Session 1
1.Ultrasound Technique and Protocol,
2.Basic understanding of scrotal sono anatomy and Doppler,
3. Congenital and developmental scrotal pathologies

"Whether you’re a radiology resident, sonographer, or an expert sharpening your edge, mastering scrotal ultrasound is essential. From undescended testes to scary scrotal lumps, this high-yield guide breaks down everything — in a practical, pattern-based, and memory-aided style. Let’s go from gonads to guts (literally) and decode every twist, turn, and torsion that can happen below the belt"

🧠 Section A: Know Thy Testis — Scrotal Sonoanatomy 101
 Start with B-mode before diving into Doppler.
What to identify: ·

• Testis: Homogeneous, mid-grey, smooth outline. ·
• Epididymis Head: Posterolateral; isoechoic or slightly hyperechoic to testis. ·
• Epididymis Body & Tail: Slender, runs inferior to the testis. ·
• Mediastinum Testis: Central echogenic band — your internal GPS. ·
• Tunica Vaginalis: Look for peritesticular fluid here. ·

Appendices:
 o Appendix Testis = Müllerian remnant
 o Appendix Epididymis = Wolffian remnant
 🔖 Memory Tip: “Testis is smooth and grey. Epididymis says ‘I do’. Appendices just hang around!”
🚦 Section B: Doppler Basics — Let the Blood Flow Talk
 Color Doppler helps differentiate between life and limb (literally).
Cheat sheet Settings:

Parameter	Ideal Setting
PRF	500–1000 Hz
Wall Filter	Low
Color Gain	High, without blooming
Angle	Parallel to vessels

📍Always test settings on the normal side first. Compare everything side-by-side
🧸 Section C: Pediatric Cases — Small Testes, Big Problems 👼 Inguinal Hernia

• Clue: Bowel pops into scrotum when baby cries.
• US: Peristalsis = bowel; static echogenicity = omentum.
  
• Red Flag: Absent peristalsis or vascularity → strangulated!

💧Hydroceles
Types:
o Encysted: Closed on both ends.
o Funicular: Communicates with peritoneum.
 o Clinical sign: Blue Dot 🔵

🔥 Section H: Acute Scrotum Made Easy — Spot the Culprit

Condition	Key Sign	Doppler Flow	Action
Torsion	Absent intratesticular flow	❌	Emergency
Appendix torsion	Avascular dot + hyperemia	✅	Conservative
Epididymitis	Enlarged, hyperemic epi	✅	Medical
Orchitis	Increased testis flow	🔥	Medical

💦 Section I & J: Cysts vs Confusions Epididymal Cyst vs Spermatocele

Feature	Epididymal Cyst	Spermatocele
Contents	Clear fluid	Sperm + debris
Internal Echoes	None	Present
Loculation	Single	Multiloculated

🧠 “Debris? It’s a spermatocele!”
📸 Section K–L: Hernias & Appendices That Fake Cysts ·

• Bowel Hernia: Peristalsis + Doppler wall vascularity.
• Omental Hernia: Static, echogenic, no peristalsis.

Appendix with Cystic Change: A cyst with a stalk = not a true cyst.
🗺️ Section M–N: Spotters & Survival Tips
 ✅ Always compare both sides 🔍 Classic Spotters:

Image Clue	Diagnosis
Avascular dot near pole	Appendix torsion
Tram-track tubular structure	Vas deferens
Cyst with stalk	Appendix Epididymis
Echogenic inguinal mass	Omental Hernia
Peristaltic bowel in sac	Inguinal Hernia (Bowel)

🌀 Section O: Doppler Flow — Art of Flow Detection

Pattern	Condition
Absent flow	Torsion
Increased flow	Orchitis/Epididymitis
Reversed diastolic	Venous infarct
Focal hot spot	Tumor

📍 RI ~ 0.5–0.7; PSV ~15–25 cm/s
🩸 Section P–Q: Infarcts, Abscesses & Cold Centers
 Segmental Testicular Infarction

•  Wedge-shaped, hypoechoic, avascular
•  Mimics tumor
  Testicular Abscess
•  Complex lesion with thick wall
•  Avascular center with rim vascularity

 🧠 “Hot rim, cold core = Abscess.”
🎨 Section R: Elastography in Scrotum

Lesion	Appearance
Tumor	Stiff (blue)
Inflammation	Soft (green/red)
Infarct	Very stiff

👉 Use with grayscale + Doppler for best results
💉 Section S: Contrast-Enhanced Ultrasound (CEUS)
 Helps distinguish: 

• Tumor → Rapid enhancement 
•  Infarct → No enhancement 

 Abscess → Rim enhancement only Not routine but a great tool if available.
📝 Section T: Final Reporting Checklist
 ✅ B-mode:

•  Testis size, echotexture
  
•  Epididymis, scrotal wall, hydrocele, appendices

 ✅ Doppler:

•  Intratesticular flow
  
•  Symmetry
•  RI, PSV, waveform
•  Symmetry
•  RI, PSV, waveform

 ✅ Extratesticular:

•   Hernia?
•   Cord?
•   Undescended testis?

 ✅ Impression (Use precise terms):

•  Avascular twisted cord → Torsion
•  Avascular appendix + hyperemia → Torsed Appendix
•  Wedge-shaped hypoechoic, no flow → Infarct

 Complex lesion with rim vascularity → Abscess

Bonus: Scrotal Inflammation — EDO, Mumps & Fournier’s

Epididymo-Orchitis

•  Gradual onset
•  Increased Doppler flow
•  Reactive hydrocele

Torsion vs EDO

Feature	Torsion	EDO
Flow	Absent	Increased
Pain onset	Sudden	Gradual
Prehn’s sign	Negative	Positive

Fournier’s Gangrene

• Dirty shadows = Subcutaneous gas
• Wall thickening
• Requires immediate surgery
  🎯 Final Takeaways ✅ Compare both testes — symmetry is your best friend
  ✅ No flow? Suspect torsion — act fast
  ✅ Epididymis loves cysts
  ✅ Appendix = Blue dot = No knife needed
  ✅ Not all scrotal pain is torsion
  ✅ Use elastography and CEUS wisely
  ✅ Always correlate clinically — scrotum never lies, but it may confuse!