[Music] the testacular parena may suffer vascular insult in one of two ways it may undergo torsion in such case the whole test is involved or patient may suffer from focal infarction testicular torsion occurs in those men who have a bell clap or deformity in that deformity the bare area where the tesus is supposed to be anchored to the wall of the scrotum is narrow or small allowing the testice to swing on stock and obstructing its blood flow the salvage rate after testticular torsion is related to the time since the beginning of the torsion if the torsion is discovered and op op ated on in less than 6 hours the salvageability of the test is excellent from 6 to 24 hours the Salvage ability declines and after 24 hours the Salvage ability of the testicle is poor this is a patient who has a bell Clapp or deformity you can see that there is a small hydral that is fluid in the scrotum around the test allowing us to see the entire bare area for this test as the yellow Arrow or pointing you can see it is relatively narrow and this is the only attachment of the tesus to the scrotal wall so this could Twist on itself particularly in the presence of this Hydro seal with testicular torsion we see absent or decreased blood flow in the affected testes and we may or may not see the Twisted cord so here is a patient who has acute test secular torsion you can see that the right test is slightly hypo eoic compared to the left one and with color Doppler there is no flow inside this test it is important when looking for blood flow inside the test to optimize this color scale for very slow flow which is here optimized to 2 cm/s and still we can identify there is no flow on the right test and there is a good flow on the left test after 4 hours the test becomes enlarged and edematous it may have decreased echogenicity and the echotexture may become heterogeneous and still have no blood flow inside the tesus we also may see thickening of the epidemis or the knot of the Twisted cord with the epidemis and a hydro seal May develop after after 4 hours so this patient has acute torsion here we can see the right test is enlarged than the left test we can see blood flow inside the left test and no blood flow in the right tesus also notice that the right test has heterogenous Echo texture and slightly hypo eoic than the left and it is increased in size compared to the left after 24 hours we have what is called M torion the torsion have blocked the blood flow to the tesus for more than a day an ultrasound will still see no flow inside the test but we may now see thickening of the scrotal wall and increased blood flow in the scrotal wall the changes in the test will continue it may be enlarged and emitus it may be hypo aoic and heterogeneous the epidemis will be still thickened and a hydral is likely to be present so here is a patient with a Mis torsion notice the normal left test with normal vascularity the right test is hypo aoic and heterogeneous and there is thickening of the scle wall as well as increased blood flow in the scrotal wall but no blood flow inside the testicle occasionally patients suffer focal infarction nobody knows exactly how it occurs but it tends to occur in older patients and this patient presents with acute pain and what we will see is either a wedge-shaped hypo eoic area at the periphery of the test or we might see complex intratesticular Mass this Mass may be indistinguishable from tumors so here is a patient who has an infarction this patient presented with pain we see a focal lesion at the upper pole of the tesus with well defined margins it looks like a mass the only thing about this mass is that it does not have any blood flow with the testicular parena does this is still concerning for a malignancy and they did remove it and pathology showed focal infarction okay let's move on to discuss other stuff this will include testicular trauma cystic lesions testicular microlithiasis verical hydral testicular atrophy and finally testicular sarcoidosis because of the scrotal location it is at risk of direct trauma after trauma a hematoma may be found in the scrotum it may be in the epidemis it may be in the scrotal wall or it may follow hem seal in addition the testicle may be damaged forming a contusion or a rupture sometimes the test get involved and we need to look at the test carefully after trauma with the contusion we have a hypo aoic or an aoic lesions that have poorly defined margin as you can see in this case there is multiple IL defined hypo eoic paranal lesions consistent with multiple contusions this patient has multiple testicular contusions contusions can look like in testicular masses and can raise concern for malignancy here we have illd defined hypo aoic lesions it is heterogeneous because this may be confusing with tumor this may sometimes come to resection also remember as we said before that 10% of testic tumors present with a history of trauma however in cases of trauma close followup may be recommended fortunately with contusions they do get better and quickly they get smaller in size and as you can see this patient who was followed monthly and you can see by 3 months the contusion are almost invisible now on ultrasound and become very smaller in size and resolved with testticular fracture you have a hypo eoic band across the test as in this case the test here is heterogeneous with hypoechoic line creating a penal discontinuity this hypoechoic line representing testicular fracture with testicular rupture there is disruption of the capsule of the tesus here is a diagram shows what happens in a testicular rupture you can see there is a tear in the Tunica alenia and some of the parena is extruded through the defect in the Tunica alenia it is very common also to have hematoma associated with this these are two patients with testicular rupture we can see that there is disruption of the Tunica Al oenia as the yellow arrows are pointing we can also see there is multiple IL defined hypoechoic paranal contusions in patients with testicular trauma so here is a patient with acute hematoma the scrotum was enlarged after trauma we see this collection in the lower portion of the scrotum blood collection in the Tunica of vaginalis is called hemal it is an eoic or shows low-level Echoes In acute stage as in this case resolving or chronic hemal has a typical web shaped septations as you can see in this case moving on to discuss the cystic lesions the lesions we will discuss are testicular cysts epidermoid cyst tubular ectasia of the re tesus epid cysts and sperata cell intest testacular cysts are uncommon but can be seen simple testacular cysts are asymptomatic and discovered incidentally on ultrasound these cysts are benign lesions and commonly found in men over 40 years of age they range in size from 2 mm to 2 cm and can be very large and replace most of the test most of the intratesticular cysts are non-p palpable that is opposed to the tunical cysts which are on the surface of the test which can be small but still palpable on ultrasound these are rounded or oval an aoic structures with posterior acoustic enhancement most of the cysts are located near the mediastinum test and are unilocular no internal vascularity on color Doppler interrogation epidermoid cyst is a benign cyst its size range from 1 to 3 cm on ultrasound it has an echogenic rim and showing onion skin or Target appearance due to layers of keratin no flow on color Doppler examination in tubular ectasia of the REI tesus you have some sort of obstruction to flow of spermatozoa you get reflux into the re tesus typically it affects men over the age of 55 on ultrasound it appear as Tiny tubular cystic spaces along the mediastinum it should not have any Mass Effect or any flow on color Doppler examination Associated sperata cell or epid cyst is common epididimo cyst and sperata cell epid cysts are common benign cystic lesions of the epidemis patients present with complaints of painless palpable mass in the scrotum larger cysts usually cause discomfort and pain however in up to onethird of patients epidi cysts are asymptomatic and found incidentally the terms epidi cyst and sperata cell are often used interchangeably to describe the same structure epid anal cysts contain Cirus fluid and do not contain sperm while spermatoceles contain non-viable spermatozoa and debris and are typically seen after puberty on ultrasound epidedmy cyst is an aoic rounded or oval structure with no internal Echoes it shows posterior acoustic enhancement it may be solitary or multiple larger cysts May may contain septations and may mimic hydral it is located at any part in the epidemis speratti seals at ultrasound are similar to epidi cysts however they show internal Echoes and located almost always in the epidermal head beside looking at masses inside the tesus we look at test for other reasons including to evaluate the testicular parena and one thing you might see is microlithiasis microlithiasis are tiny little calcifications scattered throughout the testicular parena the prevalence is about 9% with current ultrasound technology which have been improved the risk of malignant tumors in patients with microlithiasis is eight times higher than those without microlithiasis and typically the tumors are more often germ cell tumors and more often pure seminomas so here is a patient with microlithiasis you can see on this longitudinal view that the testicle is filled with these tiny little bright Echoes throughout the parena the number of microl lits detected on Imaging may vary considerably the condition has been graded as grade one if you have 5 to 10 microliths grade two if you have 10 to 20 microliths and grade three if you have more than 20 microliths depending on the count of microcalcification seen in any single view this patient has microlithiasis but developed germ cell tumor you can see the tumor is centrally located inside the test it is hypo aoic Mass but notice the testicular parena has microlithiasis also notice the increased vascularity associated with the tumor so if microlithiasis is encountered on ultrasound what do you recommend to the patient most stuff recommended that patients do self-examination to assess for the development of the tumor because also these tumors are eight times more common in patients with microlithiasis than in those without the risk of cancer still low a few have recommended annual physical examination and annual ultrasound examination and if the patient have a prior history of a testicular tumor cryptorchidism or subfertility those patients should have closer surveillance than just self-examination let's move on and discuss another pathology verical is an abnormal dilation and tortuosity of pampiniform plexus of veins this common condition is associated with testicular discomfort and may affect male fertility the iology of verical is complex however dilation and incompetency of the testicular vein with reflux of blood down into the pampiniform plexus is presumed to cause verical formation verico seals are more common on the left side with up to 80% of the men with verico Seal have a bilateral infection isolated right testicular varic coil is rare and should raise concern for variant anatomies like cytis inversus or intraabdominal pathology such as a retroperitoneal Mass the normal diameter of pampiniform plexus veins is less than 1.5 mm on ultrasound veric coil are dilated hypo eoic veins greater than 2 mm in diameter with serpiginous appearance on color Doppler there is reflux of flow with Vol Salva maneuver this is a case of verico seal as you can see on these images there is multiple dilated tortuous an aoic veins superior to the test the average vein diameter was about 3.5 mm on color Doppler examination there was reflux during Vol Salva intest ular verical is a rare entity characterized by the dilation of intratesticular veins usually seen in relation to the mediastinum tesus intratesticular veric coal typically associated with extratesticular varico seal but may be isolated there is increased incidence in men who have undergone orchidopexy for undescended tesus as you can see in this case there is a left-sided extra testicular verico seal however there is also intratesticular tubular shaped anaco structures within the mediastinum tesus color Doppler revealed blood flow during Vol Salva these are intratesticular verical hydral is an abnormal accumulation of cus fluid in the tunic of vaginalis hydral can be diagnosed at Anye age and may be congenital or acquired nearly all hydral in neonates and infants are congenital and are typically associated with patent processes vaginalis there are two main subtypes of congenital hydral communicating hydral and spermatic cord hydral acquired hydral May develop due to trauma infection inflammation or neoplastic process most hydr seals however are ideopathic on ultrasound hydral is a simple an aoic fluid collection it may contain septations or internal Echoes it is a vascular on Doppler evaluation in communicating infantile hydral as in this case you will see fluid intimately surrounding the adjacent test in contrast spermatic cord hydral such as funicular and in cste the fluid will not surround the test rather being found along the spermatic cord as in this case let's move on and discuss testicular atrophy testicular atrophy is a pathologic process involving total or partial wasting of the previously normal test the condition is characterized by the diminished size of the affected test with complete or partial function loss multiple conditions may be responsible for testicular atrophy these conditions includes testicular isia testicular trauma infection and inflammation verical anabolic steroids radiation exposure and congenital disorders such as Klein felter syndrome pain is a common sign of testicular atrophy the criteria for diagnosis of testicular atrophy are a volume of less than 12 mlit or a volume reduction of 2 Millers compared with the contralateral healthy test on ultrasound the atrophic test often has a heterogeneous hypoechoic echotexture and appears noticeably smaller than the contralateral side lastly testicular sarcoidosis sarcoidosis is a rare chronic multi- systemic disorder it is characterized by the formation of lesions in multiple organs of the body although any organ can be affected by sarcoidosis the most frequently involved sites are the lungs the skin and the eyes testicular involvement is sporadic and is most often accompanied by the epidermal infiltration the peak incidents between the second and fourth Decades of life men with testicular sarcoidosis may present with painless palpable mass or masses on ultrasound the typical presentation is multiple bilateral hypoechoic lesions with or without epid involvement when epidemis is involved it may appear heterogeneous and enlarged sonographically testic sarcoidosis May mimic malignancy leading to misdiagnosis it is is crucial to identify and correctly diagnose the condition to avoid unnecessary orchiectomy thank you very much for your attention