50 M with US showing heterogeneous testis likely reflecting orchitis Ashley Davidoff50 M with US showing heterogeneous testis likely reflecting orchitis Ashley Davidoff
Classical Epididymo Orchitis
70 year old male presents with pain in the right testes
US in the transverse plane through both testes shows thickening of the skin overlying the right testis, enlargement, heterogeneity and overall decrease in echogenicity of the right testis all consistent with the diagnosis of orchitis. Ashley Davidoff MD 133207Doppler US in the transverse plane through both testes shows hypervascularity of the right testis consistent with the diagnosis of orchitis. Ashley Davidoff MD 133206US in transverse projection shows heterogeneity of the right testis and enlargement of the epididymis consistent with a diagnosis of epididymo orchitis Ashley Davidoff MD 133197Doppler US of the right testis shows significant hyperemia of the testes as well as hyperemia and swelling of the epididymis medially Ashley Davidoff MD 13319270year old male presents with pain in the right testis. US in transverse projection shows heterogeneity of the right testis and enlargement of the epididymis consistent with a diagnosis of epididymo orchitis Ashley Davidoff MD 133197US in the sagittal plane through the right testis shows enlargement and heterogeneity of the head of the right epididymis as well as heterogeneity of the right testis consistent with the diagnosis of epididymitis and orchitis. Ashley Davidoff MD 133201US in the transverse plane through the right testis shows enlargement, heterogeneity of the right epididymis consistent with the diagnosis of epididymitis. Note the presence of a prominent hypoechoic rete testis at the hilum of the testis Ashley Davidoff MD 133199Doppler US in the longitudinal plane through the right testis shows hypervascularity both of the of the right testis and epididymis, consistent with the diagnosis of acute orchitis and epididymitis . Ashley Davidoff MD 133194 b02
Recurrent Epididymitis
65 year old Male with Recurrent Epididymitis
9 months prior presented with mild left sided testicular pain
US in the transverse plane through both testes shows heterogeneity and decrease echogenicity of the left testis as well as enlargement of the left epididymis consistent with the diagnosis of epididymitis and orchitis. Ashley Davidoff MD 133157b01US in the sagittal plane of the left testis and epididymis shows enlargement of left epididymis with cystic changes and dilatation of tubules or small focal abscess in the head of the epididymis reflecting chronic or mild acute on chronic epididymitis Ashley Davidoff MD 133157b05
US in the sagittal plane of the body and tail of the epididymis shows diffuse enlargement of left epididymis reflecting chronic or mild acute on chronic epididymitis Ashley Davidoff MD 133157b06US in the sagittal plane through the right (normal) and left (enlarged) left epididymis testis consistent with the diagnosis of epididymitis of the left epididymis Ashley Davidoff MD 133157b14Doppler US in the transverse plane through the left testis shows no significant hypervascularity of the testis but mild increase in vascularity of the head of the epididymis. This finding in association with the noted mild hypoechogenicity in the presence of mild pain would suggest mild acute on chronic epididymitis and orchitis. Ashley Davidoff MD 133157b12
9 months later 65 year old male presents with recurrent pain in the left testis
US in the transverse plane through both testes shows thickening of the skin overlying the left testis, no significant difference in the echogenicity of the testes, but a persistent prominence of the head of the left epididymis associated with a small hydrocele Ashley Davidoff MD 133160cUS in the transverse plane through the left epididymis shows significant enlargement of the epididymis with cystic spaces in the head, associated with a small hydrocele consistent with the diagnosis of acute on chronic epididymitis of the left epididymis Ashley DAvidoff MD 133173Doppler US in the sagittal plane through the left epididymis shows hyperemia of the epididymis consistent with the diagnosis of acute epididymitis of the left epididymis Ashley Davidoff MD 133166Doppler US in the transverse plane through the left epididymis shows hyperemia of the epididymis and unchanged appearance of the cystic lesion previously identified in the neck of the of the epididymis Ashley Davidoff MD 133168
The Snowstorm Hydrocele and Swollen Spermatic Cord
74 Year Old Male with Pain and Swelling of the Right Testis and Hydrocele
US in the transverse plane through both testes shows thickened overlying skin, more prominent over the right testis, no significant difference in the echogenicity of the testes but prominent right epididymis and small hydrocele Ashley Davidoff MD 133097Doppler US in the sagittal plane through testes shows hyperemia of the right testis and epididymis consistent with orchitis and epididymitis Ashley Davidoff MD 133157US in the sagittal plane through the right testis and epididymis shows mild thickening of the overlying skin and an enlarged epididymis associated with a small hydrocele consistent with the diagnosis of acute epididymitis Ashley Davidoff MD 133105US in the transverse plane through the tail of the right epididymis (above) shows enlargement of the epididymis and significant hyperemia (below) consistent with the diagnosis of acute epididymitis Ashley Davidoff MD 133121cDoppler US in the sagittal plane through the tail of the right epididymis shows enlargement of the epididymis and significant hyperemia consistent with the diagnosis of acute epididymitis Ashley Davidoff MD 133124US in the sagittal plane through the right testis shows a moderate hydrocele with snowstorm appearance caused either by cholesterol crystalline particles or high protein content, likely of no clinical significance Ashley Davidoff MD 133103
Mass like Epididymitis with Complex Hydrocele ? TB
73-year male with granulomatous lung disease presents with acute right testicular pain. US showed mass like enlargement of the epididymis attached to and compressing the right testis with a small hydrocele
US in the sagittal plane through the right testis shows a mass in the tail of the testes with mass effect of the epididymis on the testis. Associated findings include thickening of the scrotal skin and a hydrocele Ashley Davidoff MD 133286US in the sagittal plane through the right testis shows calcifications in the mass in the tail of the epididymis suggesting chronicity. Again noted is the mass effect of the epididymis on the testis with associated findings of thickening of the scrotal skin and a hydrocele. These findings suggest acute on chronic epididymitis, and granulomatous disease such as TB and dystrophic calcifications are also a possibility Ashley Davidoff MD 133293
Doppler US in the sagittal plane through the right epididymis shows mild hyperemia of the epididymis suggesting mild acute on chronic epididymitis. Ashley Davidoff MD 133290Doppler US in the transverse plane through the right testis and epididymis shows normal vascularity to the right testis and mild hyperemia of the epididymis. Ashley Davidoff MD 133296
2 weeks later US showed persistent but improved enlargement of the right epididymis.
2 weeks later US in the sagittal plane showed persistent but improved enlargement of the left epididymis and persistent skin thickening. Microcalcifications are noted in the testis Ashley Davidoff MD 133302US in the sagittal plane of the left testis shows persistent mass effect of the epididymis on the testis. There is persistent skin thickening and hydrocele. Ashley Davidoff MD 133305Doppler US in the sagittal plane through the right testis and epididymis shows normal vascularity to the testis and mild hyperemia of the epididymis, and skin thickening consistent with mild ongoing epididymitis. Ashley Davidoff MD 133309
7 years Later
7 years later he again had pain and there was persistent recurrent epididymitis and simple hydrocele which progressed over the next few months to a complex hydrocele
7 years later he again presented with pain, and US in the sagittal plane through the right testis and epididymis shows significant persistent enlargement of the epididymis with heterogeneity with cystic spaces, skin thickening and a simple hydrocele consistent with the diagnosis of acute on chronic epididymitis of the right epididymis Ashley Davidoff MD 133312US in the transverse plane through the tail of the right epididymis again shows mass like heterogeneous appearance with mass effect on the testis, necrotic fluid collection, skin thickening and simple hydrocele Ashley Davidoff MD 133313Doppler US in the sagittal plane through the right testis and epididymis shows normal vascularity to the testis, moderate hyperemia of the epididymis, associated with skin thickening and hydrocele consistent with acute on chronic ongoing epididymitis. Ashley Davidoff MD 133320
2 months later
2 months later US in the transverse plane through the scrotal sac is dominated by a large complex loculated hydrocele compressing the enlarged right epididymis and testis. Ashley Davidoff MD 133330Doppler US in the sagittal plane through the right testis and epididymis shows normal vascularity to the testis and epididymis, both significantly compressed by a complex hydrocele. Ashley Davidoff MD 133330
A Further 2 Months Later
2 months later US in the transverse plane through the scrotal sac is dominated by a large complex loculated hydrocele characterized by progressive thickening of the septations compressing the right testis. Ashley Davidoff MD 133332
These findings and the chronic history are most consistent with Tuberculous epididymitis
88 year old male presents with left scrotal pain and swelling
US in the sagittal plane through the right hemiscrotum shows a loculated collection in the left epididymis with compression of the left testis. Associated findings include overlying skin thickening. These findings are consistent with an epididymal abscess Ashley Davidoff MD 133175US in the transverse plane through the left epididymis shows a multiloculated collection in the epididymis which extends through the tunica vaginalis into the surrounding soft tissues. Associated findings include overlying skin thickening. These findings are consistent with an abscess. A tumor of the epididymis is also included in the differential diagnosis as a less likely possibility. Ashley Davidoff MD 133176US in the sagittal plane through the left testis shows a shadowing microcalcifications in the left epididymal collection suggesting chronicity. Ashley Davidoff MD 133179Doppler US in the transverse plane through the left testis and epididymis shows mild increase in vascularity surrounding the epididymal collection consistent with a subacute or chronic abscess. Ashley Davidoff MD 133178Doppler US in the transverse plane through the left testis and epididymis shows normal vascularity to the testis and enlarged epididymis. Ashley Davidoff MD 133185US in the sagittal plane of the left spermatic cord shows enlargement and thickening of the wall consistent with extension of the inflammatory process from the epididymal abscess. Ashley Davidoff MD 133187
Pyogenic Orchitis Complicated by Infarction Following Prostate Biopsy
48 year old diabetic male presented with an elevated PSA for transrectal biopsy.
Transrectal biopsy with US guidance shows a mildly enlarged prostate. Pathology showed no evidence of malignancy with findings of BPH Ashley DAvidoff MD 133209
10 days after a biopsy, he developed dysuria and hematuria. Urine culture showed E Coli, resistant to many antibiotics but sensitive to nitrofurantoin. He improved after 1 week of antibiotics, but symptoms recurred with right testicular pain and swelling with intermittent fever.
WCC was 18,000 and urine was cloudy with increased sugar
Doppler US showed epididymo-orchitis with no flow to the hypoechoic right testis consistent with an infarcted testis. The patient declined orchiectomy
US in the transverse plane through both testes shows decrease echogenicity of the right testis, enlargement of the right epididymis and thickening of the overlying skin consistent with the diagnosis of acute epididymitis and orchitis. Ashley Davidoff MD 133211US in the sagittal plane of the right testis above and normal left testis below shows enlargement of the right epididymis, and testis, with thickening of the tunica albuginea, complex hydrocele with septations and thickening of the skin. The thickening of the tunica albuginea in this instance was a clue to the abnormality of the testis which was shown by Doppler to be infarcted Ashley Davidoff MD 133227cDoppler US in the transverse plane through the right testis shows absent vascularity in the testis with mild heterogeneity consistent with infarction of the right testis. There is increase vascularity in the tail of the epididymis Ashley Davidoff MD 133221Doppler US in the transverse plane through the right testis shows absent vascularity in the testis with mild heterogeneity consistent with infarction of the right testis. There is increase vascularity in the head of the epididymis consistent with epididymitis Ashley Davidoff MD 133222US in the sagittal plane of the right testis shows enlargement of the head of the epididymis, complex hydrocele with septations and thickening of the skin. Ashley Davidoff MD 133212US in the transverse plane of the right testis shows enlargement of the tail of the epididymis, complex hydrocele with septations and thickening of the skin. Ashley Davidoff MD 133218Doppler US in the transverse plane through the right testis shows absent vascularity in the testis with mild heterogeneity consistent with infarction of the right testis. There is increase vascularity in the tail of the epididymis Ashley Davidoff MD 133221
Doppler US in the transverse plane through the left testis shows no significant hypervascularity of the testis but mild increase in vascularity of the head of the epididymis. This finding in association with the noted mild hypo echogenicity in the presence of mild pain would suggest mild acute on chronic epididymitis and orchitis.
CT scan showed an enlarged right testis, induration of the surrounding skin, and around the prostate
as well as thickening and hyperemia of the cord
Coronal reconstruction of the CT scan of the pelvis shows hyperemic and enlarged spermatic cord, (orange arrow), enlargement of the right epididymis (red arrow) and normal left epididymis (white arrow) Ashley Davidoff MD 133238Axial CT scan through the scrotal sacs bilaterally show enlargement of the right epididymis (red arrow) and normal left epididymis (white arrow), infarcted right testis (black arrow) and normal left testis (yellow arrow). Ashley Davidoff MD 133237b01Coronal reconstruction of the CT scan of the pelvis shows hyperemic and enlarged spermatic cord, (orange arrow), enlargement of the right epididymis (red arrow) and normal left epididymis (white arrow) Ashley Davidoff MD 133237b02
4 weeks Later
US performed 4 weeks later showed reduction in the size of the right testis and showing a 7mm focal area of necrosis in the parenchyma.
US performed 4 weeks later showed reduction in the size of the right testis and showing a 7mm focal area of necrosis in the parenchyma. Associated findings include persistent but improved enlargement of the epididymis and overlying skin thickening Ashley Davidoff MD 133248Doppler US in the sagittal plane through the right testis shows absent vascularity in the testis with hypervascularity of the head and tail of the epididymis consistent with ongoing but resolving epididymitis and infarction of the right testis. Ashley Davidoff MD 133253US in the transverse plane of the right testis shows persistent complex hydrocele with septations Ashley Davidoff MD 133255
