Sandbox:Preeti

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Preeti Singh, M.B.B.S.[2]

Differentiating [disease name] from other diseases on the basis of [symptom 1], [symptom 2], and [symptom 3]

On the basis [symptom 1], [symptom 2], and [symptom 3], [disease name] must be differentiated from [disease 1], [disease 2], [disease 3], [disease 4], [disease 5], and [disease 6].

Scrotal Swelling Diseases Clinical manifestations Para-clinical findings Gold standard Additional findings
Painful Symptoms Physical examination
Lab Findings Imaging Histopathology
Symptom 1 Symptom 2 Symptom 3 Tenderness Testicular Enlargement Physical exam 3 Lab 1 Lab 2 Lab 3 Imaging 1 Imaging 2 Imaging 3
Epididymitis +
Orchitis +
Testicular Torsion +
Trauma +
Incarcerated Hernia -
Insect Bite -
Rash -
Torsion of testicular appendix -
Scrotal Swelling Diseases Symptom 1 Symptom 2 Symptom 3 Tenderness Testicular Enlargemet Physical exam 3 Lab 1 Lab 2 Lab 3 Imaging 1 Imaging 2 Imaging 3 Histopathology Gold standard Additional findings
Painless Fragile X - +
Testicular Tumors - +
Henoch-Schonlein purpura - -
Hydrocele - -
Varicocele - -
Spermatocele - -
Incarcerated hernia - -
Scrotal edema - -
Disease Name History and Symptoms Physical Examination Lab Findings Imaging Findings Gross and Histologic Findings Genetic Studies / Immunohistochemistry
Germ Cell Tumors

Seminoma

  • Most common
  • 30-50 year-old with painless unilateral testicular mass or mild discomfort
  • Palpable, nontender unilateral testicular mass
  • Usually homogeneous enlargement
  • Elevated serum placental ALP (PALP)
  • Hypoechogenic intratesticular well-defined mass on ultrasound with internal blood flow on Doppler ultrasound
  • Cysts and calcificications are uncommon
  • Hypointense lesion with inhomogeneous enhancement on MRI
  • Homogeneous when small and heterogeneous when large
  • Grey-white homogeneous mass with a lobular appearance
  • Fried egg appearance on histopathology (large cells and clear cytoplasm)
  • Prominent lymphocytic infiltration and less commonly, granulomatous formation
  • Stains positively for ALP, c-KIT, CD30, EMA, and glycogen

Embryonal cell carcinoma

  • Young adults
  • Painful testicular mass
  • Manifests with early mestastasis (bone, lung, CNS)
  • Often unremarkable (small primary tumor)
  • Elevated serum hCG
  • Elevated serum AFP, when mixed
  • Variable echogenicity (usually hypoechoic on ultrasound)
  • No differentiating features on imaging
  • Commonly invade the surrounding structures (tunica albuginea)
  • Irregular calcifications
  • Pale-grey mass with areas of hemorrhagic and necrosis
  • Often mixed histopathological features (solid, papillary, tubular, pseudoglandular)
  • Stains positively for CD30 and hCG stain
  • May stain positively for AFP, when mixed

Yolk sac tumor

  • Most common testicular cancer in children less than 3 years of age
  • Rapidly growing unilateral mass in an infant or a young child
  • Palpable, nontender unilateral testicular mass
  • Usually heterogeneous enlargement
  • Elevated serum AFP
  • Diffuse enlargement of the testis with a heterogeneous appearance on ultrasound
  • Areas of hemorrhage and necrosis on MRI
  • Yellow, mucinous, non-encapsulated, heterogeneous mass with areas of necrosis and hemorrhage
  • Patterns that resemble embryonal structures (yolk sac, allantois) with reticular, papillary, or elongated forms
  • Schiller-Duval bodies (perivascular structures)
  • Stains positively for AFP, alpha-1-antitrypsin, PAS diastase

Teratoma

  • Bimodal distribution of age (infants and middle aged adults)
  • Painless tumor
  • History of congenital disease (Down syndrome, klinefelter, spina bifida)
  • Palpable, nontender unilateral testicular mass
  • Usually heterogeneous enlargement
  • Elevated serum hCG
  • Elevated serum AFP
  • Heterogeneous, cystic appearance with mucinous or sebaceous depositions
  • Variable echogenicity on ultrasound
  • Calcifications usually irregular
  • Large, heterogeneous appearance with solid, cystic, mucoid, and/or cartilageanous components
  • Presence of at least 2 germ layers
  • Chromosome 12p mutations
  • Stains positively for cytokeratin. hCG, and AFP

Teratocarcinoma

  • Middle aged adult with painless testicular mass of mild discomfort
  • May manifest with features of metastasis
  • Palpable, nontender unilateral testicular mass
  • Usually heterogeneous enlargement
  • Elevated serum hCG
  • Elevated serum AFP
  • Variable echogenicity on ultrasound
  • Features of both teratoma and embryonal carcinoma (more common) or both teratoma and choriocarcinoma (less common)
  • Solid and cystic components with mucoid, cartilagenous, sebaceous gland, myxoid stroma components
  • Additional features of underlying embryonal carcinoma or choriocarcinoma
  • Stains positively for cytokeratin. hCG, AFP, and CD30

Choriocarcinoma

  • Adolescent or young adult with extratesticular symptoms
  • Mass is small and locally asymptomatic
  • Manifests with early metastasis and signs of hemorrhage (hemorrhagic stroke, hyperthyroidism, cannon-ball metastasis in lung, liver involvement, neurological deficits)
  • Often unremarkable (small primary tumor)
  • Elevated serum hCG
  • Variable echogenicity
  • No differentiating features on imaging
  • Commonly invade the surrounding structures (tunica albuginea)
  • Prominent areas of hemorrhage and necrosis
  • Nest and sheet pattern that simultaneously includes both cytotrophoblast and syncytiotrophoblast (rarely pure)
  • Paucity of intermediate trophoblasts (unlike placental site trophoblastic tumor)
  • Stains positively for hCG

Diffuse embryoma

  • 20-25 yo man with painful testicular mass
  • Tender testicular mass
  • Elevated serum hCG
  • Elevated serum AFP
  • Poorly-defined, heterogeneous hyperechoic mass on ultrasound
  • Non-encapsulated mass
  • Intermingled (lace-like) embryonal carcinoma and yolk sac components in equal proportions, but no discrete embyoid bodies
  • Scattered trophoblastic components
  • Necklace-like arrangement of cells
  • Stains positively for cytokeratin, AFP (yolk sac component), and CD30 (embyonal component)

Polyembryoma

  • 20-25 yo man with painful testicular mass
  • Tender testicular mass
  • Elevated serum AFP
  • Elevated serum hCG
  • Poorly-defined, heterogeneous hyperechoic mass on ultrasound
  • Multiple discrete embyoid bodies (combination of both embryonal carcinoma and yolk sac components)
  • Stains positively for cytokeratin, AFP (yolk sac component), and CD30 (embyonal component)

Placental site trophoblastic tumor

  • Infant or young adult
  • Painful small testicular mass
  • Small nontender or minimally painful testicular mass
  • Elevated serum hCG
  • Variable echogenicity
  • No differentiating features on imaging
  • May have vascular flow
  • Solid yellowish mass that resembles uterine tissue
  • Less prominent foci of hemorrhage and ncerosis
  • Predominance of intermediate trophoblast cells (implantation-site type) that invade surrounding blood vessels
  • Paucity of cytotrophoblast and syncytiotrophoblast cells (unlike choriocarcinoma)
  • Stains positively for hPL (diffuse), cytokeratin, AFP, and hCG (patchy)
  • Negative p63 staining

Epithelioid trophoblastic tumor

  • Infant or young adult
  • Painful small testicular mass
  • Small nontender or minimally painful testicular mass
  • Elevated serum hCG
  • Variable echogenicity
  • No differentiating features on imaging
  • May have vascular flow
  • Solid yellowish mass that resembles uterine tissue
  • Less prominent foci of hemorrhage and ncerosis
  • Predominance of intermediate trophoblast cells (implantation-site type) that invade surrounding blood vessels
  • Paucity of cytotrophoblast and syncytiotrophoblast cells (unlike choriocarcinoma)
  • Stains positively for p63 (diffuse), p63, cytokeratin, AFP, and hCG (patchy)
  • Negative hPL staining

Mixed germ cell tumor

  • Typical age at diagnosis and other clinical features based on underlying components
  • Physical exam findings based on underlying components
  • Elevated serum hCG, AFP, and/or PALP dependeing on the underlying compoenents
  • Imaging findings based on underlying components
  • Histopathological findings based on underlying components
  • Variable proportion of choriocarcinoma, embryonal cell carcinoma, yolk sac tumor, seminoma, and/or teratoma tissue
  • May stain positively for any of CD30, hCG, AFP, ALP, c-KIT, CD30, EMA, alpha-1-antitrypsin, PAS diastase, and glycogen depending on underlying compoenents

Carcinoid
(pure neuroendocrine neoplasm)

  • Middle-aged and elderly adult
  • Manifests as a minimally painful, rapidly growing mass
  • May manifest as carcinoid syndrome
  • Tender testicular mass
  • Hydrocele or cryptorchidism
  • Elevated serum and urine 5-HIAA if carcinoid syndrome present
  • Unilateral, well-circumscribed mass without vascular invasion
  • Solid and cystic appearance
  • Mixed echogenicity on ultrasound
  • Irregular calcifications
  • Well-circumscribed, yellowish solid mass
  • Occasional cystic masses
  • Small acini, cord-forming rosettes, prominent cytoplasmic granularity
  • Salt and pepper chromatic pattern
  • Absent features of atypia
  • Neurosecretory granules on electron microscopy
  • Stains positively for cytokeratin, serotonin, chromogranin, synaptophysin, and CD56

PNET
(Ewing's tumor of the testes)

  • 30-50 yo man with rapidly enlarging mass
  • Often metastatic at presentation
  • Palpable, nontender unilateral testicular mass
  • Unremarkable
  • No differentiating features on imaging
  • Vascular flow on Doppler
  • Greyish necrotic mass of immature neural tissue
  • Sheet-like / rosette distribution of small round blue tumor cells
  • Neurosecretory granules on electron microscopy
  • Stains positively for synaptophysin, NSE, chromogranin, CD99, GFAP, FLI1
  • Split of EWS gene on chromosome 22
Sex-cord stromal tumors

Fibroma

  • Middle-aged adult (range 20-70 years) with slowly-growing, painless testicular mass
  • History of nevoid basal cell carcinoma (Gorlin syndrome)
  • Palpable, nontender unilateral testicular mass
  • Unremarkable
  • Isoechoic mass on ultrasound with prominent acoustic shadowing (fibrous component)
  • May be homogeneous or heterogeneous
  • Margins often blended with the tunica albuginea
  • No vascular flow on Dopper
  • Well-circumscribed, often non-encapsulated solid pale yellow mass
  • No hemorrhage, no necrosis
  • Pure fibromatous features of collagenized plaques and spindle cells that synthesize collagen.
  • Low cellularity
  • Mutation in PTCH gene
  • Positive staining for calretinin, inhibin, CD56, CD34, actin, vimectin
  • Usually (but not always) negative staining for S-100, keratin, CD99/MIC-2, and desmin

Granulosa cell tumor

  • Young or middle-aged adult (adult-type) or infant/child (juvenile-type) patient with slowly-enlarging painless testicular mass
  • May manifest with symptoms of metastasis or hormonal secretion (e.g. gynecomastia in estrogen-secreting tumors)
  • Palpable, nontender unilateral testicular mass
  • Unremarkable
  • Hypoechoic mass with solid and cystic appearance on ultrasound (swiss-cheese appearance)
  • Well-circumscribed tumor between the seminiferous tubules
  • May be solid, cystic, of lobular
  • Pseudo-capsule
  • No hemorrhage, no necrosis
  • Elongated grooved nuclei (coffee-bean appearance)
  • Call-Exner bodies
  • Variable atypia
  • Stains positively for calretinin, inhibin, vimentin, actin, and MIC2

Leydig (interstitial) cell tumor

  • Bimodal age distribution
  • Slowly enlarging painless unilateral mass
  • Palpable, nontender unilateral testicular mass
  • Signs of excess estradiol (e.g. gynecomastia)
  • Unremarkable
  • Well-defined, hypoechoic solid mass on ultrasound
  • May have cystic component
  • Irregular calcifications
  • Well-circumscribed, unencapsulated solid mass
  • Yellowish-brown tumor
  • May have cystic, hemorrhagic, or necrotic areas
  • Often dffuse growth of large polygonal Leydig cells, but may have unique patterns of growth
  • Vacuolated cells with marked atypia
  • Reinke crystals
  • Psammoma bodies
  • Mutation in fumarate hydratase
  • Stains positively for inhibin, cytokeratin, calretinin, synaptophysin, vimentin, Melan-A

Sertoli hyperplasia
(Sertoli adenoma, Pick's adenoma)

  • Child or young adult with history of Peutz-Jegher syndrome, androgen insensitivity syndrome, or McCune Albright syndrome
  • Slowly enlarging painless bilateral masses
  • Palpable, nontender bilateral testicular masses
  • Signs of excess estradiol (e.g. gynecomastia)
  • Elevated serum estradiol
  • Elevated anti-Mullerian hormone and inhibin B
  • Reduced androgen concentration
  • Hyperechogenic nodules on ultrasound
  • Well-demarcated yellowish nodules in the testis
  • Unencapsulated nodules composed of Sertoli cells
  • Stains positively for anti-Mullerian hormone, inhibin A, CK8, and CK18
  • Negative staining for AFP, hCG, and p53

Large cell calcifying Sertoli cell tumor

  • Young patient with history of Carney syndrome, Peutz-Jeghers syndrome, or tuberous sclerosis
  • Slowly enlarging painless unilateral/bilateral mass(es)
  • Palpable, nontender unilateral or bilateral testicular mass
  • Signs of excess estradiol (e.g. gynecomastia)
  • Elevated serum estradiol
  • Diffuse and regular (smooth, rounded, large) calcifications
  • Variable appearance on ultrasound
  • Often multiple hyperechogenic regions with strong shadowing
  • Possible increased blood flow
  • Multifocal, well-circumscribed yellowish-grey nodules
  • Absent hemorrhage or necrosis
  • Patterrns (sheet or trabeculae) of large cells and formation of solid tubules
  • Psammoma bodies
  • Charcot Bottcher crystals on electron microscopy
  • Stains positively for inhibin, vimentin, calretinin, S100, and cytokeratin
  • Negative staining for laminin, PALP, AFP, and hCG

Sclerosing Sertoli cell tumor

  • Variable age at presentation (adolescence to elderly)
  • Slowly enlarging painless unilateral mass
  • Palpable, nontender unilateral testicular mass
  • Unremarkable
  • Well-circumscribed hypoechogenic lesion on ultrasound
  • Well-circumscribed, yellowish-grey nodule
  • Absent hemorrhage or necrosis
  • Tubuules and cords of Sertoli cells surrounded by hypocellular collagenous strome (sclerosis)
  • Stains positively for calretinin, inhibin, and vimentin
  • Negative staining for cytokeratin, AFP, and hCG

Sertoli tumor, non-specific

  • Bimodal age districution: either 40-50 year old man or infants with history of Carney syndrome or Peutz-Jegher syndrome
  • Slowly enlarging testicular mass
  • Palpable, nontender unilateral testicular mass
  • Signs of excess estradiol (e.g. gynecomastia)
  • Often unremarkable
  • Elevated serum estradiol may be present, less common
  • Well-circumscribed mass with variable echogenicity
  • Well-circumscribed, yellowish-grey nodule
  • Hemorrhage and necrosis may be present, but uncommon
  • Features of fetal, prepubertal, and adult Sertoli cells present simultaneously
  • Charcot Bottcher crystals on electron microscopy
  • Stains positively for vimentin, cytokeratin, inhibin, S100, chromogranin, synaptophysin, and CD99
  • Negative staining for hCG, AFP, and PLAP

Sertoli-Leylig cell tumor (SLCT)

  • Young adult or phenotypic female with history of androgen insensitivity
  • Slowly enlarging painless unilateral mass
  • Palpable, nontender unilateral testicular mass
  • Signs of excess estradiol (e.g. gynecomastia)
  • Often unremarkable
  • Elevated serum estradiol may be present, less common
  • Abrnomally elevated testosterone among pts with androgen insensitivity
  • Well-circumscribed mass with variable echogenicity
  • Solid mass with intratumoral cysts may be present
  • Heterogeneous, lobulated, encapsulated yellowish solid mass
  • Mass contains combination of Sertoli cells and Leydig cells
  • Poorly differentiated cells (immature tubules of Sertoli cells, large Leydig cells)
  • Stains positively for inhibin, melanA, and CD99
  • Negative staining for EMA, PLAP, and S100

Testicular tumor of andrenogenital syndrome
(testicular adrenal rest tumor)

  • Post-pubertal patient with history of congenital adrenal hyperplasia (CAH)
  • Often asymptomatic, detected during screening in patients with CAH
  • Unremarkable testicular exam
  • Other signs of congenital adrenal hyperplasia
  • Elevated 11-beta-hydroxylase activity
  • Reduced concentrations of AFP, LDH, and hCG
  • Uniform hypoechogenicity on ultrasound
  • Usually multifocal and bilateral lesions
  • Hyperplasia, bilateral lesions in testicular hilum
  • Yellowish nodules
  • Cells resemble adrenocortical cells, no mitoses
  • Normal surrounding tissue
  • Absent Reinke crystals
  • Stains positively for CD56, synaptophysin, and inhibin
  • Negative staining for androgen receptor protein
Other tumors

Lymphoma

  • Elderly patient (>60 years) with history of lymphoma (commonly diffuse large B cell lymphoma)
  • Unilateral or bilateral painless testicular mass
  • Palpable, nontender unilateral or bilateral testicular mass
  • Depends on lymphoma subtype
  • Diffuse infiltration
  • Hypoechoic solid masses on ultrasound
  • Hypervascularity on Doppler ultrasound
  • Whitish-tan colored mass
  • Large, pleomorphic malignant cells
  • Seminiferous tubules may be spared or undergo sclerosis
  • Vascular invasion
  • Stains positively for CD45
  • Depends mainly on lymphoma subtype
  • Usually negative staining for PLAP and SALL4

Angiosarcoma

  • Bimodal age distribution
  • Young man with history of teratoma or elderly man with history of radiation or chronic hydrocele
  • Painless/painful testicular mass
  • Tender or non-tender testicular mass
  • Low-grade fever
  • Scrotal swelling
  • Flank pain
  • Hydrocele
  • Often unremarkable
  • Hypervascularity on Doppler ultrasound
  • Solid vascular lesion
  • Classical pattern of proliferating anastomosing blood-filled channels
  • 2 patterns: solid (sheet proliferation without lumen) and primitive (small lumina filled withblood)
  • Stains positively for CD31, CD34, lectin, and factor VIII-related antigen
  • Negative staining for pancytokeratin, PLAP, CD45, CD68, CAM5.2, and AE1/AE3

Chondrosarcoma

  • Young or middle-aged adult with history of teratoma
  • Painless testicular mass
  • Palpable, non-tender, heterogeneous mass
  • Often unremarkable
  • Lobulated mass
  • Firm, grey mass with irregular lobulations
  • Cartilaginous (chondroid) matrix surrounded by fibrovascular bands
  • Most have non-cartilagenous components (rarely pure)
  • Stains positively for S100

Hemangioma

  • Painless testicular mass among pts of any age
  • Palpable, non-tender, homogeneous mass
  • Often unremarkable
  • Homogeneous hypoechoic mass
  • Hypervascularity on Doppler ultrasound
  • Well-defined hemorrhagic mass
  • Red blood cells in tubules
  • Stains positively for CD31, CD34, FLI1, and factor VIII-related antigen
  • Negative staining for pancytokeratin, AE, keratin, PLAP, and EMA

Mesothelioma

  • Middle aged man with painless testicular mass and history of hydrocele or exposure to asbestos
  • Palpable, non-tender testicular mass
  • Scrotal swelling
  • Often unremarkable
  • Thickening of tunica vaginais
  • Solid paratesticular mass
  • Hydrocele
  • May be benign or malignant
  • Papillary patterns of uniform epithelioid cells with fibrovacular core
  • Polygonal cells with microvilli on electron microscopy
  • Psammoma bodies
  • Benign: stains positively for p53 (focal) and CEA
  • Malignant: Stains positively for calretinin, WT1, EMA, thrombomodulin, CK5, CK6, CK7 and negative staining for CEA and CK20

Plasmacytoma

  • Adult (of any age) with concurrent or history of plasma cell neoplasia (commonly multiple myeloma)
  • Symptoms of multiple myeloma (e.g. fatigue, back pain)
  • Testicular exam unremarkable
  • Lab findings of plasmacytosis (e.g. anemia, elevated creatinine, hypercalcemia)
  • No specific lab finding for testicular involvement
  • Poorly circumscribed hypoechoic lesions on ultrasound
  • Hypervascularity on Doppler ultrasound
  • Large, tan-yellow mass
  • Areas of hemorrahge
  • Atypical plasma cells
  • Tubule effacement in the center and tubule sparing in the periphery
  • Positive staining for EMA, CD45, CD79am CD138, kappa or lambda light chains, and other plasma cell markers

AIDS-related testicular cancer

  • Commonly testicular lymphoma or germ cell tumor
  • Patient with history of AIDS presents with testicular swelling or pain
  • Systemic manifestations of underlying malignancy
  • Palpable testicular mass that may be tender or non-tender
  • Depends on underlying malignancy
  • Depends on underlying malignancy
  • Depends on underlying malignancy
  • Depends on underlying malignancy
Non-neoplastic mass

Adrenal cortical rest

  • Usually asymptomatic (incidental finding)
  • Young man with scrotal swelling and dull pain
  • History of congenital adrenal hyperplasia (hydroxylase deficiency)
  • Scrotal swelling
  • May be unremarkable
  • If secretory, elevated concentration of adrenal hormone
  • Heterogeneous, well-circumscribed hypoechoic mass on ultrasound
  • No or minimal vascularity on Doppler
  • No distinguishing features
  • Well-circumscribed, small, round, orange-yellow nodule
  • Adrenal cortical tissue with absence of adrenal medullary tissue
  • Positive staining for markers of cortical adrenal tissue

Chylocele

  • Scrotal swelling in a man with history of filariasis / elephantiasis
  • Scrotal swelling
  • Negative trans-illumination test
  • Unremarkable
  • Fluid collection surrounding the testes
  • Milky chylous fluid (not waterry) on aspiration
  • Usually no evidence of microfliariae in chylous fluid
  • Abundant leukocytes
  • N/A

Cystic dysplasia

  • Young child with history of renal agenesis / dysplasia
  • May be unilateral or bilateral, painless testicular mass
  • Palpable, non-tender testicular mass
  • Unremarkable
  • Irregular cystic spaces witht varying sizes
  • Absence of solid or vascular components
  • Varying cystic spaces
  • Formation of incomplete connective tissue septa
  • Cells resembling the normal adult rete testes
  • N/A

Dermoid cyst

  • Young or middle aged adult with slowly growing painless mass
  • Ruptured cyst may manifest with scrotal swelling, erythema, and pain
  • Palpable, nontender unilateral testicular mass
  • Usually heterogeneous enlargement
  • Unremarkable
  • Onioin-skin appearance on ultrasound
  • Target-shape lesions with halo of hypoechonicity and central hyperechogenicity on ultrasound
  • No vacular flow on Doppler
  • Mature epithelial tissue
  • May have hair (similar to teratoma)
  • Keratin filled cyst
  • Epidermal epithelium surrounded by pilosebaceious units
  • Formation of lipogranulomas and microcalcifications
  • Absence of atypia
  • Absence of any mutation (normal 12p)
  • Stains positively for cytokeratin

Epidermoid cyst
(keratocyst)

  • 10-40 yo
  • Painless slowly growing testicular mass
  • Ruptured cyst may manifest with scrotal swelling, erythema, and pain
  • Palpable, non-tender testicular mass
  • Usually heterogeneous enlargement
  • Unremarkable
  • Onioin-skin appearance on ultrasound
  • Target-shape lesions with halo of hypoechonicity and central hyperechogenicity on ultrasound
  • No vacular flow on Doppler
  • Absence of dermal structures, such as hair, sebaceous glands etc. (found in dermoid cyst)
  • Cyst with white keratin debris
  • Lined by squamous epithelium
  • Laminated keratin
  • Granuloma when cyst ruptures
  • Absence of any mutation (normal 12p)

Granulomatous orchitis

  • 40-60 yo man with sudden-onset testicular tenderness and mass formation
  • History of infection, sarcoidosis, or testicular trauma
  • Tender testicular mass
  • Fever
  • Unremarkable
  • Solid hypoechoic mass
  • Solid nodule
  • Lymphocytic infiltration and formation of giant cells and macrophages
  • Not true granuloma
  • N/A

Hematocele

  • Scrotal mass in patients with history of testicular trauma, torsion, or increased bleeding tendency
  • Scrotal swelling
  • Negative trans-illumination test
  • Unremarkable
  • Fluid collection surrounding the testes
  • Bloody fluid on aspiration
  • N/A

Hydrocele

  • Scrotal mass in patients with history of testicular trauma or epidymitis
  • Scrotal swelling
  • Positive trans-illumination test
  • Unremarkable
  • Fluid collection surrounding the testes
  • Clear fluid on aspiration
  • N/A

Macroorchidism

  • History of fragile X syndrome, FSH secreting adenoma
  • Large testicle (the testicle itself is large)
  • Signs of underlying disease
  • May have elevated hormone concentration (e.g. FSH) if secretory adenoma
  • Large testicle, but normal architecture
  • Normal testicular findings
  • N/A

Malakoplakia

  • Young man with long-standing symptoms of orchi-epididymitis (pain, scrotal swelling)
  • History of immunosuppression
  • Palpable, tender testicular mass
  • Scrotal swelling
  • Erythema
  • Positive culture results for bacterial infection (chronic inflammation)
  • Hypoechogenic mass on ultrasound
  • Increased vascularity on Doppler
  • Soft yellow friable plaques (malakos=soft | plakos=plaques)
  • Von Hansemann cells (large cells with abundant eosinophilic cytoplasm) and Michaelis-Gutmann bodies (intracytoplasmic inclusion bodies with owl eyes appearance)
  • N/A

Testicular vasculitits

  • Middle aged man with history of polyarteritis nodosa (less commonly granulomatosis with polyangiomatosis, Henoch-Schonlein purpura, or giant cell arteritis)
  • History of HBV or HIV

Painful testicular mass with intra-testicular hemorrhage

  • Symptoms of underlying vasculitis
  • Signs of underlying vasculitis
  • Palpable, tender testicular mass
  • Scrotal swelling if vasculitis includes extratesticular structures
  • Unremarkable
  • Heterogeneous, hypoechogenic lesion on ultrasound
  • Inreased intralesional vascularity on Doppler
  • Soft, dark red lesion with areas of hemorrhage
  • Fibrinoid necrosis
  • Vascular wall fibrosis
  • N/A

Fibrous proliferation
(paratesticular fibrous pseudotumor)

  • Patients of all ages (peak during young adulthood)
  • Slowly growing painless unilateral scrotal masss
  • History of genitourinary infection or trauma
  • Palpable, non-tender scrotal mass
  • Unremarkable
  • Paratesticular mass between tunica layers
  • Hypoechogenic solid mass on ultrasound
  • No vascularity on Doppler
  • Whitish mass with multinoduular thickening
  • Collagen-rich fibrous tissue with increased fibroblasts
  • Dystrophic calcifications
  • No hemorrhage or necrosis
  • Stains positiively for actin and keratin
  • Negative staining for ALK-1, beta-catenin

Polyorchism
(supranumerary testes)

  • Often asymptomatic (incidental finding)
  • Young patient with scrotal pain, swelling, hydrocele, varicocele
  • Patients may present with testicular torsion
  • Palpable, non-tender scrotal mass
  • Scrotal swelling
  • Testicular torsion manifests with excruciating testicular or pelvic pain, erythema, and swelling
  • Unremarkable
  • Isoechogenic scrotal mass
  • Normal testicular tissue
  • N/A

Spermatocele

  • Young or middle aged adult with painless testicular or scrotal mass
  • Homogeneous palpable non-tender testicular or scrotal mass
  • Unremarkable
  • Well-defined, homogeneous,, hypoechoic mass on ultrasound
  • Increased vascular flow on Doppler
  • Splenic tissue (red with clear boundaries)
  • Occasional calcification, thrombi, or fibrosis
  • N/A

Splenogodal fusion syndrome
(ectopic scrotal spleen)

  • Child or adolescent with painless, left scrotal mass (not right) and history of perimelia (continuous subtype) or cardiac defect (discontinuous subtype)
  • Homogeneous palpable non-tender scrotal mass
  • Unremarkable
  • Well-defined, homogeneous,, hypoechoic mass on ultrasound
  • Increased vascular flow on Doppler
  • Splenic tissue (red with clear boundaries)
  • Occasional calcification, thrombi, or fibrosis
  • N/A

Varicocele

  • Often asymptomatic
  • Dull or sharp testicular pain that increases with standing or physical activity and improves when lying down
  • History of infertility
  • Scrotal mass and swelling
  • Often left-sided
  • Dilated, tortuous veins
  • "Bag of worms" sensation upon palpation
  • Unremarkable
  • On ultrasound, CT/MRI, and venography, apperance of dilated pampiniform plexus veins with serpentine appearance is diagnostic
  • Flow reversal (reflux) with Valsalva maneuver on Doppler
  • Enhancement following administration of gadolinium on MRI
  • Testicular atrophy in advanced cases
  • N/A

Testicular torsion

  • Excruciating, acute, sharp testicular pain that radiates to the pelvis and abdomen
  • Testicular swelling and pain
  • Scrotal swelling and tenderness
  • Unremarkable
  • Focal/diffuse hypoechogenicity on ultrasound
  • No blood flow on Doppler (vs. increased flow in infections)
  • Scrotal wall thickening
---
  • N/A
Scrotal

Brucellosis

  • Patient with history of exposure to cattle/sheep/goat/swine or animal products (milk, meat, cheese) presents with acute scrotal pain and swelling
  • Undulant fever and night sweats (characteristic wet hay odor)
  • Relapses common with similar symptoms
  • Tender testicular mass
  • Fever
  • Hydrocele
  • Elevated WBC count
  • Positive serum STA test for brucellosis
  • Elevated Brucella IgM and IgG antibodies
  • Urine PCR positive for Brucella
  • Focal/diffuse hypoechogenicity on ultrasound
  • Focal/diffusre increased blood flow on Doppler
  • Scrotal wall thickening
  • Granulomatous inflammation with lymphocytic infiltration
  • Urethral Gram stain demonstrates Gram-negative diplococci

Brucellosis

  • Patient with history of exposure to cattle/sheep/goat/swine or animal products (milk, meat, cheese) presents with acute scrotal pain and swelling

Undulant fever and night sweats (characteristic wet hay odor)

  • Relapses common with similar symptoms
  • Tender testicular mass
  • Fever
  • Hydrocele
  • Elevated WBC count
  • Positive serum STA test for brucellosis
  • Elevated Brucella IgM and IgG antibodies
  • Urine PCR positive for Brucella spp.
  • Focal/diffuse heterogeneous, hypoechoic intratesticular mass on ultrasound
  • Focal/diffuse increased blood flow on Doppler
  • Scrotal wall thickening
  • Abscess formation at diagnosis is common
  • Grey-white mass suggestive of testicular atrophy
  • Granulomatous inflammation with lymphocytic infiltration
  • N/A

Gonorrhea infection

  • Patient with history of unprotected sexual intercourse presents with unilaterla testicular pain, swelling, and fever
  • May be either acute or chronic
  • Tender testicular mass
  • Fever
  • Hydrocele
  • Elevated WBC count
  • Gram-negative diplococci on urethral Gram stain
  • Urine PCR positive for Gonorrhea
  • Focal/diffuse hypoechogenicity on ultrasound
  • Focal/diffusre increased blood flow on Doppler
  • Scrotal wall thickening
  • Granulomatous inflammation with lymphocytic infiltration
  • Urethral Gram stain demonstrates Gram-negative diplococci

Histoplasma infection

  • Chronic testicular enlargement
  • Patients may have systemic manifestations of histoplasmosis
  • Tender/non-tender testicular mass
  • Elevated WBC count and eosinophilia may be present (may be normal in chronic cases)
  • Focal/diffuse hypoechogenicity on ultrasound
  • Focal/diffusre increased blood flow on Doppler
  • Scrotal wall thickening
  • Caseating granuloma with giant cells
  • Yeast observed on silver stain

Mumps

  • Post-pubertal man with recent manifestations of mumps (e.g. parotiditis, pancreatitis, arthritis, myocarditis, meningoencephalitis) presents with acute, unilateral painful testicular mass
  • Tender testicular mass
  • Hydrocele
  • Fever
  • Parotiditis
  • Rash
  • Elevated WBC
  • Elevated paramyxovirus IgM and IgG
  • Urine PCR positive for paramyxovirus
  • Focal/diffuse hypoechogenicity on ultrasound
  • Focal/diffusre increased blood flow on Doppler
  • Scrotal wall thickening
  • Non-specific interstitial edema, degenerative changes, vascular dilation
  • Lymphocytic infiltration
  • N/A

Pyogenic epididymo-orchitis

  • Patient with history of unprotected sexual intercourse presents with acute scrotal swelling and pain
  • Tender testicular mass
  • Fever
  • Hydrocele
  • Elevated WBC
  • Bacterial growth on urethral swab specimin (usually E. coli)
  • Urine PCR positive for offending bacterial agent
  • Focal/diffuse hypoechogenicity on ultrasound
  • Focal/diffusre increased blood flow on Doppler
  • Scrotal wall thickening
  • Abscess formation in advanced cases
  • Non-specific interstitial edema, degenerative changes, vascular dilation
  • Lymphocytic infiltration
  • Grey-white mass suggestive of testicular atrophy
  • N/A

Syphilis

  • Patient with long history of unprotected sexual intercourse presents with painful testicular swelling (tertiary syphilis)
  • Often manifests as epidimo-orchitis that is resistant to conventional antibiotic therapy
  • May have other systemic symptoms of tertiary syphilis
  • Irregular tender testicular mass
  • Thickened epididymis
  • Hydrocele
  • Positive syphilis serology (suggest latent syphilis)
  • VDRL may be either positiive or negative
  • Positive dark field microscopy from lesion content
  • Heterogeneous hypoechogenicity on ultrasound
  • Solid and cystic appearance with areas of necrosis
  • May have increased blood flow on Doppler
  • Discrete gummas on gross pathology
  • Microscopic features of gumma (interstitial inflammation, lymphocytic and plasma cell infiltration, obliterative endorteritis (endoarteritis obliterans), perivascular cuffing)
  • Spirochetes may occasionally be observed
  • May stain positively for silver-based methods (Warthin-Starry stain, Wright stain, Levaditi stain)

Tuberculosis

  • Patient with history of tuberculosis presents with painless mass or chronically dull testicular discomfort
  • Positive constitutional symptoms (weight loss, malaise)
  • May be isolated or may be associated with other systemic symptoms of tuberculosis (e.g. lymphadenopathy, pulmonary lesions, renal involvement)
  • May have concomitant involvement of other GU organs (e.g. prostate, seminal vesicles)
  • Irregular testicular mass
  • May be tender or non-tender
  • Thickened scrotal skin
  • Hydrocele
  • Ejaculum may demonstrate positive acid fast bacilli (AFB) staining
  • Heterogeneous hypoechogenicity on ultrasound
  • No/minimal blood flow on Doppler
  • Hypointense lesion on T1WI MRI and hyperintense on T2WI MRI
  • Possible abscess formation
  • Caseating necrosis
  • Epithelioid cells and lymphocytic infiltration with presence of multinucleated giant cells
  • Positive acid fast bacilli staining


References

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