Emergency Ultrasound > Top 10 High-Yield Points

Top 10 High-Yield Points

  1. Always obtain a transverse view of both testes side-by-side for comparison both in grayscale and with the flow Doppler. Obtain images of the inguinal canal and the epididymal regions as well. Do not confuse the normal mediastinum or tubular ectasia (Rete Testis) with abnormal pathology.

  2. Acute testicular pain differential diagnosis mainly includes Testicular Torsion and Epididymitis. Testicular torsion is a medical emergency and prompt referral to the urologist is of utmost importance. Another emergency that requires immediate intervention is Fournier's Gangrene which can spread proximally very fast.

  3. Realize that during descent of the testes, at the inguinal canal along the lower gubernaculum, an evagination of the peritoneum arises, the vaginal process, on which the testes will slide through the inguinal canal. As a result, prior to 9 months of age, a connection exists between the peritoneal cavity and the vaginal process in the scrotum where fluid can accumulate.

  4. When encountering an abnormal mass, differentiation between an intra-parenchymal and an extra-testicular mass is of utmost importance as the differential diagnosis and the patient's prognosis vary accordingly. Most intra-parenchymal masses are malignant while most extra-testicular lesions are of benign origin.

  5. Painless palpable testicular mass is always a suspicion for testicular cancer especially in ages 25 to 35. Above 45, they mostly represent metastasis.

  6. Most common primary malignancies metastasizing to the testicle include prostate, renal, lung, gastrointestinal and melanoma. Lymphoma and leukemia are also common malignancies that spread to the testicles as these organs can act as a sanctuary for these two latter entities.

  7. The presence of an intratesticular lesion of predominantly low signal intensity on T2-weighted MR images with septa enhancing more than tumor tissue after contrast material administration is more suggestive for the diagnosis of a seminomatous lesion. Tumors that are heterogeneous both on unenhanced and contrast-enhanced images are indicative of a nonseminomatous neoplasm.

  8. Microlithiasis criteria has been described as the presence of at least 5 pinpoint hyperechoic foci of size smaller than 3 mm in one field of view without posterior shadowing. There has been studies that suggest correlation between microlithiasis with germ-cell tumors and it is recommended that patients may undergo screening for testicular cancer on a regular basis, such as annual physical exam or testicular ultrasonography.

  9. CT can be used for staging of testicular cancer: stage I (Local, 72%) is limited to testicle, stage II (Regional, 19%) has spread to lymph nodes in the abdomen, stage III (Distant, 9%) has spread to lymph nodes above the diaphragm o rdistant organs such as liver, lungs and brain. CT can also be used when varicocele presents acutely and without prior history, since it may be an indirect sign of an abnormal pelvic, retroperitoneal or renal hilar mass causing extrinsic compression and obstruction of flow to the gonadal veins.

  10. In cryptorchidism, if a testis has not descended by the age of 1 year, there is no benefit in waiting for a spontaneous descent. To prevent histological deterioration, treatment should be carried out and finished before 12-18 months of age. Medical treatment with hCG or GnRH can have a beneficial effect on increasing the patient's fertility index when given before or after surgical orchidolysis and orchidopexy.

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