Intratesticular Mass

Intratesticular Mass

Bhawan K. Paunipagar, MD, DNB

Michael P. Federle, MD, FACR



  • Epididymitis/Orchitis

  • Testicular Carcinoma

  • Testicular Torsion/Infarction

  • Testicular Hematoma

Less Common

  • Testicular Abscess

  • Testicular Lymphoma and Metastases

  • Gonadal Stromal Tumors, Testis

  • Testicular Epidermoid Cyst


Key Differential Diagnosis Issues

  • Age and clinical presentation

  • Sonographic findings are key (but overlap among various tumors)

    • Histopathological correlation is needed

Helpful Clues for Common Diagnoses

  • Epididymitis/Orchitis

    • Epididymis is primarily involved in epididymo-orchitis

      • Orchitis is usually secondary, occurring in 20-40% cases with epididymitis due to contiguous spread of infection

      • Primary orchitis is caused by mumps and is usually bilateral

    • Orchitis is characterized by inflammation, edema, and swelling of testis

      • Diffuse orchitis: Testis is diffusely enlarged with heterogeneous echo pattern

      • Focal orchitis: Hypoechoic focal area, usually adjacent to the inflamed epididymis

    • Increase in vascularity on color Doppler, without displacement of vessels

  • Testicular Carcinoma

    • Best diagnostic clue: Discrete hypoechoic or mixed echogenic testicular mass, ± vascularity

      • Tumor < 1.5 cm is commonly hypovascular

      • Tumor > 1.6 cm is more often hypervascular

      • Discrete mass on grayscale ultrasound with abnormal intrinsic vascularity on color Doppler should raise suspicion of a testicular carcinoma

    • Seminoma

      • Most common neoplasm in males between ages 15-39 years

      • Well-defined, lobulated, hypoechoic solid lesion without calcification or tunica invasion

      • May undergo necrosis and appear partly cystic

    • Teratoma/teratocarcinoma

      • Heterogeneous, complex, solid/cystic mass

      • Calcification (cartilage, immature bone) ± fibrosis characterize teratoma/teratocarcinoma

    • Embryonal cell carcinoma

      • Heterogeneous, predominantly solid, mixed echogenicity mass

      • Poorly marginated, 1/3 have cystic necrosis

      • May invade the tunica albuginea and distort testicular contour

    • Choriocarcinoma

      • Mixed echogenicity, heterogeneous mass

      • Cystic areas and calcification common

      • Hemorrhage with focal necrosis is typical feature of choriocarcinoma

      • May sometimes invade the tunica albuginea

      • Proclivity for early hematogenous spread, especially to brain

  • Testicular Torsion/Infarction

    • Acute pain, no history of trauma, in patients in hypercoagulable states or with advanced atherosclerosis such as diabetes

    • Diffusely hypoechoic small testis/focal mass in infarcted testis

    • Hyperechoic regions (hemorrhage/fibrosis), focal infarctions may have linear appearance

    • Segmental infarction may be a sequela of inflammatory process (orchitis)

  • Testicular Hematoma

    • Indicated by focal hypoechoic area within the testis, history of scrotal trauma

    • Abnormal testicular parenchymal echogenicity, avascular mass; echogenicity depends on the age of the hematoma

    • Discrete linear or irregular fracture plane within testis

    • Distorted intratesticular vascularity with interruption of vessels in the area of hematoma or injury

Helpful Clues for Less Common Diagnoses

  • Testicular Abscess

    • Epididymal abscess = 6%, testicular abscess = 6%

    • Microabscess formation is usually seen in low-grade infections (e.g., tuberculosis) and in immunocompromised host

    • Well-defined, discrete, rounded, hypoechoic lesion/lesions in the testicular parenchyma

    • Necrotic center shows no vascularity on color Doppler studies

  • Testicular Lymphoma and Metastases

    • Lymphoma

      • Most common testicular tumor in men > 60, multiple lesions; 50% of cases bilateral

      • Often large in size at the time of diagnosis, commonly occurs in association with disseminated disease

      • Ill-defined, predominantly hypoechoic lesions

      • Very vascular on color Doppler

      • Involvement of epididymis and spermatic cord is common; hemorrhage or necrosis is rare

    • Metastases are rare; most common sites include prostate, lung, and GI tract

    • Testis is a frequent site of relapse in male patients with acute leukemia

  • Gonadal Stromal Tumors, Testis

    • Bilateral in 3%

      • < 3 cm usually benign

      • > 5 cm malignant

    • Leydig cell tumor

      • Small solid hypoechoic testicular mass

      • In larger tumor hemorrhage or necrosis leads to heterogeneous echo pattern

    • Sertoli cell tumor

      • Small hypoechoic mass, solid and cystic components

      • Punctate calcification may be present; large calcified mass in calcifying Sertoli cell tumor

      • Hemorrhage may lead to heterogeneity

    • Indistinguishable from other testicular tumors by ultrasound findings

  • Testicular Epidermoid Cyst

    • Cystic cavity lined by stratified squamous epithelium

    • “Onion skin” appearance on US due to alternating layers of keratin and desquamated squamous cells

    • May have peripheral calcified rim


1. Dogra V et al: Acute painful scrotum. Radiol Clin North Am. 42(2):349-63, 2004

2. Woodward PJ et al: From the archives of the AFIP: tumors and tumorlike lesions of the testis: radiologic-pathologic correlation. Radiographics. 22(1):189-216, 2002

Aug 2, 2016 | Posted by in GENERAL | Comments Off on Intratesticular Mass
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