Undescended Testicle, Orchitis/Epididymitis

If both testicles are not found in the scrotum after the age of 3 months, the question of localizing the undescended or ectopic testicles must be addressed. Frequently, the testicle (98) is found in the inguinal canal near the anterior abdominal wall (2,5), as seen in Figure 57.1. An unsuccessful sonographic detection of an undescended or ectopic testicle, which is at risk of malignant transformation, should be supplemented by an MR examination.

The sudden onset of severe scrotal pain radiating into the groin demands differential diagnostic clarification between inflammation and torsion since the ischemic tolerance of testicular tissue before irreversible necrosis is only 6 hours. In inflammation, perfusion is maintained, and can be seen by (color) Doppler sonography as a characteristic arterial flow profile ) in the testicular tissue (Fig. 57.2), frequently increased on the affected side. Torsion, in contrast, shows decreased perfusion in relation to the other side or lacks perfusion entirely.

Orchitis or epididymitis is usually accompanied by edematous thickening of the testicle (98) or epididymis (99) (Fig. 57.3). If the findings are inconclusive, comparing both sides to determine their relative size can be helpful. A thickened and partially multilayered scrotal wall (100) can be seen as manifestation of an accompanying edematous reaction.

A homogeneous anechoic fluid collection (64) invariably represents a hydrocele (Fig. 57.4). The diagnosis of a vari-

cocele is established by the Valsalva maneuver or color-coded Doppler sonography. Occasionally, herniated bowel loops (46), a hydrocele (64), and the ipsilateral testicle (98) can be visualized together on one sonographic section (Fig. 57.5). A hydrocele can accompany a testicular malignancy. Most, but not all, testicular tumors cause a heterogeneous parenchymal pattern. A well-differentiated seminoma can be homogeneous and present as an unremarkable sonographic pattern.

Fig. 57.4a

Fig. 57.4a

Fig. 57.5a

Fig. 57.5a

To visualize the uterus (39) and ovaries (91), transabdominal sonographic imaging of the lesser pelvis requires a distended urinary bladder (38) as acoustic window (Figs.58.1 a-c). To achieve the necessary depth penetration, low frequencies (3.5-3.75 MHz) with the corresponding decreased spatial resolution have to be selected (refer to p. 8).

Fig. 58.1a

Fig. 58.1c

Better visualization can be accomplished by using endovaginal probes (Fig. 58.2a), which can be positioned close to the target organs of the uterus (39) and ovaries (91) (Fig. 58.3a) and can be operated at higher frequencies (5-10 MHz) with a correspondingly higher spatial resolution. Transvaginal sonography can be performed without a filled urinarv bladder.

Fig. 58.2 a

cranial posterior cranial posterior

sagittal view

In comparison to transabdominal images, the images are acquired from below and the endovaginal images are seen "upside down.'' The sound waves propagate from the probe (located inferiorly in the body and at the inferior border of the images) upward (superiorly). This orientation, to which the novice is unaccustomed, shows the urinary bladder (38)

and the anterior abdominal wall (1-3) at the upper border on coronal images, far away from the probe. On sagittal sections (Fig. 58.3), the urinary bladder is on the right side of the image if viewed from the right side of the patient. Some examiners prefer the images as viewed from the left side, with the anterior structures then seen on the left side of the image.

The width of the endometriuin (78) varies with the menstrual cycle: immediately after menstruation, a thin, echo-genic, linear echo is seen (Fig. 59.1). At the time of ovulation, the endometrium is separated from the myometrium (39) by an echogenic rim (ยป/) (Fig. 59.2). After ovulation, the midline echo (->) gradually disappears in the secretory endometrium (Fig. 59.3) until only an echogenic endometrium is recognized.

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