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                                                                 Trauma:
   The scrotum and its contents may be injured by penetrating or blunt
    trauma. Surgical exploration is performed after penetrating trauma,
                                         whereas ultrasound examination
   is indicated after blunt trauma .Under these circumstances,the main
         role of ultrasound is in the diagnosis of testicular rupture. Early
  surgical exploration and repair of a ruptured testis improve testicular
          survival because the salvage rate is over 80% when the testis is
       repaired within 72 hours,but it drops to 30% thereafter .Reported
                                accuracy in the diagnosis of rupture of the
   testis is in the range of 94% to 100%. Missed or untreated rupture of
         the testis may result in an ischemic atrophic testis or secondary
 infection. In addition, in cases of unilateral testis trauma, which might
or might not include orchiectomy as treatment, it has been shown that
  patients might develop subfertility in association with apoptosis (cell
  self-destruction by fragmentation of the nuclear DNA) and abnormal
                                                                    sperm.
Rupture of the testis
Scrotal hematoma with testis rupture . scrotal wall infiltration (arrows)
   and heterogeneous testis on the right side. The left side is normal.
                              Germ cell tumors:•
                  Tumors showing a single cell type:
                                          Seminoma
                                              Typical
                                          Anaplastic
                                      Spermatocytic
                               Embryonal carcinoma
                                          Adult type
                                       Infantile type
                                     Polyembryoma
                                   Choriocarcinoma
                                           Teratoma
                               Mature and immature
   Tumors showing more than one histologic pattern:
Embryonal carcinoma plus teratoma (teratocarcinoma)
                Embryonal carcinoma plus seminoma
                            Seminoma and teratoma
                                Other combinations
                Tumors of gonadal stroma:•
                                       Leydig cell tumors
          Sertoli cell, granulosa cell, theca cell tumors
                   Tumors of primitive gonadal stroma
                                Mixtures of these three
Adult Unilateral (Occasionally Bilateral) Tumors of the Testis
Classic seminoma in a 46-year-old patient
Testicular teratoma in an infant
Embryonal cell carcinoma predominant in a mixed-cell tumor
Abdominal Burkitt's lymphoma with metastasis to the
                       testes
Non-Hodgkin large B-cell lymphoma in a 66-year-old patient
Large paratesticular rhabdomyosarcoma in a 14-year-old boy
Chronic epididymitis mimicking a paratesticular mass in a 2-
                       year-old boy
                                                       Cryptorchydism •
 Cryptorchydism occurs in approximately 3% of term male infants with
       spontaneous descent in two-thirds of the cases. The incidence of
      cryptorchydism rises with prematurity because testicular descent
                       usually occurs in the seventh month of gestation.
 Orchiopexy prevents torsion of the cryptorchid testis and reduces the
         risk of trauma to the testis. The exact relationship of fertility to
cryptorchydism and subsequent orchiopexy is controversial. Boys with
   cryptorchydism have increased risk of testicular cancer. Orchiopexy
may allow earlier detection of testicular tumors, but it is controversial
 as to whether or not orchiopexy reduces the risk of testicular cancer.[
 Approximately 20% of undescended testes are nonpalpable and most
     of them are located in the inguinal canal .US is highly sensitive for
     identifying the inguinal undescended testis. Using US to guide the
     surgical approach saves most boys from the need for laparoscopy.
                                    Inguinal hernia and hydrocele: •
Obliteration of the processus vaginalis occurs after the seventh month
  of gestation. Failure of the processus vaginalis to obliterate can result
 in passage of peritoneal fluid, leading to hydrocele or intestinal loops,
                                  or omentum, leading to inguinal hernia.
The incidence of congenital inguinal hernia is between 0.8% and 4% of
   live births. The risk of incarceration is up to 60% in the first 6 months
 of life. Right inguinal hernias are more common as the right processus
         vaginalis closes later. US can be helpful for inconclusive physical
examination or to evaluate for contralateral involvement. US can show
      bowel loops in the inguinal canal or scrotum, and during real-time
     imaging it can demonstrate peristaltic activity or movement of fluid
                                                            and air bubbles.
  Omental hernia is seen as a continuous echogenic structure from the
                                    pelvis to the inguinal canal or scrotum.
 A clinically occult contralateral hernia can be found in 88% of cases.
       Congenital hydrocele appears as fluid collection surrounding the
        anterolateral aspects of the testis, sometimes extending to the
inguinal canal. When the processus vaginalis is completely patent, the
          hydrocele is communicating. This leads to elective repair. The
     processus vaginalis may obliterate at any point leading to various
      types of hydroceles. Closure of the processus vaginalis below the
   internal inguinal ring leads to noncommunicating hydrocele, which
                                   usually resolves by the age of 1 year.
Closure of the processus vaginalis below the internal inguinal ring and
     above the testis leads to spermatic cord hydrocele. A rare type of
  hydrocele is referred to as abdominoscrotal hydrocele. This is a large
communicating hydrocele that protrudes through the internal inguinal
    ring into the abdominal cavity and appears as a pelvic cystic mass.
Normal anatomy of the inguinal canal
Omental hernia in a 16-year-old boy
Inguinal hernia containing bowel
                                        Testicular Calcifications:•
              Testicular calcifications are of different types. Isolated
         calcifications with no associated findings are common and
     may represent benign phleboliths, fibrosed-calcified spermatic
         granulomas, the end result of previous epididymoorchitis,
                       or trauma. They are of no clinical significance.
              A different situation arises when the calcifications are
        multiple, minute, and grouped. They should be considered
          highly suggestive of malignancy. Necrotic or hemorrhagic
                    areas in germ cell tumors may calcify. Embryonal
carcinoma is the most common tumor to present with necrosis and
                             hemorrhage, whereas seminomas rarely
           necrose and calcify. Calcifications may also be seen with
        teratoma, but in this case they represent calcified cartilage
                                                    or bone fragments.
                     Testicular microlithiasis is an uncommon, usually
       incidental, finding. It is caused by the formation of microliths
                 from degenerating cells in the seminiferous tubules.
                          Microlithiasis may occur in healthy patients,
         but it has also been found in nonneoplastic conditions such
as Klinefelter’s syndrome, Peutz-Jeghers syndrome, cryptorchidism,
                postorchiopexy testis, testicular infarcts, granulomas,
                subfertility, infertility, male pseudohermaphroditism,
           Down’s syndrome, and pulmonary alveolar microlithiasis.
                          Testicular microlithiasis has been associated
                with germ cell tumors: seminomas, seminoteratoma ,
                     and intratubular germ cell neoplasia . In cases of
   seminoma with pathologic correlation, the area of microlithiasis
                       was confined to the nontumoral portion of the
                        testis. Because of the described association of
           microlithiasis with neoplasia, the ultrasound diagnosis of
            microlithiasis should warrant more aggressive follow-up.
Bilateral microlithiasis of the testes
Seminoma (calipers) in a patient with testicular microlithiasis
   Varicoceles are a dilation and tortuosity of the pampiniform plexus•
                      veins in the spermatic cord or the epididymis .Most
       varicoceles are primary and affect adolescents and young adults.
                   They usually involve the left side, a finding attributed
                        to the drainage pattern of the more tortuous left
                internal spermatic vein into the left renal vein. Bilateral
              varicoceles have been reported with an incidence varying
                     from 10% to 70%. Secondary varicoceles result from
increased intra-abdominal pressure such as from hepatosplenomegaly
                          and abdominal masses. They are less frequent.
                      An acute onset on either side, a right varicocele, or
                a varicocele in a mature man raises the possibility of an
                         abdominal or pelvic mass. Varicocele is the most
             common single, correctable cause of male infertility, and it
  is found in 37% of patients with this problem. Two or more tortuous,
                    sonolucent tubular structures with a caliber of 2 mm
               or more are seen as the hallmark findings in varicoceles.
                     On the basis of the Doppler tracing during a
           Valsalva maneuver, varicoceles have been classified in
          two types. The stop type shows only retrograde blood
in the internal spermatic vein. An explanation for this situation
        is the presence of competent valves in the pampiniform
             plexus. Small and subclinical varicoceles are usually
         of this type. The shunt type shows both retrograde and
       antegrade (physiologic) blood flow in the same vein. This
     phenomenon is explained by the presence of incompetent
    valves in the pampiniform plexus that allow communication
          and collateral circulation by way of the deferential and
        cremasteric veins. Moderate-to-large varicoceles display
                                                      this pattern.
Ali shahbazi

				
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posted:8/16/2012
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