Conventional US of the scrotum: revisiting a classic technique
Type:Educational Electronic Presentation
Authors: Athina Tsili, Christina Bougia, Ourania Pappa, Maria Argyropoulou
Keywords:Ultrasonography, Color Doppler sonography, Scrotum, Testis, Testicular neoplasms.
Educational objective

To review the technical specifications for scrotal US and the normal sonographic findings. To discuss grayscale and Color Doppler US (CDUS) findings of common acute scrotal diseases and scrotal masses. To present recommendations of the European Society of Urogenital Radiology Scrotal and Penile Imaging Working Group (ESUR-SPIWG) for the application of scrotal US in the evaluation of various pathologies, including testicular microlithiasis (TML), small, impalpable incidentally detected testicular masses, varicocele and scrotal trauma.

Fig. 1. Normal sonographic findings. (a) Transverse US image shows normal testis as an ovoid structure, with homogenous intermediate echogenicity.The mediastinum testis can be recognized as a well-defined, highly echogenic area (arrow). (b) CDUS shows normal intratesticular arteries and veins. The transmediastinal artery (arrows) is seen traversing the mediastinum testis. (c) Spectral Doppler interrogation shows low-impedance, high-diastolic flow pattern of intratesticular arteries, reflecting the low testicular vascular resistance.

Topic Review

Conventional US, including grayscale and color Doppler US (CDUS) represents the imaging modality of choice for the assessment of scrotal pathology [1-4]. The main indications of scrotal US include: assessment of scrotal pain; palpable scrotal mass; scrotal enlargement; and, evaluation of varicoceles [5]. Recently, the ESUR-SPIWG established recommendations on the use of scrotal US in the evaluation of TML, small, impalpable, incidentally detected testicular mass, varicocele and scrotal trauma [6-9].

Conventional US technical specifications

Scrotal US is typically performed with the patient supine. A towel is placed between the thighs to support the scrotum and the penis is positioned superiorly by the patient [1-4]. Optimal results are obtained with a 7-15-MHz high-frequency linear-array transducer. CDUS... more

Fig. 2. Acute epididymitis. (a) Sagittal grayscale image shows a diffusely enlarged, markedly hypoechoic epididymis (arrow). (c) Power Doppler US shows hyperaemia of the inflamed epididymis. (d) A large pyocele with multiple, thick internal septa and echogenic debris is also seen.
Fig. 3. Complete testicular torsion, surgically confirmed, after radical orchiectomy. (a) Transverse US image of the pathologic hemiscrotum depicts the torsed testis swollen with spherical morphology, with markedly inhomogeneous echogenicity, mainly hypoechoic. Scattered areas of increased echogenicity within the affected testicular parenchyma corresponded to haemorrhagic foci on pathology. (b,c) CDUS images of the diseased side show absence of detectable vascularisation within the torsed testis, indicating non-viability. Note, reactive hyperaemia (arrow, c) in the paratesticular space.


Conventional US, including grayscale and CDUS represents the primary technique for diagnostic imaging of the scrotum. Adherence to technical requirements and knowledge of the normal sonographic anatomy enhances the probability to detect and characterize scrotal abnormalities.

US is the first imaging examination for the assessment of acute scrotum, often permitting discrimination between entities requiring urgent surgery, such as, testicular torsion from those that can be treated conservatively. US represents the first-line diagnostic tool for imaging scrotal trauma. The technique is highly accurate in determining the location of a scrotal mass and in detecting testicular germ cell tumors. The vast majority of small, impalpable testicular masses, incidentally found on US, without microliths or hypoechoic areas are benign. Radiologists should be familiar to the US findings of... more

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