Diagnostic ultrasound ( PDFDrive )

838 PART III Small Parts, Carotid Artery, and Peripheral Vessel Sonography
A
B
FIG. 22.20 Varicocele. (A) Longitudinal and (B) color Doppler images show serpentine, hypoechoic, dilated veins posterior to the testis. The
blood low in a varicocele is slow and may be detected only with low-low Doppler settings or the Valsalva maneuver. See also Video 22.3.
at a right angle, as opposed to the right spermatic vein, which
drains directly into the vena cava. Idiopathic varices normally
distend when the patient is upright or performs the Valsalva
maneuver and decompress when the patient is supine. Primary
varicoceles are bilateral in up to 50% of cases. 135
Secondary varicoceles result from increased pressure on the
spermatic vein or its tributaries by marked hydronephrosis, an
enlarged liver, abdominal neoplasms, or venous compression by
a retroperitoneal mass. 43 Secondary varicoceles may also occur
in nutcracker syndrome (nutcracker phenomenon), in which
the superior mesenteric artery compresses the let renal vein. 136
A search for neoplastic obstruction of gonadal venous return
must be undertaken in cases of a right-sided, nondecompressible,
or newly discovered varicocele in a patient older than 40 years 14
(Fig. 22.21). he appearance of secondary varicoceles is not
afected by patient position.
In infertile men, sonography aids in the diagnosis of clinically
palpable and subclinical varicoceles. Sonography is also of value
in assessing testicular size before and ater treatment, because
varicocele may be associated with a decreased testicular volume. 133
here is poor correlation between the size of the varicocele and
the degree of testicular tissue damage leading to infertility, and
surgical repair of subclinical varicoceles for infertility has been
controversial. 137
Sonographically, a varicocele consists of multiple, serpentine,
anechoic structures more than 2 mm in diameter, creating a
tortuous, multicystic collection located adjacent or proximal to
the upper pole of the testis and head of the epididymis. A highfrequency
transducer in conjunction with low-low Doppler
settings should be used to optimize slow-low detection within
varices. Slowly moving red blood cells may be visualized with
high-frequency transducers, even when low is too slow to be
detected by Doppler imaging. Venous low can be augmented
with the patient in the upright position or during Valsalva
maneuver (Video 22.3). Varicoceles follow the course of the
spermatic cord into the inguinal canal and are easily compressed
by the transducer. 3 Rarely, varicoceles may be intratesticular,
either in a subcapsular location or around the mediastinum
testis 138,139 (Fig. 22.22).
Fibrous Pseudotumor
Fibrous pseudotumor is a rare, nonneoplastic mass of reactive
ibrous tissue that most commonly involves the tunica vaginalis.
hese masses are known by a number of names, including
ibroma, paratesticular ibrosis, or inlammatory pseudotumor,
and can become quite large and mimic neoplasms. Most patients
present with a painless scrotal mass, possibly with a prior history
of infection or trauma. Histologically, masses are composed of
hyalinized collagen and granulation tissue and may be partially
calciied. On sonography, ibrous pseudotumors may appear as
one or more solid masses attached to or closely associated with
the capsule of the testis. here may be an associated hydrocele.
Echogenicity is variable and they may be seen as a hypoechoic,
hyperechoic, or heterogeneous paratesticular mass with posterior
acoustic shadowing depending on extent of calicications 140-142
(Fig. 22.23A and B).
Polyorchidism
Polyorchidism, or supernumerary testes, is a rare entity thought
to result from abnormal division of the genital ridge embryologically.
he supernumery testes are intrascrotal in location in
approximately 75% of cases and present as a painless scrotal