Fine needle aspiration cytology of epididymal nodules and its corroboration with ultrasonographic-histological findings.

BACKGROUND: Fine needle aspiration cytology (FNAC) assisted with scrotal ultrasonography is the best preoperative diagnostic modality for palpable epididymal nodules. It also aids in their successive remedial approach as well as serves semi-therapeutically in cystic lesions. The objectives of this study are to recognize the spectrum of pathological conditions giving rise to epididymal nodules, then to compare them with corresponding ultrasound images, and to evaluate the histological features wherever practicable. METHODS: Total 62 patients underwent FNAC as well as sonographic evaluation for their epididymal nodules. Histopathology was performed in only 20 cases. RESULTS: Epididymitis either caused by tuberculosis (30.6%), or in its acute (11.3%) and chronic (8.1%) forms remained the commonest cytological diagnosis. Neoplastic lesions included mostly adenomatoid tumors (8.1%), and another case of seminomatous spread from ipsilateral testicular primary. Nineteen of the excised masses corroborated with their respective cytodiagnoses. The discrepant lesion was actually a papillary cystadenoma, which was cytologically misinterpreted as adenomatoid tumor. CONCLUSIONS: FNAC becomes the first-hand investigative measure for epididymal nodules, by virtue of its early, easy and highly accurate diagnostic implications. It segregates the patients into proper therapeutic protocol and thereby estranges those who really need operative management. When deployed together with ultrasound, the diagnostic accuracy of FNAC improves further.

Is follow-up ultrasound necessary after acute epididymitis? A retrospective analysis from a large university hospital.

OBJECTIVES: To evaluate the role of scrotal ultrasound in the follow-up after epididymitis for underlying serious testicular pathologies, which could be overseen in the acute phase. METHODS: Retrospective chart reviews were performed for patients diagnosed with acute epididymitis at Herlev-Gentofte Hospital between 2006 and 2013. Patients were included if they had received the diagnosis after a clinical evaluation in the emergency department and had subsequently undergone antibiotic treatment and a follow-up scrotal ultrasound at a later date. RESULTS: Overall, 118 patients fulfilled the inclusion criteria. The median age was 45 years (range = 18-80). The follow-up ultrasound scans showed no signs of significant pathology in 92/118. Incidental findings of hydroceles, spermatoceles, and varicoceles were made in eight, five and five of the 118, respectively. One patient had testicular tuberculosis and one had neglected testicular torsion. Six patients were diagnosed with suspicious testicular lesions and underwent surgery. Cancer was confirmed in four men (27, 32, 40, and 45 years old). CONCLUSIONS: Epididymitis can be diagnosed and treated correctly without scrotal ultrasound in the majority of cases. However, the risk of underlying testicular cancer should be kept in mind. Patients below 50 years of age without bacteriuria and patients with persistent symptoms after antibiotic treatment should be referred to an urologist for a re-evaluation or for a follow-up ultrasound.

131I Whole-Body Scan Incidental Uptake Due to Spermatocele.

A 46-year-old man with papillary thyroid cancer post total thyroidectomy was referred for post radioiodine (I) whole-body scan. Whole-body images revealed intense I uptake in the bed thyroid and a focal abnormal uptake in the testicular area. Subsequent SPECT/CT demonstrated that the focal uptake corresponded to the left epididymis, and the pathology report revealed a spermatocele with no immunohistochemical features for thyroid tissue. Many cases of unexpected radioiodine uptake have been reported, and spermatocele could be counted for another possibility of incidental I uptake despite an unclear mechanism.

Epididymal Cystadenomas in von Hippel-Lindau Disease Showing Increased Activity on 68Ga DOTATATE PET/CT.

von Hippel-Lindau (VHL) disease is a familial cancer syndrome characterized by the development of a variety of malignant and benign tumors, including epididymal cystadenomas. We report a case of a VHL patient with bilateral epididymal cystadenomas who was evaluated with Ga DOTATATE PET/CT, showing intensely increased activity (SUVmax, 21.6) associated with the epididymal cystadenomas, indicating cell-surface overexpression of somatostatin receptors. The presented case supports the usefulness of somatostatin receptor imaging using Ga DOTA-conjugated peptides for detection and follow-up of VHL manifestations, as well as surveillance of asymptomatic gene carriers.

Tubular ectasia of the rete testis (TERT). Differential diagnosis of cystic testicular disorders.

The ultrasound scan plays an essential role in the urological-andrological diagnosis. High-resolution transducers (8-15 MHz) make it possible to prove increasingly small changes. The assessment of cystic masses in the testis can also be difficult for experienced doctors. However, a precise diagnosis is crucial for the patient to avoid further invasive diagnostics and therapy. The differential diagnosis of benign intra-testicular cystic lesions include the tubular ectasia of the rete testis (TERT), the cystic dysplasia, epidermoid cysts, dermoid cysts, simple testicular cysts and cysts of the tunica albuginea. Malign testicular tumours with cystic changes are particularly the mature teratoma, carcinomas of the epididymis and metastasis. The following overview shows different sonographic images and interpretations with a particular focus on TERT.

Extratesticular masses in children: taking ultrasound beyond paratesticular rhabdomyosarcoma.

Extratesticular cystic and solid scrotal masses are commonly encountered in pediatrics. The most common extratesticular malignancy is paratesticular rhabdomyosarcoma. The remainder of the common pathologies encountered -- appendage torsion, epididymitis and varicoceles -- are mostly benign. These frequently encountered benign lesions are confidently differentiated from paratesticular rhadbomyosarcoma using high-frequency scrotal sonography in combination with clinical features. Less commonly encountered extratesticular masses may not be as easily classified; however, these also have distinguishing features that can enable differentiation from malignancy. This review discusses the sonographic findings, and relevant clinical and pathological manifestations of the more unusual extratesticular masses encountered in two tertiary pediatric institutions during a 10-year period. While these extratesticular pathologies are encountered relatively infrequently, recognition of their manifestations enables appropriate management.

Epididymal cysts in childhood - conservative or surgical approach?

THE AIM OF THE STUDY: To decide on the accurate way of treatment and to establish criteria for operation in boys with pubertal epididymal cysts (ECs). MATERIAL AND METHODS: Results of scrotal ultrasound of 363 boys and adolescents, aged 2 months to 18 years, were reviewed retrospectively. RESULTS: Of all 363 patients with scrotal ultrasound 59 (16.2%) at mean age of 14.03 yrs had ECs. The EC incidence increased with age and 42 out of 124 boys (33.8%) older than 14 yrs had cysts (chi2=27.627, p=0.000). Out of 59 patients, in 30 (50.8%) cysts were diagnosed incidentally at the time of scrotal US, 29 boys (49.2%) presented with scrotal mass and/or pain. 31 patients with ECs (52.5%) underwent elective surgery and the remaining 28 boys (47.5%) received conservative treatment. The age of boys with ECs who underwent surgery ranged from 8 to 18 years (mean 14.32). The age range of patients treated conservatively was 7-18 (mean 13.71). There was no statistical difference in age between boys treated surgically and conservatively (t=0.924, p=0.36). ECs resolved in 17 patients out of 28 boys treated conservatively, in remaining 11 boys the size of cysts was stabile and they remain asymptomatic. Clinical and ultrasonographic follow-up were carried out from 11 months to 5 years. CONCLUSIONS: ECs are more common in older boys (over 14 years). Management of ECs smaller than 10 mm should be conservative with clinical and ultrasound controls, leaving surgery for cysts increasing in size over 10 mm which did not involute with time.

Mobile echogenicities on scrotal sonography: is the finding associated with vasectomy?

OBJECTIVES: The purpose of this study was to determine whether mobile echogenicities seen in the epididymis on scrotal sonography are associated with prior vasectomy. METHODS: We prospectively obtained a sonographic video clip of each epididymal body in outpatients sent for scrotal sonography. The presence of punctate mobile echogenicities in the epididymal body was noted, and the indication for the sonogram, patient age, and history of vasectomy were recorded. This study was compliant with the Health Insurance Portability and Accountability Act and was approved by the Institutional Review Board. RESULTS: Of 345 patients (mean age, 44.9 years), 56 (16.2%) had undergone vasectomy and 289 had not. Mobile echogenicities were found in 8 patients, 7 of whom were postvasectomy. The rates of mobile echogenicities appearing were 12.5% (7 of 56) in the vasectomy group and 0.3% (1 of 289) in the nonvasectomy group (P < .0001, Fisher exact test). Epididymal cysts were seen in 184 of 345 patients (53.3%). There was no significant difference in the presence of epididymal cysts in the patients who had undergone vasectomy compared to those who had not (P = .34), including 30 of 56 postvasectomy patients (53.6%) and 154 of 289 patients without vasectomy (53.3%). Pain was reported by 177 patients (51.3%), including 34 of 56 (60.7%) in the postvasectomy group and 143 of 289 (49.5%) without vasectomy. The presence of pain was similar in both groups (P = .15). CONCLUSIONS: The presence of mobile echogenicities in the epididymis is almost always a postvasectomy finding and occurs in approximately 12.5% of such patients. There is no significant difference in the rate of epididymal cysts or pain after vasectomy compared to those who have not had vasectomies.

Extra scrotal spermatocele causing lower abdominal pain: a first case report.

Lower quadrant abdominal pain is a common complaint evaluated in emergency departments (EDs). The number of differential diagnoses is lowered when the pain in a male patient is associated with a palpable tender mass. These diagnoses include inguinal hernia, inflamed inguinal lymph node, rectus sheath hematoma, cryptorchidism, mass derived from the spermatic cord, and polyorchidism. We report a case of extra scrotal spermatocele causing lower quadrant abdominal pain that was misdiagnosed as an inguinal hernia on several ED visits. Lower quadrant mass and pain caused by a spermatocele are unusual conditions. Upon the patient's third (ED) visit, the painful mass remained located in his right lower quadrant. The lower quadrant mass was movable on palpation and with pressure could be delivered into the superior aspect of the scrotum. The patient had an abdominal and pelvic computed tomography scan and lower quadrant ultrasound. The imaging studies revealed the mass to be a cystic structure. Surgical excision confirmed that the mass was a spermatocele. Differential diagnoses, diagnostic approaches, and treatment are discussed.

Imaging of non-neoplastic intratesticular masses.

The use of high-frequency ultrasound is increasing for the treatment of cystic, vascular, and solid non-neoplastic intratesticular masses. Cystic lesions examined include simple testicular cysts, tunica albuginea cysts, epidermoid cysts, tubular ectasia of rete testis, and intratesticular abscesses. Vascular lesions examined include intratesticular varicocele and intratesticular arteriovenous malformations. Solid lesions examined include fibrous pseudotumor of the testis, focal or segmental testicular infarct, fibrosis of the testis, testicular hematoma, congenital testicular adrenal rests, tuberculoma, and sarcoidosis. Gray-scale and color-flow Doppler sonography facilitate the visualization of the benign characteristics of the lesions. Magnetic resonance imaging can also help as a problem-solving modality in some cases.

Tubular ectasia of the rete testis associated with azoospermia: a case report.

Tubular ectasia of the rete testis (TERT) is a rare benign condition of the testis due to dilatation of the tubules of the rete testis. It must be differentiated from neoplastic disease of the testis clinically by patient's age, mode of presentation, tumour marker status and characteristic ultrasound and colour Doppler findings. Awareness and diagnosis of TERT should prevent unnecessary surgical intervention such as orchidectomy or biopsy. We report a case of severe bilateral tubular ectasia of the rete testis associated with azoospermia and review the relevant literature. This association has not been reported before in the literature to the best of our knowledge.

Ultrasound findings of masses of the paratesticular space.

Ultrasound is a routine investigation for the assessment of scrotal masses. Many of the detected lesions involve the paratesticular structures. The most common paratesticular masses in clinical practice are epididymal cysts and spermatoceles, but there are a large number of other pathologies that can be encountered and may result in diagnostic uncertainty. This review covers a wide range of the common and the rare, but important, causes of paratesticular masses. The ultrasound findings (both typical and atypical) of these lesions are clarified, and emphasis is given to the features that help to differentiate between them.

A unique radiological pentad of mesonephric duct abnormalities in a young man presenting with testicular swelling.

Cystic dysplasia of the rete testis with associated ipsilateral renal agenesis is a very rare congenital abnormality, mainly described in the paediatric literature. In addition, the presence of a seminal vesicle cyst with ipsilateral renal agenesis is a rare but well-described entity. We present an adult who was found to have a unique pentad of mesonephric duct abnormalities on radiological imaging, including cystic dysplasia of the rete testis, seminal vesicle cyst, ipsilateral renal agenesis, partial hemitrigonal development and epididymal dilatation. We review and discuss the relevant literature of this case and discuss in detail the embryological basis for this unusual combination of findings.

Do mountain bikers have a higher risk of scrotal disorders than on-road cyclists?

OBJECTIVE: To sonographically investigate whether mountain bikers have a higher prevalence of scrotal abnormalities compared with on-road cyclists. DESIGN: We studied 85 male mountain bikers (mean age: 25 years; range 17-45 years) and 50 male on-road cyclists (mean age: 23 years, range 15-46 years) with regard to scrotal findings on ultrasound (US). SETTING: Medical University Innsbruck, Austria. PARTICIPANTS: Only males who gave a history of extensive mountain biking or on-road bicycling (2 hours or more per day on 6 days a week with a covered distance of more than 5,000 km/year) were entered in our study. INTERVENTIONS: In addition to clinical evaluation, a standard ultrasonographic examination of the scrotum was performed using a linear array transducer operating at a frequency of 8.0 MHz (Acuson Sequoia 512). MAIN OUTCOME MEASUREMENTS: The sonographic findings obtained in mountain bikers were compared with those obtained in on-road cyclists. RESULTS: Eighty of 85 mountain bikers (94%) and 24 of 50 on-road cyclists (48%) presented with abnormal findings on scrotal US. Abnormal US findings in mountain bikers included scrotoliths in 69 bikers (81%), spermatoceles in 39 bikers (46%), and epididymal calcifications in 34 bikers (40%). US findings in on-road cyclists were scrotoliths in 8 cyclists (16%), spermatoceles in 13 cyclists (26%), and epididymal calcifications in 6 cyclists (12%). The overall number of scrotal abnormalities was significantly greater in mountain bikers than in on-road cyclists (P < 0.001). CONCLUSIONS: Mountain bikers compared with on-road cyclists have shown to be at a higher risk for scrotal disorders on US examination. Not only protective measures but also the awareness of the bikers are required to reduce the potential risk. Further studies should be undertaken to determine the clinical significance of the sonographic changes.