Diagnostic ultrasound ( PDFDrive )

1902 PART V Pediatric Sonography
Herniated Mesentery
Testis
RT HEMISCROTUM/INGUINAL AREA SAG
FIG. 54.49 Inguinal Hernia in Baby With Right Inguinal Mass. Sagittal
sonogram of the right hemiscrotum and inguinal area demonstrates
brightly echoic fatty mesentery extending from the peritoneal cavity
into the right inguinal canal, abutting the right testis.
FIG. 54.48 Bilateral Hydroceles in Newborn. Transverse view of
the scrotum shows both testes outlined by large, anechoic luid
collections.
making regarding testis-sparing surgery without additional
oncologic risk, and with an esthetic, psychological, and functional
beneit. 177 Patients with solitary simple cysts, which are uncommon
testicular masses, have painless scrotal enlargement. 178 he
cysts are anechoic masses with smooth walls, no nodular or solid
elements, and increased sound transmission. hey difer from
epidermoid cysts and other cystic neoplasms that contain internal
echoes. hese simple cysts are benign and thus may be followed
with sonography. In infants, growth of the cyst may cause
compression and replacement of testicular parenchyma. hus
early conservative surgery with removal of the cyst and preservation
of the adjacent parenchyma may be performed. 179 Simple
enucleation suices when sonography demonstrates that the cyst
is undoubtedly simple.
Extratesticular Causes
Hydroceles are an abnormal collection of serous luid in the
scrotal sac and represent the most common cause of painless
scrotal enlargement in children. Hydroceles may be congenital
or acquired. In neonates and infants, virtually all hydroceles are
congenital. As the testis descends into the scrotum, it becomes
invested with a portion of peritoneum, the processus vaginalis.
At birth, the processus vaginalis normally closes of proximally
and forms the tunica vaginalis. A variable amount of peritoneal
luid may be trapped within the tunica vaginalis, forming a stable
hydrocele in the neonate. his luid is resorbed slowly during
the irst 18 months of life. If the processus vaginalis fails to close,
an open communication exists between the peritoneal cavity
and the scrotum. his can result in a scrotal hernia or a communicating
hydrocele with a varying amount of luid. Extension
of the hydrocele into the pelvis can be seen in a communicating
hydrocele. Surgical ligation is required to close the patent processus
vaginalis. 180
he usual sonographic appearance of a hydrocele is anechoic
luid in the scrotum (Fig. 54.48). In older children, hydroceles
are usually acquired. he presence of echoes or septations in the
luid suggests a reactive hydrocele caused by infection, torsion,
trauma, or tumor. Other collections, such as chronic hemorrhage
or lymphoceles (associated with ipsilateral renal transplantation),
may be seen and mistaken for a reactive hydrocele. hese result
from lymphatic disruption with leakage of lymph luid into the
tunica vaginalis or from direct extension of a periallograt
lymphocele through the inguinal canal. 181 hey appear on
ultrasound as septated luid collections surrounding the testes.
Hematoceles are collections of blood in the tunica vaginalis.
Most are the result of surgery or trauma, 180 but they may also
be secondary to bleeding disorders or malignant tumors. 182,183
hey appear on sonography as luid collections with low-level
internal debris, septations, or luid-debris levels. Scrotal wall
thickening may be present with chronic hematoceles.
Scrotal hernia is a common mass in boys that is usually
evident clinically. Inguinal hernias are almost always the result
of a patent processus vaginalis (indirect hernia) into the scrotal
sac. Hernias are more frequently right-sided because the right
processus vaginalis closes ater the let. Sonography may demonstrate
bowel loops in the scrotum, normal testis, and epididymis,
and an echogenic area representing herniated omentum 184 (Fig.
54.49). Lack of peristalsis within herniated bowel loops suggests
ischemia. Ischemia and incarceration (nonreducibility of bowel
loops) convert an elective procedure to emergent surgery.
Extratesticular pathology, such as hematoceles, loculated
hydroceles, scrotal abscesses, and urinomas, can mimic luidilled
bowel loops, and herniated omentum can be confused
for a primary scrotal mass. hus examination of the inguinal
canal and the region of the Hesselbach triangle is recommended
to evaluate for a hernia sac and exclude a primary scrotal
pathology.
Other scrotal masses oten identiied in adolescent and
postpubertal males are varicoceles, spermatoceles, and epididymal
cysts. 184 Varicoceles represent dilated veins in the pampiniform
plexus positioned posterior to the testis. he majority (85%-98%)
are on the let side. 185 he presence of varicoceles in young boys
is uncommon and may result from compression of the spermatic
cord by tumor. Sonographic evaluation reveals small serpentine
structures that display low on color Doppler imaging and venous
waveforms on spectral Doppler imaging. Augmentation of
Doppler low occurs with a Valsalva maneuver and upright
positioning (Fig. 54.50). Spermatoceles occur in the epididymal
head and consist of luid, spermatozoa, and sediment. Epididymal
cysts contain no spermatozoa and can occur in the epididymal
head, body, or tail. Sonographic examination shows round
structures with good through transmission and well-deined back