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{{Authors
|author1=[[User:Mikael Häggström|Mikael Häggström]]
|author2=Authors of Creative Commons article<ref name="MakTzeng2012">Content originally copied from: {{cite journal|last1=Mak|first1=Chee-Wai|last2=Tzeng|first2=Wen-Sheng|title=Sonography of the Scrotum|year=2012|doi=10.5772/27586}} from {{cite web|url=https://www.intechopen.com/books/sonography/sonography-of-the-scrotum||title=Sonography|author=Kerry Thoirs}} {{ISBN|978-953-307-947-9}}, Published: February 3, 2012, under the [https://creativecommons.org/licenses/by/3.0/ CC-BY-3.0 license].</ref>
}}
==Extratesticular tumors==
Although most of the extratesticular lesions are benign, malignancy does occur; the most
common malignant tumors in infants and children are rhabdomyosarcomas. Other malignant tumors include liposarcoma, leiomyosarcoma, malignant fibrous histiocytoma and mesothelioma.<ref name="MakTzeng2012"/>
===Rhabdomyosarcoma===
[[File:Scrotal ultrasonography of rhabdomyosarcoma.jpg|thumb|Rhabdomyosarcoma (a) Longituidinal section (composite image) of high resolution ultrasound of a 14 year-old boy shows a well defined hypoechoic extratesticular mass is found in the left scrotum, hydrocele is also present. (b) Color Doppler ultrasound shows that the mass is hypervascular.<ref name="MakTzeng2012"/>]]
Rhabdomyosarcoma is the most common tumor of the lower genitourinary tract in children in
the first two decades, it may develop anywhere in the body, and 4% occur in the paratesticular
region which carries a better outcome than lesions elsewhere in the genitourinary tract. Clinically, the patient usually presents with non-specific complaints of a unilateral, painless intrascrotal swelling not associated with fever.<ref name="MakTzeng2012"/>
Transillumination test is positive when a hydrocele is present, often resulting in a
misdiagnosis of epididymitis, which is more commonly associated with hydrocele.
The ultrasound findings of paratesticular rhabdomyosarcoma are variable. It usually
presents as an echo-poor mass [Fig. 11a] with or without hydrocele. With color Doppler sonography these tumors are generally hypervascular.<ref name="MakTzeng2012"/>
===Mesothelioma===
[[File:Scrotal ultrasonography of mesothelioma.jpg|thumb|Mesothelioma arising from the tunica vaginalis. Color Doppler ultrasound demonstrates a well-defined hypoechoic nodule occupying the left epididymal head, with a few areas of color flow demonstrated. The left testis is intact with no focal nodule detected. Hydrocele is also present.<ref name="MakTzeng2012"/>]]
Malignant mesothelioma is an uncommon tumor arising in body cavities lined by
mesothelium. The majority of these tumors are found in the pleura, peritoneum and less
frequently pericardium. As the tunica vaginalis is a layer of reflected peritoneum,
mesothelioma can occur in the scrotal sac. Although trauma, herniorrhaphy and long term
hydrocele have been considered as the predisposing factors for development of malignant mesothelioma, the only well
established risk factor is asbestos exposure. Patients with
malignant mesothelioma of the tunica vaginalis frequently have a progressively enlarging
hydrocele and less frequently a scrotal mass, rapid re-accumulation of fluid after aspiration
raises the suggestion of malignancy.<ref name="MakTzeng2012"/>
The reported ultrasound features of mesothelioma of the tunica vaginalis testis are variable.
Hydrocele, either simple or complex is present and may be associated with:<ref name="MakTzeng2012"/>
#multiple extratesticular papillary projections of mixed echogenicity;
#multiple extratesticular nodular masses of increased echogenicity;
#focal irregular thickening of the tunica vaginalis testis; (4) a simple
hydrocele as the only finding and
#A single hypoechoic mass located in the epididymal head. With color Doppler sonography, mesothelioma is hypovascular [Fig. 12].
===Leiomyoma===
[[File:Scrotal ultrasonography of leiomyoma.jpg|thumb|Leiomyoma arising from tunica albuginea. (a) Montage of 2 contiguous sonograms of a 67 year-old man shows a well-defined extratesticular mass with a whorl-shaped echotexture. (b) Color
Doppler sonogram shows no internal vascularity. Note the presence of multiple shadows
not associated with echogenic foci in the mass.<ref name="MakTzeng2012"/>]]
Leiomyomas are benign neoplasms that may arise from any structure or organ containing
smooth muscle. The majority of genitourinary leiomyomas are found in the renal capsule,
but this tumor has also been reported in the epididymis, spermatic cord, and tunica
albuginea. Scrotal leiomyomas have been reported in patients from the fourth to ninth
decades of life with most presenting during the fifth decade. These tumors are generally
slow growth and asymptomatic. The sonographic features of leiomyomas have been
reported as solid hypoechoic or heterogeneous masses that may or may not contain
shadowing calcification. Other findings include whorl shaped configuration [Fig. 13a] of the nodule and multiple, narrow areas of shadowing not cast by calcifications [Fig. 13b], but corresponding to transition zones between the various tissue components of the mass are characteristic of leiomyoma and may help
differentiate it from other scrotal tumors.<ref name="MakTzeng2012"/>
===Fat containing tumors===
====Lipoma====
[[File:Scrotal ultrasonography of lipoma.jpg|thumb|Lipoma at spermatic cord and testiscle. (a) Longitudinal scrotal sonography of a 61 year-old patient shows a well defined hyperechoic nodule is seen in the scrotum. (b) Scrotal sonography of the same patient shows a hyper echoic nodule in the left testis, pathology proved that this is a lipoma too.]]
Lipoma is the most common nontesticular intrascrotal tumor. It can be divided into 3 types
depending upon the site of origination and spread:<ref name="MakTzeng2012"/>
#Originating in the spermatic cord with spread to the scrotum;
#Originating and developing within the cord (most common type) and
#Originating and developing within the scrotum.
At ultrasound, lipoma is a well–defined, homogeneous, hyperechoic paratesticular lesion of
varying size [Fig. 14]. The simple finding of an echogenic fatty mass within the inguinal
canal, while suggestive of a lipoma, should also raise a question of fat from the omentum
secondary to an inguinal hernia. However lipomas are well-defined masses, whereas
herniated omentum appears to be more elongated and can be traced to the inguinal area,
hence scanning along the inguinal canal as well as the scrotum is necessary to make the
differential diagnosis. Magnetic resonance imaging and computerized tomography are
helpful in doubtful cases.<ref name="MakTzeng2012"/>
====Liposarcoma====
Malignant extratesticular tumors are rare. Most of the malignant tumors are solid and have
nonspecific features on ultrasonography. The majority of the malignant extratesticular
tumors arise from spermatic cord with liposarcoma being the most common in adults. On gross specimen, liposarcoma is a solid, bulky lipomatous tumor
with heterogeneous architecture, often containing areas of calcification. Although the sonographic appearances of liposarcoma are variable and nonspecific, it
still provides a clue about the presence of lipomatous matrix.Echogenic areas corresponding
to fat often associated with poor sound transmission and areas of heterogeneous
echogenicity corresponding to nonlipomatous component are present. Some
liposarcomas may also mimic the sonographic appearance of lipomas [Fig. 16] and hernias
that contain omentum, but lipomas are generally smaller and more homogeneous and
hernias are elongated masses that can often be traced back to the inguinal canal. CT and MR
imaging are more specific, as they can easily recognize fatty component along with other
soft tissue component more clearly than ultrasound.
<gallery widths=180 heights=150>
File:Scrotal ultrasonography of liposarcoma.jpg|Liposarcoma. A heterogeneous mass consists of an upper hyperechoic portion corresponds to lipomatous matrix and areas of hypoechogenicity corresponds to nonlipomatous component is seen.<ref name="MakTzeng2012"/>
File:Scrotal ultrasonography of liposarcoma mimicking a lipoma.jpg|Fig. 16. Liposarcoma mimicking lipoma. A homogeneous hypoechoic mass presents with the same appearance of lipoma, rapid growth of this tumors grants surgical intervention with pathology proved to be well differentiated liposarcoma.<ref name="MakTzeng2012"/>
</gallery>
===Adenomatoid tumor===
[[File:Scrotal ultrasonography of adenomatoid tumor at epididymis.jpg|thumb|Adenomatoid tumor at epididymis. A nodule that is isoechoic to the testis is seen occupying nearly the entire epididymal tail.<ref name="MakTzeng2012"/>]]
Adenomatoid tumors are the most common tumors of the epididymis and account for
approximately 30% of all paratesticular neoplasms, second only to lipoma. They are usually unilateral, more common on the left side, and usually involve the
epididymal tail. Adenomatoid tumor typically occurs in men during the third and fourth
decades of life. Patients usually present with a painless scrotal mass that is smooth, round
and well circumscribed on palpation. They are believed to be of mesothelial origin and are
universally benign. Their sonographic appearance is that of a round shaped, well-defined,
homogeneous mass with echogenicity ranging from hypo- to iso- to hyperechoic.<ref name="MakTzeng2012"/>
===Fibrous pseudotumor===
Fibrous pseudotumors, also known as fibromas are thought to be reactive, nonneoplastic
lesions. They can occur at any age, about 50% of fibromas are associated with hydrocele, and
30% are associated with a history of trauma or inflammation (Akbar et al, 2003). Although
the exact cause of this tumor is not completely understood, it is generally believed that these
lesions represent a benign reactive proliferation of inflammatory and fibrous tissue, in
response to chronic irritation.
Sonographic evaluation generally shows one or more solid nodules arising from the tunica
vaginalis, epididymis, spermatic cord and tunica albuginea [Fig. 18]. A hydrocele is frequently
present too. The nodules may appear hypoechoic or hyperechoic, depending on the amount of collagen or fibroblast present.
Acoustic shadowing may occur in the absence of calcification due to the dense collagen
component of this tumor. With color Doppler sonography, a small to moderate amount of
vascularity may be seen [Fig. 19].<ref name="MakTzeng2012"/>
<gallery widths=180 heights=150>
File:Scrotal ultrasonography of fibrous pseudotumour.jpg|Fig. 18. Fibrous pseudotumor. A homogeneous hypoechoic nodular lesion is seen attached to the tunica associated with minimal amount of hydrocele.<ref name="MakTzeng2012"/>
File:Scrotal ultrasonography with Doppler of fibrous pseudotumour.jpg|Fig. 19. Fibrous pseudotumor. With color Doppler, a little vascular flow is seen in this fibrous pseudotumor.<ref name="MakTzeng2012"/>
</gallery>
==References==
{{reflist}}
|author1=[[User:Mikael Häggström|Mikael Häggström]]
|author2=Authors of Creative Commons article<ref name="MakTzeng2012">Content originally copied from: {{cite journal|last1=Mak|first1=Chee-Wai|last2=Tzeng|first2=Wen-Sheng|title=Sonography of the Scrotum|year=2012|doi=10.5772/27586}} from {{cite web|url=https://www.intechopen.com/books/sonography/sonography-of-the-scrotum||title=Sonography|author=Kerry Thoirs}} {{ISBN|978-953-307-947-9}}, Published: February 3, 2012, under the [https://creativecommons.org/licenses/by/3.0/ CC-BY-3.0 license].</ref>
}}
==Extratesticular tumors==
Although most of the extratesticular lesions are benign, malignancy does occur; the most
common malignant tumors in infants and children are rhabdomyosarcomas. Other malignant tumors include liposarcoma, leiomyosarcoma, malignant fibrous histiocytoma and mesothelioma.<ref name="MakTzeng2012"/>
===Rhabdomyosarcoma===
[[File:Scrotal ultrasonography of rhabdomyosarcoma.jpg|thumb|Rhabdomyosarcoma (a) Longituidinal section (composite image) of high resolution ultrasound of a 14 year-old boy shows a well defined hypoechoic extratesticular mass is found in the left scrotum, hydrocele is also present. (b) Color Doppler ultrasound shows that the mass is hypervascular.<ref name="MakTzeng2012"/>]]
Rhabdomyosarcoma is the most common tumor of the lower genitourinary tract in children in
the first two decades, it may develop anywhere in the body, and 4% occur in the paratesticular
region which carries a better outcome than lesions elsewhere in the genitourinary tract. Clinically, the patient usually presents with non-specific complaints of a unilateral, painless intrascrotal swelling not associated with fever.<ref name="MakTzeng2012"/>
Transillumination test is positive when a hydrocele is present, often resulting in a
misdiagnosis of epididymitis, which is more commonly associated with hydrocele.
The ultrasound findings of paratesticular rhabdomyosarcoma are variable. It usually
presents as an echo-poor mass [Fig. 11a] with or without hydrocele. With color Doppler sonography these tumors are generally hypervascular.<ref name="MakTzeng2012"/>
===Mesothelioma===
[[File:Scrotal ultrasonography of mesothelioma.jpg|thumb|Mesothelioma arising from the tunica vaginalis. Color Doppler ultrasound demonstrates a well-defined hypoechoic nodule occupying the left epididymal head, with a few areas of color flow demonstrated. The left testis is intact with no focal nodule detected. Hydrocele is also present.<ref name="MakTzeng2012"/>]]
Malignant mesothelioma is an uncommon tumor arising in body cavities lined by
mesothelium. The majority of these tumors are found in the pleura, peritoneum and less
frequently pericardium. As the tunica vaginalis is a layer of reflected peritoneum,
mesothelioma can occur in the scrotal sac. Although trauma, herniorrhaphy and long term
hydrocele have been considered as the predisposing factors for development of malignant mesothelioma, the only well
established risk factor is asbestos exposure. Patients with
malignant mesothelioma of the tunica vaginalis frequently have a progressively enlarging
hydrocele and less frequently a scrotal mass, rapid re-accumulation of fluid after aspiration
raises the suggestion of malignancy.<ref name="MakTzeng2012"/>
The reported ultrasound features of mesothelioma of the tunica vaginalis testis are variable.
Hydrocele, either simple or complex is present and may be associated with:<ref name="MakTzeng2012"/>
#multiple extratesticular papillary projections of mixed echogenicity;
#multiple extratesticular nodular masses of increased echogenicity;
#focal irregular thickening of the tunica vaginalis testis; (4) a simple
hydrocele as the only finding and
#A single hypoechoic mass located in the epididymal head. With color Doppler sonography, mesothelioma is hypovascular [Fig. 12].
===Leiomyoma===
[[File:Scrotal ultrasonography of leiomyoma.jpg|thumb|Leiomyoma arising from tunica albuginea. (a) Montage of 2 contiguous sonograms of a 67 year-old man shows a well-defined extratesticular mass with a whorl-shaped echotexture. (b) Color
Doppler sonogram shows no internal vascularity. Note the presence of multiple shadows
not associated with echogenic foci in the mass.<ref name="MakTzeng2012"/>]]
Leiomyomas are benign neoplasms that may arise from any structure or organ containing
smooth muscle. The majority of genitourinary leiomyomas are found in the renal capsule,
but this tumor has also been reported in the epididymis, spermatic cord, and tunica
albuginea. Scrotal leiomyomas have been reported in patients from the fourth to ninth
decades of life with most presenting during the fifth decade. These tumors are generally
slow growth and asymptomatic. The sonographic features of leiomyomas have been
reported as solid hypoechoic or heterogeneous masses that may or may not contain
shadowing calcification. Other findings include whorl shaped configuration [Fig. 13a] of the nodule and multiple, narrow areas of shadowing not cast by calcifications [Fig. 13b], but corresponding to transition zones between the various tissue components of the mass are characteristic of leiomyoma and may help
differentiate it from other scrotal tumors.<ref name="MakTzeng2012"/>
===Fat containing tumors===
====Lipoma====
[[File:Scrotal ultrasonography of lipoma.jpg|thumb|Lipoma at spermatic cord and testiscle. (a) Longitudinal scrotal sonography of a 61 year-old patient shows a well defined hyperechoic nodule is seen in the scrotum. (b) Scrotal sonography of the same patient shows a hyper echoic nodule in the left testis, pathology proved that this is a lipoma too.]]
Lipoma is the most common nontesticular intrascrotal tumor. It can be divided into 3 types
depending upon the site of origination and spread:<ref name="MakTzeng2012"/>
#Originating in the spermatic cord with spread to the scrotum;
#Originating and developing within the cord (most common type) and
#Originating and developing within the scrotum.
At ultrasound, lipoma is a well–defined, homogeneous, hyperechoic paratesticular lesion of
varying size [Fig. 14]. The simple finding of an echogenic fatty mass within the inguinal
canal, while suggestive of a lipoma, should also raise a question of fat from the omentum
secondary to an inguinal hernia. However lipomas are well-defined masses, whereas
herniated omentum appears to be more elongated and can be traced to the inguinal area,
hence scanning along the inguinal canal as well as the scrotum is necessary to make the
differential diagnosis. Magnetic resonance imaging and computerized tomography are
helpful in doubtful cases.<ref name="MakTzeng2012"/>
====Liposarcoma====
Malignant extratesticular tumors are rare. Most of the malignant tumors are solid and have
nonspecific features on ultrasonography. The majority of the malignant extratesticular
tumors arise from spermatic cord with liposarcoma being the most common in adults. On gross specimen, liposarcoma is a solid, bulky lipomatous tumor
with heterogeneous architecture, often containing areas of calcification. Although the sonographic appearances of liposarcoma are variable and nonspecific, it
still provides a clue about the presence of lipomatous matrix.Echogenic areas corresponding
to fat often associated with poor sound transmission and areas of heterogeneous
echogenicity corresponding to nonlipomatous component are present. Some
liposarcomas may also mimic the sonographic appearance of lipomas [Fig. 16] and hernias
that contain omentum, but lipomas are generally smaller and more homogeneous and
hernias are elongated masses that can often be traced back to the inguinal canal. CT and MR
imaging are more specific, as they can easily recognize fatty component along with other
soft tissue component more clearly than ultrasound.
<gallery widths=180 heights=150>
File:Scrotal ultrasonography of liposarcoma.jpg|Liposarcoma. A heterogeneous mass consists of an upper hyperechoic portion corresponds to lipomatous matrix and areas of hypoechogenicity corresponds to nonlipomatous component is seen.<ref name="MakTzeng2012"/>
File:Scrotal ultrasonography of liposarcoma mimicking a lipoma.jpg|Fig. 16. Liposarcoma mimicking lipoma. A homogeneous hypoechoic mass presents with the same appearance of lipoma, rapid growth of this tumors grants surgical intervention with pathology proved to be well differentiated liposarcoma.<ref name="MakTzeng2012"/>
</gallery>
===Adenomatoid tumor===
[[File:Scrotal ultrasonography of adenomatoid tumor at epididymis.jpg|thumb|Adenomatoid tumor at epididymis. A nodule that is isoechoic to the testis is seen occupying nearly the entire epididymal tail.<ref name="MakTzeng2012"/>]]
Adenomatoid tumors are the most common tumors of the epididymis and account for
approximately 30% of all paratesticular neoplasms, second only to lipoma. They are usually unilateral, more common on the left side, and usually involve the
epididymal tail. Adenomatoid tumor typically occurs in men during the third and fourth
decades of life. Patients usually present with a painless scrotal mass that is smooth, round
and well circumscribed on palpation. They are believed to be of mesothelial origin and are
universally benign. Their sonographic appearance is that of a round shaped, well-defined,
homogeneous mass with echogenicity ranging from hypo- to iso- to hyperechoic.<ref name="MakTzeng2012"/>
===Fibrous pseudotumor===
Fibrous pseudotumors, also known as fibromas are thought to be reactive, nonneoplastic
lesions. They can occur at any age, about 50% of fibromas are associated with hydrocele, and
30% are associated with a history of trauma or inflammation (Akbar et al, 2003). Although
the exact cause of this tumor is not completely understood, it is generally believed that these
lesions represent a benign reactive proliferation of inflammatory and fibrous tissue, in
response to chronic irritation.
Sonographic evaluation generally shows one or more solid nodules arising from the tunica
vaginalis, epididymis, spermatic cord and tunica albuginea [Fig. 18]. A hydrocele is frequently
present too. The nodules may appear hypoechoic or hyperechoic, depending on the amount of collagen or fibroblast present.
Acoustic shadowing may occur in the absence of calcification due to the dense collagen
component of this tumor. With color Doppler sonography, a small to moderate amount of
vascularity may be seen [Fig. 19].<ref name="MakTzeng2012"/>
<gallery widths=180 heights=150>
File:Scrotal ultrasonography of fibrous pseudotumour.jpg|Fig. 18. Fibrous pseudotumor. A homogeneous hypoechoic nodular lesion is seen attached to the tunica associated with minimal amount of hydrocele.<ref name="MakTzeng2012"/>
File:Scrotal ultrasonography with Doppler of fibrous pseudotumour.jpg|Fig. 19. Fibrous pseudotumor. With color Doppler, a little vascular flow is seen in this fibrous pseudotumor.<ref name="MakTzeng2012"/>
</gallery>
==References==
{{reflist}}
