Gambar Usg Testis

8/9/2019 Gambar Usg Testis

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Figure 5: Transverse scan of both testicles showing normal left testicle and

right testicular torsion. Note the hypoechogenicity of the right testicle. (Courtesy

of Michael Blaivas, M.D (T!"# T$"T#"%


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Figure 6: Transverse plane through both testes. The power Doppler image of

the scrotum demonstrates right testicular perfusion. The swollen left testicle is

not perfused. (Courtesy of Michael Blaivas, M.D.% T!"# T$"T#"


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Figure 7: & slightly obli'ue view of a testicle with an enlarged hypoechoic

epididymis. (Courtesy of Michael Blaivas, M.D.% $#D#D#M#"


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Figure 8: rchitis. Mar)ed increase in blood *ow is seen along with a reactive

hydrocele. (Courtesy of Michael Blaivas, M.D.%


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Figure 9: Testicular +racture. Note the inhomgenicity of the testicular

echoteture and fracture line. (Courtesy of Michael Blaivas, M.D.%


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Figure 4: -ongitudinal view of testicle with enlarged pampiniform pleus. &lso

note the thic)ening of the surrounding connective tissue secondary to scrotal

in*ammation after a failed penile implant. (Courtesy of Beatrice o/mann, M.D.%

0&!#11$-


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Figure 3: #mage of right and left testicles with hydrocele on right.


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"crotal hernia ana)


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+luid surrounding the right testicle and normal left scrotum transverse


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0aricocele with dilatated venous pleus and re*u during straining


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Torsion of the epididymal appendi and a normal vasculari2ed testis and

epididymis

"wollen hydatide (left arrow% and epididymis transverse (right arrow%

Torsion of the epididymal appendage (Morgagni3s hydatide% with a hypoechoic

mass between the right testis and the epididymis in a 45 year old boy


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ID: /4412-Afbeelding!.jpg

Longitudinal

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#o$al %&poe$%oi$ area 'it% in$reased flo' transverse

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#o$al %&poe$%oi$ area 'it% in$reased flo' transverse

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#o$al %&poe$%oi$ area 'it% in$reased flo' longitudinal

ID: /441!*-Afbeelding".jpg


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+or,al flo' in t%e ot%er testis

ID: /441!1-Afbeelding(.jpg


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-N6#T7D#N&-


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Normal testis


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A$ute s$rotal pain a$$ounts for approi,atel& *.5 3 of all $o,plaints presenting to t%e

e,ergen$& depart,ent. Differential diagnosis of a$ute s$rotal pain in$ludes epidid&,itis0

or$%itis0 testi$ular torsion0 torsion of t%e testi$ular appendage0 testi$ular trau,a0 and

%erniation of abdo,inal $ontents into t%e s$rotu,. T%e %istor& and p%&si$al ea,ination

findings of various etiologies of a$ute s$rotal pain %ave a signifi$ant overlap0 t%erefore

,aing it diffi$ult to differentiate t%ese entities $lini$all&. o'ever0 distin$tion bet'een t%eunderl&ing pat%olog& is $riti$al as pro,pt intervention is reuired in $ases of testi$ular

torsion0 trau,a0 and in$ar$erated %ernias. isdiagnosing testi$ular torsion $an lead to organ

loss and infertilit&. 6atient distress and t%e possibilit& of fertilit&-t%reatening disease pla$e

signifi$ant pressure on t%e e,ergen$& p%&si$ian to ,ae an a$$urate diagnosis. 7edside

ultrasonograp%& of t%e a$ute s$rotu, is a relativel& ne' appli$ation to e,ergen$& ,edi$ine

ultrasound and %as %ig% utilit& for e,ergen$& p%&si$ians ,anaging patients 'it% a$ute s$rotal

$o,plaints.

Indications:

1. Testi$ular pain

2. Testi$ular s'elling/,ass

!. Trau,a

II. Anatomy

T%e s$rotu, is a sa$$ular stru$ture divided into t'o $o,part,ents b& t%e ,edian rap%e. 8a$%

$o,part,ent $ontains a testi$le0 epidid&,is0 vas deferens0 and sper,ati$ $ord. T%e testes are

surrounded b& a fibrous $apsule0 $alled t%e tuni$a albuginea0 '%i$% is $overed b& t%e tuni$avaginalis. T%e tuni$a vaginalis %as t'o la&ers0 an outer parietal la&er and an inner vis$eral

la&er '%i$% are separated b& a s,all a,ount of fluid. T%e nor,al adult testis is ovoid in

s%ape and ,easures approi,atel& 2 to ! $, in 'idt% and ! to 5 $, in lengt%. T%e si9e of t%e

testi$le varies 'it% age0 in$reasing in si9e fro, birt% to pubert& and t%en de$reasing later in

life. tru$turall&0 t%e testes are divided into lobules b& septa radiating fro, t%e tuni$a

albuginea. it%in t%e testi$ular paren$%&,a0 se,iniferous tubules $onverge at t%e

,ediastinu, testis0 an in$o,plete septu, for,ed t%roug% invagination of t%e tuni$a

albuginea. It is lo$ated in t%e posterior aspe$t of t%e testis.

T%e epidid&,is is found along t%e posterolateral aspe$t of ea$% testis. T%e epidid&,is

,easures approi,atel& to " ,, in lengt% and $onsists of a %ead0 bod& and tail. T%e %eadof t%e epidid&,is is lo$ated adja$ent to t%e superior pole of t%e testis0 t%e bod& runs

posteriorl&0 'it% t%e tail at t%e inferior pole. T%e largest portion of t%e epidid&,is is t%e %ead

and is usuall& round or triangular in s%ape. T%e tail of t%e epidid&,is be$o,es t%e vas

deferens as it as$ends superiorl& out of t%e s$rotu,. T%e sper,ati$ $ord suspends t%e testis in

t%e s$rotu, and $onsists of arteries0 veins0 nerves0 l&,p%ati$s0 and t%e vas deferens. T%e

appendi testis and t%e appendi epidid&,is are bot% e,br&ologi$al re,nants t%at are found

to'ard t%e superior pole of t%e testis. 7lood suppl& to t%e testis pri,aril& originates fro, t%e

testi$ular arter&0 '%i$% arises fro, t%e aorta. ;t%er sour$es of blood suppl& in$lude t%e

deferential arter&0 '%i$% supplies t%e epidid&,is and t%e vas deferens and t%e $re,asteri$

arter& supplies t%e peritesti$ular tissues.


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Illustration 1: ;vervie' of testi$ular anato,&.

Normal Variants

In 5* 3 of ,en t%e trans,ediastinal arter&0 a large bran$% of t%e testi$ular arter&0 $ourses

t%roug% t%e ,ediastinu, testis to suppl& t%e $apsular arteries and is usuall& a$$o,panied b&

a large vein.

III. Scanning Technique and Normal Findings

6rior to perfor,ing a s$rotal ultrasound ea,ination adeuate analgesia and reassuran$e

s%ould be provided. T%e patient is pla$ed in a supine position 'it% t%e legs slig%tl& spread

apart. T%e s$rotu, is pla$ed in a sling designed fro, a to'el to i,prove eposure and s%ould

be supported and i,,obili9ed on a rolled to'el pla$ed bet'een t%e patient?s t%ig%s. T%e

penis is $overed 'it% a to'el and t%e to'el is taped to t%e abdo,inal 'all. Alternativel&0 one

$an reuest t%e patient to support t%e penis 'it% %is %and in a $ep%alad dire$tion and a drape

$an be pla$ed on top. ;f note0 utili9ing $old gel ,a& $ause t%e sin on t%e s$rotu, to $ontra$t

and be$o,e t%i$ or ,a& $ause t%e testi$les to as$end in t%e s$rotal sa$ ,aing i,aging ,ore

diffi$ult.

A %ig% freuen$& broadband linear transdu$er =".5-1* 9> t%at $an perfor, bot% po'er and

spe$tral Doppler ultrasonograp%& is used. T%e s$rotu, and its $ontents are s$anned in at least

t'o planes0 along t%e longitudinal and transverse ais. T%e unaffe$ted %e,is$rotu, is

s$anned initiall& to fa,iliari9e t%e patient 'it% t%e pro$ess0 and also to provide a $o,parison

of anato,& and blood flo' as 'ell. T%e s$an is perfor,ed initiall& in a long ais to t%e

testi$le0 'it% t%e indi$ator dire$ted $ep%alad s%o'ing a longitudinal $ut t%roug% t%e testis

'it% t%e epidid&,is on t%e left side of t%e s$reen =#igure 1>.

Figure 1: A properl& eposed and draped patient 'it% t%e s$rotu, supported in a sling of

to'els. =@ourtes& of i$%ael 7laivas0 .D.>

T%e entire testis is s$anned fro, one etre,e to anot%er0 noting t%e e$%oteture and

abnor,alities. T%e epidid&,is is visuali9ed as 'ell. T%e transdu$er is ,oved s,oot%l& and

slo'l&0 ea,ining all aspe$ts of t%e anato,&. T%e s$an is t%en repeated 'it% t%e probe turned)* to'ard t%e patient?s rig%t to obtain a transverse i,age of t%e testi$le. A $oronal s$an


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s%o'ing bot% testi$les side b& side s%ould be perfor,ed to identif& differen$es in si9e and

e$%ogeni$it&0 and vas$ularit&.

T%e vis$eral and parietal la&ers of t%e tuni$a are visuali9ed as one e$%ogeni$ stripe. T%e

nor,al testis %as ,idgra& or ,ediu,-level e$%oes and is %o,ogenous in appearan$e. T%e

e$%ogeni$it& of t%e testis is si,ilar to t%at of t%e liver or t%e t%&roid gland. T%e epidid&,is%as si,ilar or slig%tl& in$reased e$%ogeni$it& as $o,pared to t%e nor,al testis. T%e

,ediastinu, testis is seen as a linear e$%ogeni$ band running $ranio$audall& or parallel to t%e

epidid&,is. T%e appendi testis and appendi epidid&,is are s,all ovoid %&pere$%oi$

protuberan$es found at t%e superior pole of t%e testis0 nor,all& %idden b& t%e epidid&,al

%ead. Bnless outlined b& fluid fro, a %&dro$ele0 t%e& are diffi$ult to find on ultrasound. T%e

sper,ati$ $ord appears as ,ultiple %&poe$%oi$ linear stru$tures in t%e longitudinal plane and

$ir$ular %&poe$%oi$ stru$tures in t%e transverse plane. =10500">

6o'er Doppler ea,ination is perfor,ed after gra&-s$ale i,aging is $o,plete. T%e

unaffe$ted side is s$anned initiall& to obtain a$$urate Doppler settings. To adeuatel&

evaluate blood flo'0 Doppler para,eters s%ould be adjusted to t%eir ,ost sensitive settings'it%out introdu$ing signifi$ant artifa$t. 6o'er Doppler and pulsed Doppler s%ould be

opti,i9ed to displa& lo'-flo' velo$ities to de,onstrate blood flo' in t%e testes and adja$ent

stru$tures. T%e 'all filter0 s$ale and gain ,a& need to be adjusted to pi$ up ,ai,al blood

flo' 'it%out signifi$ant artifa$t. T%e 'all filter s%ould be set at t%e lo'est sele$tion possible

and t%e 6# =6ulse epetition #reuen$&> is ,ini,i9ed as 'ell. T%e $olor gain s%ould be

adjusted $arefull&0 as t%e artifa$tual appearan$e of flo' ,a& be $reated in a torsed testi$le.

Intratesti$ular and epidid&,al flo' s%ould be $onfir,ed using bot% po'er Doppler and

spe$tral Doppler 'avefor, anal&sis. 6o'er Doppler %elps to dete$t blood flo' 'it%in t%e

testi$le and spe$tral Doppler allo's identifi$ation of t%e flo' '%et%er it is venous or arterial.

pe$tral Doppler 'avefor,s s%ould be obtained in several areas of blood flo' dete$ted b&

po'er Doppler to do$u,ent bot% arterial and venous flo' patterns. T&pi$all&0 po'er and

spe$tral Doppler s$an $an be perfor,ed on t%e sa,e ultrasound 'indo'.

Figure : I,age of t%e nor,al testi$le 'it% t%e epidid&,al %ead on t%e left and bod& of

testi$le on t%e rig%t. =@ourtes& of i$%ael 7laivas0 .D.>

VI. !athology
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Illustration : $%e,ati$ overvie' of testi$ular pat%olog&.

"ydrocele

A %&dro$ele is t%e ,ost $o,,on $ause of s$rotal s'elling. T%e nor,al s$rotu, $ontains

s,all a,ounts of serous fluid bet'een t%e la&ers of t%e tuni$a vaginalis. Abnor,al $olle$tion

of fluid in t%e spa$e bet'een t%e vis$eral and parietal la&ers of t%e tuni$a vaginalis results in

a %&dro$ele. T%e fluid $olle$tions are usuall& $onfined to t%e anterolateral portions of t%e

s$rotu, be$ause of t%e posterior lo$ation of atta$%,ents of t%e tuni$a to t%e testis and

s$rotu,. &dro$eles ,a& be unilateral or bilateral and $an be seen as an isolated finding or in

$onjun$tion 'it% a$ute or $%roni$ pat%olog&. an& of t%ese fluid $olle$tions are $ongenital.

A$uired %&dro$eles are asso$iated 'it% infe$tion0 tu,ors0 trau,a0 torsion and radiation

t%erap&. e,ato$eles and p&o$eles are $o,ple %&dro$eles. onograp%i$all&0 a si,ple

%&dro$ele is seen as an ane$%oi$ dar fluid $olle$tion surrounding t%e testi$le =#igure !>0

'%ereas a $o,ple %&dro$ele ,a& $ontain internal e$%oes 'it% septations and lo$ulations. A

$%roni$ %&dro$ele ,a& also de,onstrate internal e$%oes fro, $%olesterol $r&stal for,ation.

=1020!0>

Figure #: I,age of rig%t and left testi$les 'it% %&dro$ele on rig%t. =@ourtes& of i$%ael

7laivas0 .D.>

Varicocele

A vari$o$ele is a $olle$tion of tortuous and dilated veins 'it%in t%e pa,pinifor, pleus of

t%e sper,ati$ $ord. T%e& are found in approi,atel& 15 3 of adult ,ales and $an result in

infertilit& se$ondar& to de$reased sper, ,otilit& and $ount. T%e& are due to in$o,petent

valves in t%e testi$ular vein. T%e vast ,ajorit& of vari$o$eles are lo$ated on t%e left side and

onl& 1 3 are bilateral. T%e left sided predo,inan$e of vari$o$eles is t%oug%t to be due to t%e

long $ourse and angle of entr& of t%e left testi$ular vein as it e,pties into t%e left renal vein.

T%e rig%t testi$ular vein is s%orter and e,pties dire$tl& into t%e inferior vena $ava.


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stru$tures of var&ing si9es =larger t%an 2 ,, in dia,eter> in t%e region of t%e epidid&,is

=#igure 4>. 6o'er Doppler s%ould be used to $onfir, flo' in t%e vari$o$ele. =500">

Figure $: Longitudinal vie' of testi$le 'it% enlarged pa,pinifor, pleus. Also note t%e

t%i$ening of t%e surrounding $onne$tive tissue se$ondar& to s$rotal infla,,ation after a

failed penile i,plant. =@ourtes& of 7eatri$e off,ann0 .D.>

Testicular Torsion

Testi$ular torsion is a urologi$ e,ergen$&. 6ro,pt diagnosis and earl& treat,ent is essentialas ti,e is $riti$al for testi$ular salvage. Torsion is ,ore $o,,on in $%ildren but $an o$$ur in

post pubertal ,ales. T%e ,ajorit& of testi$ular torsions result fro, anato,i$ defe$ts t%at lead

to redundant sper,ati$ $ord and ano,alous suspension of t%e testes in t%e s$rotu,. An

undes$ended testi$le also in$reases t%e lieli%ood of torsion. A redundant sper,ati$ $ord is

,obile and during torsion it begins to t'ist upon itself. As t%e t'isting progresses0 venous

flo' is interrupted initiall& due to easil& $ollapsible vessel 'alls and t%e lo' intravas$ular

pressure. . Bnfortunatel&

ultrasound ,a& not al'a&s be %elpful0 as sonograp%i$ findings ,a& be subtle earl& in t%e

$ourse. @olor Doppler or po'er Doppler ,a& be %elpful to identif& flo' patterns in t%e

a$utel& tender testi$le =#igure >. %en blood flo' is absent in t%e affe$ted testi$le0 t%e

diagnosis of testi$ular torsion is $lear. ;$$asionall& de$reased blood flo' seen in earl&

torsion $an be erroneousl& diagnosed as nor,al. T%us0 $o,parison to t%e $ontralateral side is

$ru$ial. @olor Doppler alone 'ill not assure bot% venous and arterial flo' in t%e testi$le.

pe$tral Doppler tra$ings s%ould also be obtained to $onfir, bot% arterial and venous flo'.

T%e absen$e of a venous pattern b& spe$tral Doppler on t%e affe$ted side suggests earl&

torsion. If t%e diagnosis is in doubt due to torsion-detorsion0 repeat $olor Doppler i,aging

along 'it% spe$tral ea,ination in one %our is re$o,,ended. =20!04>
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Figure %: Transverse s$an of bot% testi$les s%o'ing nor,al left testi$le and rig%t testi$ular

torsion. +ote t%e %&poe$%ogeni$it& of t%e rig%t testi$le. =@ourtes& of i$%ael 7laivas0 .D.>

Figure &: Transverse plane t%roug% bot% testes. T%e po'er Doppler i,age of t%e s$rotu,

de,onstrates rig%t testi$ular perfusion. T%e s'ollen left testi$le is not perfused. =@ourtes& of

i$%ael 7laivas0 .D.>

'pididymitis

8pidid&,itis is t%e ,ost $o,,on $ause of a$ute s$rotal pain in postpubertal ,ales.

@lassi$all&0 patients present 'it% a painful tender s$rotu,0 d&suria0 and fever. etrograde

spread of infe$tion fro, t%e bladder or prostate is usuall& t%e underl&ing etiolog& 'it% t%e

%ead of t%e epidid&,is ,ost $o,,onl& involved. Cra&-s$ale findings of a$ute epidid&,its

in$lude an enlarged epidid&,is 'it% de$reased e$%ogeni$it&. ;ften0 a rea$tive %&dro$ele is

noted as 'ell =#igure ">. A $%roni$all& infla,ed epidid&,is be$o,es t%i$ened and %as fo$al

e$%ogeni$it& 'it% areas of $al$ifi$ation. it% Doppler sonograp%& in$reased blood flo'

se$ondar& to epidid&,al infla,,ation is noted. T%e presen$e of nor,al or in$reased blood

flo' in t%e affe$ted testi$le '%en $o,pared to t%e $ontralateral side differentiates

epidid&,itis fro, testi$ular torsion. =20!04>

Figure (: A slig%tl& obliue vie' of a testi$le 'it% an enlarged %&poe$%oi$ epidid&,is.

=@ourtes& of i$%ael 7laivas0 .D.>

)rchitis

;r$%itis is an a$ute infe$tion of t%e testi$le usuall& follo'ing epidid&,itis. ;r$%itis often

presents 'it% a tender and infla,ed testi$le. ;n gra&-s$ale ultrasound0 or$%itis is seen as an

enlarged testi$le 'it% %eterogeneous e$%ogeni$it&. T%is appearan$e is nonspe$ifi$ and $an be

seen in ,an& ot%er $onditions su$% as tu,ors0 ,etastasis0 infar$t and torsion. tandard 7-

,ode is not a reliable ,et%od to differentiate bet'een or$%itis and testi$ular torsion. #or bot%

or$%itis and torsion0 infla,,ation and ede,a $an lead to enlarge,ent and %eterogeneous

e$%ogeni$it& of t%e testis. @olor Doppler is %elpful to differentiate bet'een or$%itis and
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torsion sin$e blood flo' in or$%itis is in$reased in $o,parison 'it% t%e unaffe$ted side due to

infla,,ation =#igure (>. =20!04>

Figure *: ;r$%itis. ared in$rease in blood flo' is seen along 'it% a rea$tive %&dro$ele.

=@ourtes& of i$%ael 7laivas0 .D.>

Scrotal Trauma

7lunt trau,a to t%e s$rotu, $an lead to da,age of t%e testi$le and adja$ent stru$tures.

Injuries to s$rotu, in$lude la$eration0 %e,orr%age0 or $ontusion of t%e testi$le. T%e goal ofs$rotal ultrasound in patients 'it% a$ute trau,a to t%e s$rotu, is to evaluate injur& to t%e

testi$le. 7lood flo' to t%e testi$le s%ould also be evaluated sin$e trau,a $ould lead to

testi$ular torsion.

Figure +: Testi$ular #ra$ture. +ote t%e in%o,geni$it& of t%e testi$ular e$%oteture and

fra$ture line. =@ourtes& of i$%ael 7laivas0 .D.>

V. !earls and !itfalls

Bse t%e ,ediastinu, testis as a point of referen$e '%en de,onstrating intratesti$ularflo'. +ote0 t%at if ,ediastinu, testis is i,aged at an obliue angle0 it $an be ,istaen
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for a ,ass.

@olor Doppler $annot differentiate ,alignant %&pervas$ularit& fro, infla,,ator&

%&pervas$ularit&.

Diagnosing earl& testi$ular torsion '%en it is still in$o,plete $an be $%allenging 'it%

$olor Doppler alone. T%is ,et%od relies on subtle differen$es bet'een t%e t'o testi$les.

:)*-)!.

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Ambulatory Medicine. osb&: t. Louis0 ;0 1))":25*.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=15301848&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSumhttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=11136159&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSumhttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=11136158&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSumhttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=10750932&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSumhttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=15602220&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSumhttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=15301848&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSumhttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=11136159&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSumhttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=11136158&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSumhttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=10750932&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSumhttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=15602220&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum


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