detorsion / manual relief of torsion : detwisting testis by rotation in
steps of 180°, checking for reappearance of perfusion – does not obviate surgery as
partial detorsion may still exist (reactive hyperaemia will always show some asymmetric perfusion – thus residual partial torsion cannot be ruled out).
10.8.6.1 Torsion of Appendages
Quite common. Important DDx for testicular torsion/infl ammation (clinical fi ndings may be similar) or inguinal hernia.
US Finding
Enlarged appendage (hydatid) with lack of perfusion, hyperaemia of adjacent structures, but always symmetric intratesticular perfusion. Often some hydrocele, scrotal
swelling, epididymitis-like changes observed (Fig. 10.51 ).
After appendiceal torsion extratesticular calcifi cations often present.
DDx criteria
Scrotal oedema, normal testis, hydrocele, increased vascularisation. No inguinal
hernia.
10.8.6.2 Inguinal Hernia
If inguinal hernia detected, try to follow through inguinal canal, assess inner ring
and describe content (mesentery, fl uid, intestines – potentially with peristalsis, perfused bowel wall?) Other rare hernia contents: parts of bladder, in girls ovaries/
uterus (see Fig. 9.17 ).
Particularly if incarcerated – confusing images seen; sometimes spermatic cord
vessels compromised thus endangering testis.
May sometimes only be seen with increased intra-abdominal pressure – consider
provocative manoeuvres (imaging while crying/straining, valsalva, image with
patient standing).
10.8.7 Testicular Tumours
Rather rare in childhood, most commonly germ cell tumours or teratoma.
10.9 Female Genit als
US Findings
Typically appearance of ovoid space occupying lesion. May be cystic, particularly
in teratoma/epidermoids, or completely solid. May have more complex cystic
appearance with septae:
• Often mild associated hydrocele. Defi nition of underlying entity rarely achievable.
• Always assess pelvic/retroperitoneal lymph nodes, and perform abdominal survey.
• Secondary involvement in systemic diseases (e.g. leukaemia/lymphoma, neuroblastoma) where testis can even serve as host region for recurrence, involvement
may be uni- or bilateral.
DDx
Intratesticular cysts, dermoids, septated hydroceles, epithelial cysts, cystic dysplasia of rete testis, intratesticular ectopic adrenal tissue, infection/abscesses/necrosis,
posttraumatic alteration.
NOTE : Rhabdomyosarcoma in male pelvis mostly from pelvic fl oor muscles, pros-
tate, seminal vesicles, or bladder, rarer in scrotum.
No other sonographically important aspects of prostate need to be addressed in
childhood; only sometimes after infection prostate calcifi cation may be seen, as
well as an atypical appearance of enlarged seminal vesicles in cystic dysplasia and
then often combined with other urogenital malformations.
385
10.8.8 Role of US and Additional Imaging
US – ideal initial imaging tool with high reliability, when performed skillfully.
Supplementing Investigations
• Scintigraphy and MRI have been performed for torsion – but potential time delay
usually demands early surgery in unclear cases.
• In tumours: staging by CT/MR.
• Assessment of ectopic testis/cryptorchidism: may benefi t from MRI, although
small dysplastic testis in abdominal cavity may be diffi cult to depict – many
centres perform laparoscopy if testis not found in pelvis/inguinal region directly.
• Assessment of complex genital (cloacal)/intersex states: may benefi t from MRI/
ce-CT and fl uoroscopy/genitography.
• Angiography of spermatic vein only performed in complex/recurrent varicocele
for therapeutic reasons (embolisation in same session).
10.9 Female Genitals
10.9.1 Indications
Suspected genital malformation/disease by clinical fi ndings on inspection, ambiguous gender, associated urogenital malformation, hormonal abnormality (e.g. precocious puberty, adrenogenital syndrome).
386
10 Ultrasound of the Urogenital Tract
10.9.2 Requisites
Suffi ciently fi lled bladder mandatory for detailed assessment.
Perineal approach very helpful – looking at vagina/pelvic fl oor/rectum (cloacal
malformation):
• In unclear fi ndings/obvious pathology, fi lling of bladder and vagina with saline
helpful (“ Sonogenitography ”) (see Figs. 2.4 and 2.5 ).
• For depiction of fi stulae, optional/additional US-CM instillation.
10.9.3 Transducers
Particularly in neonates, high-resolution linear/micro-curved arrays applied.
Otherwise use curved linear areas with highest applicable frequency.
Transvaginal investigations usually only performed after puberty:
• Some centres perform transrectal investigations.
10.9.4 How to Perform Investigation
Consecutive longitudinal and axial sections through region of genital organs behind
bladder by rotating transducer into respective organ axis of fallopian tube, ovaries,
uterus.
Take size measurements, document fi ndings:
• Always include entire US of all other pelvic structures/urinary tract, include
adrenal glands.
Measurements particularly important in suspected hypodysplasia or early onset of
puberty:
• Compare results to tables with normal values.
Always try to assess detailed structure of ovary (size? follicles present?) and uterus
(size, shape, horns, wall structure/endometrium?):
• In older girls additional assessment of breast valuable for complete workup in
hormonal imbalance.
10.9.5 Normal Findings
Uterus changes during growth/development (Fig. 10.52 ):
• In neonate (stimulated by maternal hormones): rather large, with long cervix,
endometrium nicely differentiated.
• In infancy/early childhood: small, diffi cult to assess.
• With onset of peri-/prepuberty/hormonal activity: uterus grows again. Eventually
becomes shape of typical adult uterus – pear shaped = relatively short cervix,
large body, exhibits well-differential wall/endometrium (varies throughout cycle).
Uterus: muscle rather hypoechoic, with clear contour. Thickness of endometrium
depends on hormonal situation. Often positioned not strictly sagittal/in midline –
some deviation physiological: