Diagnostic ultrasound ( PDFDrive )

836 PART III Small Parts, Carotid Artery, and Peripheral Vessel Sonography
collection communicates with the peritoneum but not the
scrotum, a funicular hydrocele 125 (Fig. 22.17B and C).
Hematoceles and pyoceles are less common than simple
hydroceles. Hematoceles (accumulation of blood within the tunica
vaginalis) result from trauma, surgery, neoplasms, or torsion. 126
Pyoceles result from untreated epididymo-orchitis or rupture
of an intratesticular abscess into the space between the layers of
the tunica vaginalis. Both hematoceles and pyoceles appear as
complex luid collections with internal septations and loculations
(Fig. 22.17). hickening of the scrotal skin and calciications
may be seen in chronic cases.
Paratesticular Masses
Most extratesticular neoplasms in adults are benign, but extratesticular
neoplasms in children are frequently malignant. 127
Extratesticular Tumors/Masses
BENIGN
Hernia
Adenomatoid tumor
Fibroma/ibrous pseudotumor
Lipoma
Hemangioma
Leiomyoma
Neuroibroma
Cholesterol granuloma
Polyorchidism
Papillary cystadenoma
Adrenal rest
MALIGNANT
Fibrosarcoma
Liposarcoma
Rhabdosarcoma
Histiocytoma
Lymphoma
Metastases
Hernia
An inguinal hernia is a common paratesticular mass. 128 Although
scrotal hernias are usually diagnosed on the basis of clinical
history and physical examination, sonography is useful in the
evaluation of atypical cases. Hernias are classiied as either direct
or indirect. An indirect hernia exits the abdominal cavity through
the internal inguinal ring, can traverse the inguinal canal, and
extend into the scrotum. Indirect hernias are associated with a
patent processus vaginalis. A direct hernia represents a protrusion
through the abdominal wall at Hesselbach triangle, an area of
weakness bordered by the lateral border of the rectus sheath
medially, the inferior epigastric artery laterally, and the inguinal
ligament inferiorly.
Sonographic appearance of an inguinal hernia depends on
its contents. Bowel will oten be luid illed with multiple internal
bright echoes. Bowel gas may cause shadowing, a inding also
seen with abscesses and thus potentially confusing. he presence
of bowel loops within the hernia may be conirmed by the
visualization of valvulae conniventes or haustrations and detection
of peristalsis on real-time examination (Fig. 22.18A). he presence
of highly echogenic material within the scrotum may result from
a hernia containing omentum or other fatty masses such as
lipomas, although lipomas are typically well deined and herniated
omentum can typically be traced back to the inguinal canal (Fig.
22.18B). Sonographic examination of the inguinal canal into the
scrotum is necessary to make the diagnosis. 129 Additional discussion
of hernias can be found in Chapter 13.
Calculi
Extratesticular scrotal calculi are calciications within the tunica
vaginalis (Fig. 22.19). hese ibrinoid loose bodies have been
called scrotoliths, or “scrotal pearls” because of their macroscopic
appearance, which is usually rounded, pearly white, and rubbery.
Histologically, they consist of ibrinoid material deposited around
a central nucleus of hydroxyapatite. 130 hey may result from
inlammatory deposits that form and then ultimately separate
A
B
FIG. 22.18 Indirect Inguinal Hernias: Spectrum of Appearances. (A) Herniated small bowel. Oblique scan shows herniated small
bowel (arrow) superior to and abutting the testis (T). (B) Herniated mesenteric fat. Longitudinal scan shows herniated fat (H) above testis (T) and
epididymis (E).