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Imaging orchitis epidydmitis epidydmo orchitis DrAhmed Esawy


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Imaging orchitis epidydmitis epidydmo orchitis
include different cases for oral radiodiagnosis examination all over the world
CT /MRI Plain X ray ultrasound TRANSRECTAL ULTRASOUND images
Seminal vesiculitis

Published in: Health & Medicine
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Imaging orchitis epidydmitis epidydmo orchitis DrAhmed Esawy

  1. 1. Orchitis epididymitis epidydmo-orchitis imaging Dr. Ahmed Esawy MBBS M.Sc MD Dr Ahmed Esawy
  2. 2. Evaluation of the Scrotum  Three Key Areas:  Testicle  Epididymis  Surrounding layers Dr Ahmed Esawy
  3. 3. Evaluation of the Scrotum  Three Key Areas -Testicle - Epididymis -Surrounding layers Dr Ahmed Esawy
  4. 4. These two transverse ultrasound images demonstrate the normal blood flow through the left testicle.The left ultrasound image shows an area through the mid testicle without color Doppler; the right image shows blood flow towards the transducer (red) and flow away from the transducer (blue). Dr Ahmed Esawy
  5. 5. These two ultrasound images demonstrate a normal blood flow pattern in the testicle. The left is a longitudinal image and the right is a transverse image through the right testicle of the same patient. Compare this waveform with later images of pathologies of the testis for greater appreciation of what is being demonstrated. Dr Ahmed Esawy
  6. 6. These two ultrasound images demonstrate waveforms seen with color Doppler and pulsed wave Doppler.The pulse wave signal seen of the right testicle (left picture) shows a vessel with flow away from the transducer (white arrow). On the right is an ultrasound image showing Doppler signal in a vessel in the left testicle having blood flow towards the transducer. Dr Ahmed Esawy
  7. 7. Blood FlowWaveform for theTestis Diferential artery: high resistance Cremasteric artery: high resistance Testicular artery: low resistance Dr Ahmed Esawy
  8. 8. The ultrasound image on the left demonstrates a normal tunica vaginalis surrounding the testis.On the right, the left testis is surrounded by a hydrocele. Notice the parietal layer of the tunica vaginalis apposed to the testis and the large fluid filled space and parietal layer. This is a large hydrocele, which is only partially demonstrated on this view. Dr Ahmed Esawy
  9. 9. Scrotal sac infection Dr Ahmed Esawy
  10. 10. Scrotal ultrasound showing a normal appearing testicle with a scrotal free fluid with newly developed septations and echogenic debris and thickened scrotal skin without evidence of free air within the scrotal wall Dr Ahmed Esawy
  11. 11. Chronic pyocele. Longitudinal US with panoramic view of right scrotum shows low level internal ecoes (P), with thickened and calcified wall (c) with posterior acoustic shadowing (S), inferiorly displaced right testis (T). Dr Ahmed Esawy
  12. 12. Post inflammatory secondary hydrocele Longitudinal US of scrotum shows, septations(S), inflamed testis (T). Dr Ahmed Esawy
  13. 13. Acute orchitis pyocele Dr Ahmed Esawy
  14. 14. Scrotal abscess pyocele Dr Ahmed Esawy
  15. 15. Dr Ahmed Esawy
  16. 16. Inflammatory Diseases of Scrotal wall Dr Ahmed Esawy
  17. 17. Cellulitis of Scrotal Wall: Ultrasonographic findings include thickening of the scrotal wall and loss of uniform hyperechogenecity of the scrotal wall.Testis and epididymis may be normal. Complications: Scrotal wall abscess. Dr Ahmed Esawy
  18. 18.  Idiopathic scrotal edema in a 1-year-old boy.Transverse US scan of both hemiscrota shows marked thickening of the scrotal walls ( ).The testes (T) and their tunicae appear normal. Increased vascularity was seen at color Doppler imaging. Dr Ahmed Esawy
  19. 19. : Inflammatory diseases of scrotal contents include · Acute epididymitis and epididymo-orchitis, · Chronic epididymitis and epididymo-orchitis · Acute orchitis and Complications of inflammatory diseases of the testis and epididymis. Dr Ahmed Esawy
  20. 20. Orchitis =testicular infection Dr Ahmed Esawy
  21. 21. Primary orchitis in isolation is rare and most commonly caused by mumps testes appear enlarged decreased echogenicity. increased testicular vascularity Hyperemia and heterogeneity isolated to the testis can be seen in cases of orchitis, tumor, infarction, and especially in transient torsion of the testis Dr Ahmed Esawy
  22. 22. Orchitis findings  The testicle may appear normal or enlarged in size  The echogenicity may be decreased.  Reactive hydroceles and skin thickening are associated with orchitis.  Increased color Doppler flow to the infected testes. Chronic orchitis appears as layers of heterogeneous disruption within the testicle.  Focal orchitis may occur without involvement of the epididymis and has the same appearance as a neoplasm. Dr Ahmed Esawy
  23. 23. Orchitis Dr Ahmed Esawy
  24. 24. Epididymo-orchitis Dr Ahmed Esawy
  25. 25. Testicular abscess Dr Ahmed Esawy
  26. 26. Testicular abscess Dr Ahmed Esawy
  27. 27. Chronic orchitis Dr Ahmed Esawy
  28. 28. Focal Orchitis The study shows an intraparenchymatous hypoechoic area in the upper portion of the right testicle, corresponding to focal acute orchitis.The patient evolved favorably with antibiotic therapy. Dr Ahmed Esawy
  29. 29. Focal Orchitis with Pyocele: Grayscale scrotal ultrasound image of the right testicle reveals a round heterogenous hypoechoic region in the right testicle, which is surrounded by fluid with echogenic debris, compatible with focal orchitis and pyocele. Focal orchitis: Doppler color ultrasound in the same patient reveals increased flow within the hypoechoic region, compatible with focal orchitis Dr Ahmed Esawy
  30. 30. Testicular Abscess Ultrasound image: heterogeneous mass (ABSC), with an increase of the perilesional flow, corresponding to an intratesticular abscess Dr Ahmed Esawy
  31. 31. Ischemic orchitis Sonography of the scrotum shows: 1) hypoechoic left testes 2) 2) swelling of the left testes 3) 3) absence of vascularity in left testes. These ultrasound and color doppler images suggest left ischemic orchitis. Ischemic orchitis is a known complication of herniorraphy Dr Ahmed Esawy
  33. 33. MRI. Presence of an abscess in the left scrotum with rectal fistula. A,B:Axial (A) and coronal (B) sections ofT2-weighted sequence where a multiloculated collection is observed with hypersignal in the left scrotum (asterisk) without extension to the testes (T), and fistulous tract (arrow) which crosses the anal sphincter muscle towards the anterior rectal wall. AxialT1-weighted image after contrast agent injection (C) demonstrating hyposignal from the collection (asterisk) and the enhancement of its walls.The large field of view provided by MRI facilitates the assessment of the lesion extent. Dr Ahmed Esawy
  34. 34. Epididymitis Acute Epididymitis And Epididymo-Orchitis- It is the most common cause of acute scrotal pain in Dr Ahmed Esawy
  35. 35. Normal Epididymal Architecture Right Epididymis Longitudinal Axis Right EpididymisTransverse Axis Dr Ahmed Esawy
  36. 36. This ultrasound image shows the head of the epididymis (white arrow) next to the testis. Compared to the normal testicle the epididymis is normally isoechoic or slightly more echogenic. Notice the coarse composition of the epididymis relative to the echotexture of the testicle.The contour of the epididymis over the superior portion of the testicle can be seen on the ultrasound image on the right Dr Ahmed Esawy
  37. 37. These two ultrasound images demonstrate the head of the epididymis.The head of the epididymis is coarse in appearance compared to the homogenous echotexture of the testis seen in the image on the right.The white arrow in the left image of a longitudinal view of the left epididymis points to the head Dr Ahmed Esawy
  38. 38. These two ultrasound images are selections from a scan of the epididymis. Demonstrated is the body (left image) and tail (right image) of the epididymis.The coarse structure of the epididymis is due to its extremely long convoluted system of tubules that store sperm. Demonstrating the head, body, and tail of the epididymis is part of the ultrasound imaging sequence for the scrotal and testicular scan. Dr Ahmed Esawy
  39. 39. Epididymitis Inflammation of the epididymis Symptoms: Acute scrotal pain Fever, dysuria, discharge Ultrasound findings: Enlarged epididymis, coarse appearance Chronic-hyperechoic Acute-hypoechoic, increased blood flow Dr Ahmed Esawy
  40. 40. Right Epididymis Longitudinal Axis Left Epididymis Longitudinal Axis Epididymitis  Infection of epididymis  Hypoechoic body and tail of epididymis  Hyperemia on Doppler  Pain reduced by elevation of testicle Dr Ahmed Esawy
  41. 41. These two ultrasound images demonstrate the epididymis. On the left is a transverse section through the epididymis. Notice its coarse appearance, which is a characteristic of chronic epididymitis.The ultrasound image on the right is a longitudinal section through the tail of the epididymis. Notice how large and hyperechoic the epididymis appears in these two images.This is chronic epididymitis.Acute epididymitis would be hypoechoic. Dr Ahmed Esawy
  42. 42.  Clinically proved epididymitis in an 11-year-old boy. (a) Longitudinal US scan of the right hemiscrotum shows an enlarged hypoechoic epididymal head (E), reactive hydrocele (h), and thickening of the scrotal wall (*). m = mediastinum. (b) Color and pulsed-wave Doppler image shows increased vascularity in the epididymal head with a low-flow, low-resistance waveform pattern.
  43. 43. These two ultrasound color Doppler images demonstrate the blood flow to the epididymis.The image on the left is a transverse section, and the right a longitudinal section. Both images demonstrate increased blood flow to the epididymis, which is a characteristic of chronic epididymitis.
  44. 44.  Acute epididymitis in a 9- year-old boy with scrotal pain and redness. Longitudinal US scan shows that the epididymal head and body (arrows) are enlarged and hypoechoic relative to the normal testis (T).Wall thickening (*) and reactive hydrocele (h) are also seen. Power Doppler imaging showed increased perfusion of the epididymis. Dr Ahmed Esawy
  45. 45. EPIDIDYMITIS The case on the left shows the typical features of epididymitis. The epididymis is swollen and heterogeneous.There is a hydrocele and scrotal wall thickening.With color Doppler there is increased flow. A normal epididymis has only limited color flow. Dr Ahmed Esawy
  46. 46. Right Epididymis Longitudinal Axis Left Epididymis Longitudinal Axis Epididymitis  Infection of epididymis  Hypoechoic body and tail of epididymis  Hyperemia on Doppler  Pain reduced by elevation of testicle Dr Ahmed Esawy
  47. 47.  Granulomatous epididymitis in a 17-year-old boy with a painful scrotal mass. Longitudinal US scan shows a heterogeneous extratesticular mass (cursors) that replaces the epididymal tail.The mass resolved with medical treatment. Dr Ahmed Esawy
  48. 48.  Transverse sonogram of the testis shows an enlarged and predominantly hypoechoic epididymis with a reactive hydrocele in a patient with acute epididymitis. Dr Ahmed Esawy
  49. 49.  Color flow sonogram shows increased vascularity in the epididymis. An enlarged epididymis with increased vascularity in the appropriate clinical setting is diagnostic of acute epididymitis. Dr Ahmed Esawy
  50. 50.  Epididymitis. Longitudinal color Doppler image depicts normal vascularity of the right testicle, with increased flow in the epididymal tail and a small hydrocele Dr Ahmed Esawy
  51. 51.  Henoch-Schönlein purpura in a 9-year-old boy with bilateral scrotal pain and swelling. (a) Longitudinal US scan of the right hemiscrotum shows thickening of the scrotal wall (*) and scrotal tunica (arrows), an enlarged epididymal head (E), and a small hydrocele (h). Similar findings were seen in the left hemiscrotum
  52. 52. Acute Epididymitis. Ultrasound image, axial view of the epididymis tail: increased in volume and heterogeneous signal because of parenchymatous inflammatory changes Dr Ahmed Esawy
  53. 53. Epididymal abscess Dr Ahmed Esawy
  54. 54. Acute Epididymitis and Doppler Longitudinal image: increase in diameter of the left epididymis at the level of the head, which is heterogeneous with an increase of flow in Doppler mode. Dr Ahmed Esawy
  55. 55. Epididymis  Acute epididymitis. (a) Longitudinal US image shows a markedly thickened, heterogeneous epididymal tail (arrowhead) and edema within the scrotal wall (arrow). T = testis.  (b) Color Doppler image shows increased flow. (c) Photograph of the gross specimen shows a markedly thickened, hyperemic epididymis (arrow). T = testis.
  56. 56.  Tuberculous epididymitis. (a) Longitudinal US image shows a heterogeneous, hypoechoic mass in the region of the epididymal tail (arrow). It is difficult to differentiate the mass from a testicular one. T = testis. Dr Ahmed Esawy
  57. 57.  Tuberculous epididymo-orchitis. (a) Longitudinal US image shows a markedly enlarged epididymal head (arrowhead) with one large and several smaller hypoechoic masses (curved arrows).There are also multiple small hypoechoic lesions within the testis (straight arrows). Dr Ahmed Esawy
  58. 58.  Sarcoidosis. (a)Transverse US image shows a markedly enlarged, hypoechoic epididymis (E). T = testis. Dr Ahmed Esawy
  59. 59.  Clinically proved acute epididymitis in a 21-year-old man. Left:Transverse US scan of right testis and epididymis shows an enlarged hypoechoic epididymis (arrow). Right:Transverse color Doppler US scan of same epididymis demonstrates increased vascularity (arrow).The testis is normal. Dr Ahmed Esawy
  60. 60.  Epididymitis. A, Color and spectral Doppler image showing an enlarged hypoechoic epididymis and hyperemic blood flow. Note the normal testicular echo texture and lack of visible testicular blood flow at this color Doppler scale setting. B, Enlarged hypoechoic epididymal body (arrowheads) with associated hydrocele and scrotal wall thickening.
  61. 61.  Granulomatous epididymitis in a 17-year-old boy with a painful scrotal mass. Longitudinal US scan shows a heterogeneous extratesticular mass (cursors) that replaces the epididymal tail.The mass resolved with medical treatment. Dr Ahmed Esawy
  62. 62. Evaluation of Acute Scrotal Pain Dr Ahmed Esawy
  63. 63. epididymo-orchitis Dr Ahmed Esawy
  64. 64. Epididymo-orchitis  Common cause of acute scrotal pain in young adult  Clinically: pain relief when the testis is elevated above the symphysis pubis)  Caused by sexually transmitted organism  Start at the tail of epididymis  Complications: abscess- atrophy- infertility-pyocele  US: enlarged epididymis and testis with hypoechoic heterogenous pattern ( DD lymphoma-leukaemia -metastasis)- Hypervascular on Doppler May hyperechogenicity if Hge scrotal wall edema- Hydrocele Dr Ahmed Esawy
  65. 65.  Epididymo-orchitis.  A, Mottled testicular echo texture with hypoechoic regions.  B, Color and spectral Doppler image showing testicular hyperemia.  C, Color Doppler image showing hyperemic, enlarged, hypoechoic epididymis and testis.
  66. 66.  Clinically proved acute epididymo-orchitis in a 32-year-old man. Transverse US scan of testis shows acute epididymo-orchitis as focal areas of decreased echogenicity (arrowhead) in testicular parenchyma (T), resembling a metastatic lesion with reactive hydrocele (F).These hypoechoic areas were completely resolved at follow-up US after 2 weeks of antibiotic treatment. Dr Ahmed Esawy
  67. 67. Acute epididymo-orchitis. Longitudinal gray scale US shows enlarged testis (T), thickened scrotal wall (arrow) with hydrocele with septations. Dr Ahmed Esawy
  68. 68. Acute epididymo-orchitis. Dual transverse power Doppler US of both testes shows increased flow in right side testis compared to normal left testis. Dr Ahmed Esawy
  69. 69. Acute epididymo-orchitis. Pulse Doppler of intra testicular vessels shows low resistance flow pattern (arrow) and increased PSV. Dr Ahmed Esawy
  70. 70.  Epididymo-orchitis. Longitudinal color Doppler image of the left testis shows diffuse, markedly increased vascularity. Dr Ahmed Esawy
  71. 71.  Epididymo-orchitis.Transverse color Doppler image demonstrates increased epididymal flow and a hydrocele Dr Ahmed Esawy
  72. 72. Chronic Epididymoorchitis. Panoramic longitudinal gray scale US shows enlarged and heterogenous right testis (t), head of epididymus (E)is enlarged and Funiculitis with thick spermatic cord (SC). Dr Ahmed Esawy
  73. 73. Chronic tubercular Epididymoorchitis. Longitudinal US shows enlarged and heterogenous epididymus with calcification, with increased flow on power Doppler. Dr Ahmed Esawy
  74. 74. Acute epididymo-orchitis in a 47-year-old Sri Lankan man with multiple myeloma on bortezomib therapy, suffering from fever and acute scrotal pain, tenderness and induration. Contrast-enhanced CT (a, b) performed to investigate impending urosepsis depicted a thickened engorged left spermatic cord, with inhomogeneous vascularisation of the ipsilateral epididymis (thin arrows) and testis (arrows). Note catheter (in a), thickened and increased oedematous attenuation of the scrotal skin and external tunicae. CD-US (c) revealed hypervascularisation of the epididymis (+). Unresponsive to antibiotics, Klebsiella pneumoniae ultimately required orchiectomy Dr Ahmed Esawy
  75. 75. Surgically confirmed epididymo-orchitis with pyocele in a 72-year-old diabetic man with haematuria and enlarged left scrotum, history of transurethral resection of bladder carcinoma and bladder neck stricture treated by long-term catheterisation. Ultrasound revealed ipsilateral enlarged inhomogeneous epididymal head (+ in a) and hypervascularised testis (* in b). After unsuccessful antibiotic therapy, contrast-enhanced CT (c, d) showed hyperaemic left epididymis (thin arrows) and testis (arrows) compared to contralateral structures, and development of posterior scrotal collection (§).Another surgically proven case of testicular abscess and necrosis in a 59-year-old man with epididymo-orchitis unresponsive to medical therapy: post-contrast CT (e, f) revealed vascular engorgement along the left spermatic cord (arrowhead), faintly enhanced epididymal head (thin arrow in e), and ipsilateral scrotum occupied by fluid-like collection (*) with thin peripheral enhancing rim Dr Ahmed Esawy
  76. 76. Inflammatory MyofibroblasticTumor of the Paratestis Split-screen transverse sonogram showing a complex cystic mass with multiple septa compressing the left testis, giving it a commalike appearance (arrows). R.T. indicates right testis. B, Color-coded oblique sonogram showing no internal vascularity in the multicystic component of the mass. C, Panoramic view (the scrotum was traced in a coronal axis, from right to left and then upward along the left groin).The solid component of the paratesticular IMT (+) abuts the testicular surface (T). Retrospectively, the hypoechoic area (asterisk) probably represents part of the separate IMT of the spermatic cord. Dr Ahmed Esawy
  77. 77. Idiopathic scrotal edema Sonography of the scrotum was done in this child who had acute swelling of the scrotum and penis. Ultrasound images reveal 1) thickening (11mm.) of the scrotal and penile skin and subcutaneous tissue and 2) 2) marked hyperemia of the scrotum as well as the prepuce. 3) The testes show normal appearance on sonography. These ultrasound and color doppler images are diagnostic of idiopathic scrotal edema Dr Ahmed Esawy
  78. 78. Idiopathic scrotal edema Dr Ahmed Esawy
  79. 79. Is it easy to differentiate orchitis from testicular torsion ? No not easy Dr Ahmed Esawy
  80. 80. orchitis Epididymitis vs. Torsion  Epididimitis  Enlarged  Hypoechoic  IncreasedVascularity  Torsion  Enlarged  Hypoechoic  Decreased vascularity This differentiation in cases of complete continous testicular torsion Dr Ahmed Esawy
  81. 81. differentiation between orchitis incomplete intermittent testicular torsion Is difficult and need experience differentiation between ischemic orchitis complete testicular torsion Is difficult and need experience Dr Ahmed Esawy