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13 Ultrasound inMale Infertility
217
The role for scrotal ultrasonography in the
evaluation of the infertile male has been previously established. Scrotal abnormalities have
been reported to occur in 38–65% of infertile
men, approximately 60–70% of which were not
found clinically on physical examination alone
[15, 16]. In reporting scrotal ultrasound ndings
in 545 infertile males with a mean age of 36years,
Sakamoto and colleagues identied left varicoceles in 313 (57.4%), testicular microlithiasis in
30 (5.5%), epididymal cysts in 21 (3.9%), right
varicoceles in 4 (0.8%), testicular cysts in 3
(0.6%), and a testicular tumor, intrascrotal hemangioma, and hydrocele of the spermatic cord in
1 (0.2%) patient, respectively [15]. When compared to normospermic men, males with infertility have been conrmed to have signicantly
increased rates of scrotal ndings including varicocele (35.5% vs. 16%), hydrocele (16.7% vs.
8.7%), testicular microlithiasis (9.8% vs. 2%),
epididymal enlargement (9% vs. 2.6%), and epididymal cysts (7.7% vs. 2%) [17].
Color ow Doppler adds further value to scrotal ultrasonography as it provides real-time
assessments with increased sensitivity to testicular blood ow. This is particularly useful in cases
of testicular ischemia, trauma, differentiation of
testicular/paratesticular lesions, and infectious
processes. Elastosonography, which further
assesses tissue rmness, has also been reported to
improve characterization of testicular lesions
<1cm [18].
Mapping testicular perfusion may provide
useful information for potential future procedures as well such as for testicular sperm extraction (TESE) in men with azoospermia. Limited
data suggests that patients with azoospermia tend
to have enhanced quality and quantity of sperm
in TESE areas with increased testicular perfusion
[19]. Information provided by scrotal ultrasound
may allow urologists to better localize areas of
high perfusion during the biopsy among men
with nonobstructive azoospermia.
Testicular volume is another indicator of fertility that can be accurately characterized through
ultrasound. Ultrasound is superior to the traditional orchidometer in evaluating testicular volume as the latter tends to overestimate volume,
especially when measuring smaller testes that are
more prevalent in infertile patients [20]. A study
of almost 500 patients demonstrated a correlation
between testicular volume and sperm parameters
including total motile sperm, total sperm count,
and sperm density [21]. A later study by Sakamoto
et al. conrmed the association between
decreased testicular volume and reduced total
sperm counts [22]. Despite this data, it should be
noted that in some cases, large testicles may be
indicative of obstructive azoospermia. In addition
to directly correlating to worsened sperm parameters, lower testicular volume may also suggest a
potential varicocele. Both Sakamoto et al. and
Diamond et al. performed studies indicating an
association between smaller testicles on ultrasound with presence of a varicocele [23, 24].
A testicular resistive index (RI) also provides
useful information on male infertility as well. RI
is derived from scrotal ultrasound and is calculated with the peak systolic (PSV) and end diastolic velocities (EDV) from testicular vessel
groups, utilizing the equation RI=PSV−EDV/
PSV×100. Generally, providers use a cutoff of
greater than 0.6 to suggest possible nonobstructive infertility [25]. A higher RI has been associated with varicoceles, lower sperm count, and
other scrotal pathologies [26, 27]. Obtaining a RI
may therefore provide additional information in
the characterization of male infertility.
Although a denitive role for ultrasound in the
routine evaluation of the infertile male remains
debatable, given the high rate of intrascrotal ndings in infertile men, particularly the increased
risk of signicant pathology such as testicular
tumors, scrotal ultrasound is becoming increasingly utilized in the assessment of males presenting with infertility. Additionally, it may provide
helpful supplementary information as noted
above.
Paratesticular Structures
Epididymis
Ultrasound evaluation of the epididymis is performed to assess for the presence of infectious
ndings, masses or lesions, or evidence of epididymal obstruction. Measurements of the epididymis
218
I. S. Lam et al.
are obtained at the caput. A normal epididymis
measures 7–8 mm in diameter, with increasing
diameter associated with infectious processes
[28]. Epididymitis as a clinical diagnosis may be
conrmed with ultrasound ndings, which include
an enlarged or thickened epididymis with
decreased echogenicity.
Infectious processes associated with infertility
are more broadly categorized as male accessory
gland infections (MAGI), which include infections of the epididymis, seminal vesicles, prostate, or bladder. Organisms commonly identied
are Chlamydia, Mycoplasma, and E. coli.
However, organisms such as tuberculosis have
also been directly associated with infertility [29].
Although relatively limited data exist and vary by
region, the prevalence of MAGI and infertility
have been reported to occur in up to 12% of cases
[30]. Several studies have identied abnormal
semen parameters in patients with MAGI including decreased motility, increased abnormal
forms, and a higher rate of DNA fragmentation
[31, 32]. Despite these ndings, the etiologic role
of MAGI with male-factor infertility remains
unclear, as reports have failed to demonstrate
consistent ndings [33, 34].
Epididymal masses may be further dened as
solid versus cystic. Solid masses are most commonly benign adenomatoid tumors with additional lesions encountered including
cystadenoma, mesothelioma, or sarcomas
(Fig.13.3). Cysts of the epididymis are benign
lesions commonly located at the head of the epididymis and may represent simple cysts (no
sperm in uid) or spermatoceles (sperm in uid)
(Fig. 13.4). Although epididymal cysts are
found more commonly among men with infertility, they have not been shown to result in epididymal obstruction or infertility [17]. In
performing surgical resection of spermatoceles
and hydroceles, epididymal injury has been
reported to occur in 17 and 6% of cases, respectively [35]. A more recent report by Kauffman
and colleagues describing a microsurgical technique of spermatocelectomy demonstrated no
changes in sperm count among patients with
pre- and postoperative semen analyses, suggesting the absence of iatrogenic epididymal
obstruction [36].
In addition to identifying paratesticular
masses and infectious processes, improvements
in ultrasound resolution have led to its utility in
Fig. 13.3 Solid
epididymal mass:
longitudinal sonogram
shows a normal right
testis and a solid,
heterogeneous mass
(between calipers) of the
epididymal tail that
proved to be an
adenomatoid tumor
13 Ultrasound inMale Infertility
Fig. 13.4 Cystic
epididymal mass:
longitudinal sonogram
shows a large cystic
mass of the epididymal
head, along the superior
aspect of the testis.
Spermatocele is likely a
diagnosis, particularly
given the few low-level
echoes within the mass
219
diagnosing epididymal obstruction. Clinical and
laboratory ndings of epididymal obstruction
include normal-volume ejaculate with oligo- or
azoospermia. Imaging ndings may demonstrate
epididymal enlargement with prominence of the
rete testis and a hypoechoic appearance.
Epididymal ndings have further been described
to help delineate between congenital and
acquired causes of obstructive azoospermia. In a
report of 211 infertile males undergoing scrotal
ultrasonography for obstructive azoospermia,
men with a congenital etiology were found to
have higher rates of ectasia in the epididymal
head with tapering and absence of the epididymal body and tail [37]. In contrast, acquired azoospermia exhibited increased rates of epididymal
body and tail duct ectasia and an epididymal
inammatory mass. Other studies have also
demonstrated similar ndings. Moon etal. established a correlation between epididymal abnormalities and caput diameter with obstructive
azoospermia, and another study achieved over
91% in specicity using caput epididymis diameter to evaluate obstruction as the cause of azoospermia [38, 39]. Using ultrasound during the
initial workup can be useful in differentiating the
etiology of infertility and helpful in guiding the
provider and patient in decision-making for next
management steps.
Varicocele
Varicoceles are reported to occur in approximately 15–25 and 35–60% of fertile and infertile
males, respectively, and remain the most common, reversible cause of male-factor infertility
[15, 17, 40]. Clinical varicoceles are more common on the left and are graded on a scale of I–III
with grade I varicoceles palpable in the standing
position with Valsalva maneuver, grade II palpable in the standing position without Valsalva
maneuver, and grade III in the standing position
grossly visible. Intratesticular varicoceles identied on ultrasonography are relatively uncommon
and are likely of minimal signicance for malefactor infertility [41].
Ultrasonography is able to detect varicoceles
with a 97% sensitivity and 94% specicity [42]
(Fig.13.5). When using the commonly accepted
denition of internal spermatic veins measuring
≥3mm in diameter, ultrasound has been demonstrated to have 53% sensitivity and 91% specicity in identifying varicoceles when compared to
physical examination [43].
The presence of a varicocele is associated
with infertility and impaired semen characteristics including decreased sperm count, motility,
and abnormal morphology [44]. In addition, the
grade of the varicocele has been shown to be
220
Fig. 13.5 Varicocele:
longitudinal sonogram
(a) shows multiple
serpiginous, dilated
scrotal veins.
Longitudinal color
Doppler sonogram
(b) during Valsalva
maneuver shows
prominent color ow
within the vessels
I. S. Lam et al.
a
b
inversely associated with sperm density. Among
infertile patients with a palpable varicocele, only
33.3% were found to have normozoospermia,
highlighting the signicant impact on semen
characteristics [45]. Similarly, the presence of a
varicocele is associated with impaired sperm
function, with up to 45% of infertile males with
varicoceles demonstrating an abnormal acrosome
reaction [46].
Although there is controversy regarding the
optimal treatment of males with clinical and subclinical (detected on imaging alone) varicoceles,
correction of a palpable varicocele has been consistently shown to improve semen parameters and
may prevent progressive decline [10, 47–51].
A further role for scrotal ultrasonography in
the evaluation of patients with clinical varicoceles
is the ability to assess and compare testicular
13 Ultrasound inMale Infertility
221
volumes. Men presenting with a left clinically
palpable varicocele have been shown to have
increased rates of ipsilateral testicular atrophy,
while subclinical varicoceles have not been associated with discrepant testicular volumes [24].
These ndings are signicant as adolescents with
testicular volume differentials >10% have been
shown to have signicantly lower sperm concentrations when compared to those with <10% differential. This nding was even more pronounced
among those with a>20% differential volume.
Beyond its initial diagnostic role with varicoceles, ultrasonography has further prognostic value
in determining paternity success following varicocelectomy. Patients with testicular atrophy were
shown to have decreased paternity (11%) compared
to those with normal testicular volumes (30%).
Similarly, those with clinically apparent varicoceles, bilateral varicoceles, shunt- type varicoceles
(both retrograde and antegrade reux demonstrated
on ultrasound), or a permanent degree of varicocele
were associated with decreased paternity [52].
An additional study evaluating the impact of preoperative parameters on surgical outcomes demonstrated signicant improvements following
microsurgical varicocelectomy in sperm concentration, motility, and morphology in patients with testicular vein measurements (taken at the inferior pole
of the testis) >2.5mm compared to veins measuring
<2.5mm [53]. Reux identied at the inferior pole
was similarly associated with improved sperm characteristics compared to those with reux only identied in the supratesticular venous channels.
Following surgical repair, ultrasound has been
reported as a reliable tool in follow-up assessments
to document decreased venous diameter at rest
and with Valsalva maneuver, although this is of
questionable clinical relevance [54].
Vas Deferens
Congenital bilateral absence of the vas deferens
(CBAVD) is identied in 1–2% of infertile males
and in approximately 10% of males with azoospermia [55, 56]. It is found in essentially all patients
with cystic brosis and is associated with genitourinary abnormalities including absence of the
vasal ampulla and seminal vesicles (SV) [57, 58].
Unilateral absence of the vas deferens is associated
with both absence (90% of ipsilateral and 20% of
contralateral) of the SVs and SV anomalies including hypoplasia, cysts, and calcications [58, 59].
Patients found to have an absence of the vas
deferens either unilaterally or bilaterally on physical examination can be considered for a conrmatory scrotal ultrasound. Ultrasound ndings
include absence of the body or tail of the epididymides as well as dilated efferent ducts with associated prominent epididymal heads and rete testis
[57, 60, 61]. In the absence of cystic brosis,
patients with unilateral or bilateral absence of the
vas deferens should undergo imaging of the retroperitoneum, as up to 21 or 85% of patients,
respectively, have been reported to have upper
tract abnormalities (renal agenesis, renal ectopia,
horseshoe kidney) [62, 63].
Testicular Ultrasound
Testicular ultrasonography provides signicant
information regarding potential etiologies for infertility, identication of prognostic ndings, and as a
screening modality for associated lesions. Testicular
volume assessment may be obtained through various methodologies, with Lambert’s formula (volume [mL]=length×width×AP depth [cm]×0.71)
most commonly utilized [20, 64].
Testicular volume is directly associated with
semen parameters including total sperm counts,
sperm density, and motility. As seminiferous
tubules comprise 70–80% of testicular volume
and are responsible for spermatogenesis, a
reduced testicular volume has been correlated
with global gonadal dysfunction, as indicated by
elevated FSH and LH levels [22, 65–68].
Sakamoto and colleagues noted signicant oligospermia in patients with testicular volumes
<10 mL (normal 15–20 mL), including length
<3.5 cm, depth <1.75 cm, and width <2.5 cm
with direct correlations noted with sperm density,
222
I. S. Lam et al.
total sperm count, motility, and FSH and LH levels [65]. Diminished testicular volume may be
secondary to several etiologies including varicoceles, current or previous cryptorchidism, postpubertal mumps, Klinefelter’s syndrome, or
hormonal abnormalities, among others.
In addition to estimating testicular volume,
Doppler ultrasound may be utilized to identify and
assess testicular microcirculation. As spermatogenesis is dependent upon microcirculatory perfusion, diminished testicular blood ow as visualized
on ultrasound directly correlates with elevated
FSH levels and decreased sperm quality [19, 69,
70]. Resistive indices may be obtained to further
quantify testicular tissue perfusion and are commonly obtained at the level of the testicular artery
and via intratesticular branches near the rete testis.
Intratesticular branch resistive indices less than 0.6
have been suggested as a threshold level of normal
tissue perfusion, with elevated levels indicative of
impaired microcirculation [26, 71].
Testicular ultrasound may assist in differentiating between obstructive and nonobstructive etiologies for infertility. Moon and colleagues
demonstrated a reduced median testicular volume in patients with nonobstructive (8.3 mL,
range 1.2–16.4) versus obstructive (11.6 mL,
range 7.7–25.8) azoospermia [39]. Similarly,
patients with azoospermia secondary to obstruction were shown to have dilation of the mediastinum testis, epididymis, and intrascrotal portion
of the vas deferens. The sensitivity, specicity,
and accuracy for differentiating obstructive versus nonobstructive azoospermia were noted to be
82.1, 100, and 87.5%, respectively. Further ndings which suggest a nonobstructive etiology
include reduced or absent testicular vessels, with
isolated regions of visualized blood ow potentially indicative of residual spermatogenic production [72].
Cryptorchidism
Cryptorchidism is estimated to occur in approximately 2–5% of boys born at term and is associated with impaired future fertility [73]. Although
there is ongoing debate as to the optimal time for
orchiopexy, there is increasing consensus that
earlier repair (at 6–12months of age) results in
improved long-term fertility potential [74].
In evaluating future paternity in males previously undergoing orchiopexy for undescended
testes, Lee and colleagues observed successful
paternity within 12 months in 90 and 65% of
patients with prior unilateral or bilateral cryptorchidism, respectively [75]. This was compared
against control subjects who demonstrated a 93%
rate of successful paternity. The author concluded
that patients with unilateral cryptorchidism have
equal rates of paternity to controls, while patients
with repaired bilateral cryptorchidism continue to
have lifelong impairments in paternity. Further
ndings indicated that although patients with unilateral cryptorchidism demonstrated equal rates
of paternity, they exhibited elevated levels of
FSH, decreased inhibin B, and preserved levels of
LH/testosterone compared to controls, suggesting
subclinical impairments in spermatogenesis.
To further evaluate the effect of timing of
orchiopexy on paternity outcomes among azoospermic patients undergoing IVF, Wiser and
colleagues found no difference in rates of sperm
retrieval, fertilization, implantation, pregnancy,
or live birth rates among men with a history of
unilateral (2 patients) or bilateral (40 patients)
orchiopexy at ≤10years of age versus >10years
[76]. Despite the late repairs performed, 60% of
patients were found to have sperm at the time of
testicular sperm extraction (TESE).
The role for ultrasonography is likely limited
in the initial evaluation of patients presenting
with cryptorchidism (Fig.13.6). Tasian and colleagues performed a meta-analysis to review the
diagnostic performance of ultrasonography
among patients with non-palpable cryptorchidism
with results demonstrating a sensitivity of 45%
and specicity of 78% inlocalizing non- palpable
testes [77]. These ndings increased or decreased
in the probability of actually nding an intraabdominal testicle based on imaging from 55 to
64% and 49%, respectively. Given these low rates
of precision, the authors indicated that abdominal-scrotal ultrasonography did not reliably assist
in the management decision tree for patients with
non-palpable testes and was therefore of limited
13 Ultrasound inMale Infertility
Fig. 13.6 Undescended testis: longitudinal sonogram
shows a small, hypoechoic testis in the inguinal canal
utility. Other imaging modalities also demonstrate notable limitations. Given the radiation
exposure and high cost that comes with CT imaging, it is not recommended for the workup of
cryptorchidism. In the past, MRI had been utilized for this purpose more frequently given a
somewhat greater sensitivity and specicity, but
its use is currently advised against due to cost,
availability, and need for anesthesia [78].
To date, there are no imaging modalities that
can effectively determine the absence of a testis.
In contrast, surgical exploration has high sensitivity and specicity in conrming testicular
absence. Thus, diagnostic laparoscopy is the current gold standard for the diagnosis of cryptorchidism [78]. If absence of the testicle is conrmed
during the procedure, then the procedure is complete. However, if a testis is found, an orchidopexy should be attempted simultaneously. A key
“takeway” from the guidelines is that imaging
studies rarely help in decision-making and can
sometimes provide misleading information about
the presence or absence of the testicle.
Although there is likely limited utility for
ultrasound during the initial evaluation of undescended testes, patients with a history of cryptorchidism have a known two- to eightfold increased
risk of testicular cancer, with 5–10% of men with
testicular cancer having a prior history of cryptorchidism [73, 79]. This nding has led some
authors to advocate for the routine use of scrotal
ultrasonography as a screening tool for testicular
223
malignancy among patients presenting with
infertility, particularly those with a history of
cryptorchidism [80–82].
Cysts, Hydrocele, Infectious Processes
Testicular ultrasonography is an excellent modality for identifying benign testicular structures
including cysts, hydroceles, and infectious processes. Intratesticular cysts are identied as
hypoechoic/anechoic regions, can represent cystic dilation of the rete testes, and may be a result
of postinfectious or posttraumatic epididymal
obstruction [83, 84]. Testicular cysts have been
reported to occur in 1.2% of infertile men and are
of unclear signicance [85].
Scrotal hydroceles represent accumulation of
uid within the tunica vaginalis and are commonly the result of prior trauma, inammatory, or
infectious processes. Although there is a known
increased prevalence of hydroceles in infertile
males (17% vs. 9%), it is unclear if treatment of
the hydrocele results in improved semen parameters or fertility [17]. Epididymal injury has been
reported to occur in up to 6% of patients undergoing hydrocelectomy, and this injury may result in
impaired fertility, including azoospermia [35, 86].
A long-term follow-up study of children undergoing inguinal hernia repairs demonstrated a 5%
infertility rate, with 15% of patients previously
undergoing hydrocelectomy at the time of herniorrhaphy [87]. To our knowledge, no study has
examined the impact of hydrocelectomy on semen
parameters in infertile males.
Infectious processes of the testicles visualized
on ultrasonography may frequently demonstrate
decreased echogenicity, increased heterogeneity,
hypervascularity, and testicular enlargement
(Fig. 13.7). Similar to MAGI, orchitis may be
secondary to infectious (E. coli, Chlamydia,
Mycobacterium, and mumps, among others) or
noninfectious etiologies. Although there remains
limited epidemiological data on the impact of
orchitis on overall infertility, previous reports have
demonstrated oligospermia and azoospermia
occurring at follow-up among 15–33% and 8–27%
of males with unilateral epididymo- orchitis,
224
Fig. 13.7 Orchitis:
transverse color Doppler
sonogram shows both
testes with abnormally
increased blood ow in
the symptomatic left
testis
Fig. 13.8 Testicular
tumor: transverse color
Doppler sonogram
shows a large, wellcircumscribed
hypoechoic mass with
prominent blood ow in
the left testis and both
testes with numerous
tiny hyperechoic foci,
characteristic of
microlithiasis. The mass
proved to be a seminoma
I. S. Lam et al.
respectively [88, 89]. Subsequent pathologic
analysis of patients with prior epididymo-orchitis
has demonstrated scarring of the seminiferous
tubules involving both the ipsilateral and contralateral testicles with chronic inammatory
changes noted [88].
Mumps orchitis is the most common complication of pubertal and postpubertal mumps and is
reported to occur in 5–37% of patients with
mumps, with 16–65% occurring bilaterally [90].
Among patients with a history of mumps orchitis,
approximately 50% will demonstrate some
degree of testicular atrophy with one study dem-
onstrating complete atrophy of seminiferous
tubules in 38% of biopsies obtained [34, 91, 92].
These ndings may be persistent, even in the setting of appropriate acute phase treatment [91].
Testicular Masses
Males presenting with infertility are at increased
risk for both immediate and subsequent development of testicular malignancy (Fig. 13.8). The
reported incidence of testicular malignancy in
infertile males ranges from 0.2% to 1% and is esti-
13 Ultrasound inMale Infertility
225
mated to be 20–100-fold more common than in the
general population [28, 93–96]. Men with abnormal semen parameters are also at an increased risk
of testicular malignancy with an incidence ratio of
1.6 [97]. Additionally, infertile men continue to be
at risk for malignancy following sterility with one
report of subsequent development of testicular
cancer occurring 14 years after initial evaluation
[80]. These ndings have led some authors to
advocate for the routine use of ultrasound during
the initial infertility evaluation [81].
The increasing utilization and improved resolution of scrotal ultrasonography have additionally resulted in an increased rate of detection of
testicular lesions with series reporting incidental
testicular masses in 1–6% of infertile patients
[81, 98, 99]. When the criteria for an incidental
testicular lesion are broadened to include
hypoechoic/hyperechoic regions, 34% (49/145)
of azoospermic patients are found to have focal
abnormalities, with only one of the 49 cases subsequently found to represent malignancy [94].
This increased rate of detection has also led to
an altered ratio of benign versus malignant
lesions [100]. Carmignani and colleagues
reported on a series of patients undergoing scrotal ultrasonography for infertility evaluations as
well as multiple causes (varicoceles, testicular
pain) with benign pathology found at surgical
excision in 75–80% of incidentally discovered
testicular lesions [99]. Other groups have reported
higher ratios of malignancies occurring in 50%
(2/4)–71% (7/9) of incidental lesions, albeit these
series were comprised of relatively small numbers [81, 93]. When benign ndings are reported
on frozen section with later determination of
malignancy on nal pathology, subsequent orchiectomy specimens were found to have no residual malignancy detected [93].
Given the higher rate of incidental, benign
lesions, close observation with repeat physical
examinations and ultrasonography has been proposed for non-palpable testicular lesions, particularly those <1cm [101]. Despite the increasing
rate of detection of benign testicular lesions, the
decision as to perform radical excision, testicular
sparing surgery, or active surveillance remains an
area of active debate.
Of interest, testicular ultrasound ndings following sperm retrievals including PESA, TESA,
and TESE demonstrate focal abnormalities which
persist in 77 and 54% of patients at 5days and
6months, respectively [102]. These ndings are
not to be misinterpreted as concerning for malignancy in this otherwise at-risk population.
Microlithiasis
Microlithiasis is identied on testicular ultrasonography as hyperechoic regions measuring 3mm
or smaller without denitive shadowing present
(Fig.13.9). Among asymptomatic patients undergoing screening scrotal sonography, testicular
microlithiasis is reported in 2.4–6% of individuals
with a higher frequency of testicular microlithiasis
present in infertile males (10% vs. 2% in controls)
[103–105]. Despite the known association between
testicular microlithiasis and infertility, Yee and
colleagues reported no differences noted in semen
analyses between infertile males with microlithiasis versus those without microlithiasis [104].
Microlithiasis has additionally been associated with a relative risk of testicular malignancy
of 21.6, with testicular tumors occurring in
approximately 6% of patients with microlithiasis
[106, 107]. Patients with microlithiasis and unilateral testicular germ cell tumors have an
increased incidence of carcinoma in situ in the
Fig. 13.9 Microlithiasis: transverse sonogram shows
multiple diffuse hyperechoic foci with no acoustic shadowing in both testes
226
contralateral testicle, with some authors recommending routine biopsy of the contralateral testicle [108]. However, subsequent surveillance of
patients with isolated testicular microlithiasis followed over a period of 7 years has not been
shown to develop malignancy [109].
Given the increased incidence of testicular
microlithiasis with malignancy and indeterminate clinical relevance of carcinoma in situ, routine surveillance is commonly recommended
with repeat self-testicular exams with or without
serial scrotal ultrasonography [106, 107].
Although there has been more research on testicular microlithiasis and testicular cancer in
recent years, most of the studies have reported
ambiguous results. The most robust data to date
comes from a meta-analysis done by Wang etal.
[110]. The meta-analysis involved 35,578
patients and suggested that individuals with testicular microlithiasis may be 12 times more likely
to have testicular cancer. Based on available data
of the incidence of testicular cancer, the European
Association of Urology recommends that individuals with testicular microlithiasis receive routine follow-up until the age of 55 [111]. Whether
the patient receives further workup depends on
whether the patient has additional risk factors for
testicular cancer. If the patient has isolated testicular microlithiasis, no further ultrasound or
biopsy is needed [112]. However, patients with
additional risk factors should receive annual
ultrasounds along with month self-examinations
[113]. The recommendation on when it is appropriate to perform a biopsy remains controversial.
Testicular Torsion/Trauma
Scrotal ultrasonography is an excellent imaging
modality for the rapid assessment and triage of testicular injuries. In the case of testicular trauma,
ultrasonography provides visualization of the
tunica albuginea and assessment of rupture of seminiferous tubules, scrotal and testicular hematomas,
and incidental testicular lesions [114]. In patients
with an acute scrotum, Doppler ultrasonography is
able to differentiate between infectious processes
and testicular torsion [115]. Epididymitis and/or
orchitis may present with various imaging ndings
I. S. Lam et al.
Fig. 13.10 Torsion: transverse color Doppler sonogram
shows absence of blood ow in the symptomatic left testis, which is slightly enlarged and surrounded by a small
hydrocele. Note normal color ow in the left extratesticular soft tissues (arrows)
including diffuse hypoechogenicity, enlarged epididymis/testicle, increased heterogeneity, increased
Doppler ow, or straightened spermatic cord. In
contrast, early or partial testicular torsion may
present with venous congestion and preserved arterial inow. Complete torsion is characterized by
the absence of testicular blood ow, frequently
with a proximal “whirlpool” sign (Fig. 13.10).
Given the occasional difculty in identifying early
ischemic injuries, alternative imaging techniques
including pulse inversion ultrasound may eventually offer a superior assessment in cases of acute
ischemia [116].
Multiple studies have examined hormonal and
semen proles following unilateral testicular
loss. In patients undergoing orchiectomy secondary to testicular trauma, impaired hormonal and
semen characteristics were identied including
decreased sperm density and elevated FSH/LH
compared to fertile controls [117]. Studies comparing outcomes following orchiectomy versus
orchiopexy for acute testicular torsion have
reported varied results. Arap and colleagues
reported decreased sperm counts and morphology with preserved hormonal levels in patients
undergoing either orchiectomy or orchiopexy,
while a second study noted decreased inhibin B
levels in both groups, indicating possible persistent subclinical gonadal dysfunction [118, 119].
Other studies demonstrate decreased inhibin B