Role of multiparametric ultrasound in testicular focal lesions and diffuse pathology evaluation, with particular regard to elastography: Review of literature

Testicular Two-Dimensional Shear Wave Elastography, Peak Systolic Velocity, Volume and Epididymal Thickness: Establishment of Normal Reference Values and Discrimination From Orchitis in Adult Patients Presenting With Acute Scrotal Pain

Aim

To establish normal testicular stiffness reference values using two-dimensional shear wave elastography (2D-SWE) and together with volume, PSV and epididymal thickness to discriminate from inflammatory pathology, specifically orchitis, in adult patients presenting with acute scrotal symptoms.

Materials and Methods

Retrospective analysis of patients referred for scrotal ultrasonography for investigation of scrotal pain or discomfort. Evaluation of 494 testes included B-Mode, colour and pulsed wave (PW) Doppler, testicular volume, peak systolic velocity (PSV) and the median elasticity (SWE). Statistical evaluation was performed to identify stiffness threshold values to rule in normal.

Results

In normal testes, the median volume, PSV and SWE were 13.8 mL (10.3-17.2 mL), 6.3 cm/s (4.9-7.7 cm/s) and 2.5 kPa (2.15-2.85 kPa). The right testes were larger (right 14.4 mL, left 13.2 mL, p < 0.05) with both decreasing in size and increasing in stiffness with increasing age (> 60 years, p < 0.05). In patients with normal testes but extra-testicular pathology, the median volume, PSV and SWE were 13.3 mL (9.75-16.8 mL), 6.3 cm/s (4.55-8.05 cm/s) and 2.8 kPa (2.3-3.3 kPa), respectively. In patients with orchitis, the median volume, PSV and SWE were 18.1 mL (11.5-24.7 mL), 7.9 cm/s (2.8-13 cm/s) and 5.4 kPa (3.4-7.4 kPa), respectively. The PSV and SWE values in this group were age- and side-independent. Differentiating normal testes from orchitis using SWE had AUC, accuracy, sensitivity and specificity of 0.91, 0.801, 0.892 and 0.792.

Conclusion

Normal adult testes have a median stiffness of 2.5 kPa. A threshold cut-off median value of 3.6 kPa suggests the diagnosis of an inflammatory testicular pathology such as orchitis, with AUC, accuracy, sensitivity and specificity of 0.922, 0.840, 0.928 and 0.831. Caution is required in the presence of extra-testicular pathology, where there is a wider range of SWE and other parameters.

Development and Validation of an Ultrasound Imaging Algorithm for Structured Reporting in Testicular Pathology

Background/Objectives: Testicular ultrasound (US) imaging is a critical modality for diagnosing a variety of testicular pathologies, including malignancies. This study aimed to develop and validate a standardized diagnostic algorithm to enhance diagnostic accuracy and consistency in evaluating testicular lesions, particularly for distinguishing between benign and malignant conditions. Methods: The algorithm was applied retrospectively to 110 testicular imaging cases, including 90 abnormal and 20 normal cases, analyzed by three radiologists with varying experience levels. Key diagnostic features, including lesion morphology, vascularity, and echotexture, were evaluated to guide the differentiation process. Results: demonstrated high diagnostic accuracy, with sensitivity reaching 100% for detecting abnormal cases and specificity ranging between 80% and 95%. In distinguishing benign from malignant lesions, the algorithm achieved an area under the curve (AUC) of up to 0.917, with specificities exceeding 93%. Notably, strong inter-rater agreement was observed, underscoring the algorithm's reliability across different expertise levels. While the algorithm significantly improved standardization and diagnostic performance, some variability in sensitivity for less experienced evaluators highlights the need for further refinement. Conclusions: This study shows that the proposed diagnostic algorithm is an effective tool for testicular US, facilitating accurate and reproducible assessments, which are crucial for early detection and optimal management of testicular pathologies.

Bilateral segmental testicular infarction secondary to iron deficiency anemia: a case report

Segmental testicular infarction (STI) is an idiopathic testicular disease with a low incidence. Accurately diagnosing and treating this disease presents a challenge for clinicians. Iron deficiency anemia (IDA) is a relatively common blood disorder and is generally accompanied by thrombocytosis, which increases the risk of thrombosis. In the present study, we report a 38-year-old man who suffered from a rare bilateral STI, which may be related to IDA. After conservative treatment and timely administration of iron supplementation, we observed an improvement in the patient's IDA and bilateral STI. Ultrasound, magnetic resonance imaging, and laboratory tests helped us to accurately diagnose the disease and avoid unnecessary surgery. Following a month of follow-up, continuous ultrasound monitoring showed that the patient's lesions had completely disappeared, with no indications of recurrence. Therefore, ultrasound is a useful tool for the diagnosis and continuous monitoring of this type of disease.

MRI fingerprints in testes of infertile men with clinical varicocoele: A narrative review

BACKGROUND

Varicocoele represents the most common cause of male infertility, although most men with varicocoele remain fertile. Currently, no specific or sufficiently reliable criteria exist to identify patients who would benefit from varicocoele treatment to prevent impaired spermatogenesis. Emerging evidence suggests that magnetic resonance imaging (MRI) may provide valuable noninvasive insights into the mechanisms of testicular parenchymal damage in infertile men with clinical varicocoele.

OBJECTIVES

The aim of this narrative review was to discuss the applications of advanced MRI techniques, including diffusion-weighted imaging (DWI), diffusion tensor imaging (DTI), dynamic contrast-enhanced MRI (DCE-MRI), and proton magnetic resonance spectroscopy (1H-MRS) in the assessment of testes in infertile men with clinical varicocoele and their role in uncovering the complex mechanisms impairing fertility.

MATERIALS AND METHODS

PubMed database was searched for original articles published during 2010-2024.

RESULTS

Advanced MRI techniques reveal alterations in apparent diffusion coefficient (ADC), fractional anisotropy (FA), intratesticular vasculature, and testicular metabolites in men with varicocoele compared to healthy controls. Decrease in testicular ADC and FA is detected in men with varicocoele, indicating microstructural abnormalities. Testes with varicocoele enhance fast and strongly during the early phases of dynamic imaging, providing a valuable insight into tissue perfusion. Proton MR spectra of infertile testes with varicocoele show a decrease in concentrations of choline, myoinositol, Glx complex, and lipids, signifying metabolic signatures of deranged spermatogenesis.

CONCLUSIONS

Preliminary findings from advanced MRI techniques, including DWI, DTI, DCE-MRI, and 1H-MRS have demonstrated potential as noninvasive biomarkers of impaired spermatogenesis, by evaluating testicular microstructure, perfusion, and biochemical milieu.

Management of Small Testicular Masses: A Delphi Consensus Study

BACKGROUND AND OBJECTIVE

The majority of small testicular masses (STMs) are benign and therefore radical orchidectomy (RO) may represent overtreatment. In appropriately selected patients, surveillance or testis-sparing surgery (TSS) is an alternative option to preserve testicular function. Since there are no clear guidelines, we aimed to develop consensus recommendations on the management of STMs.

METHODS

A four-round Delphi study was conducted by 24 experts representing multiple subspecialties to reach consensus. Consensus was defined as ≥75% of the participants scoring within the same 3-point grouping (1-3, disagree; 4-6, uncertain; 7-9, agree.). The first two rounds were survey based, the third round was an online meeting to discuss uncertainties from the first two rounds, and the fourth round was a review of the final consensus statements from rounds 1-3.

KEY FINDINGS AND LIMITATIONS

The initial survey consisted of 126 statements. Following the four rounds of assessment, a list of 96 statements were produced, which focused on clinical and biochemical assessment, colour Doppler ultrasound (CDUS) characteristics, and management options including surveillance, RO, and TSS. Management should be personalised according to risk factors for testicular cancer, fertility status, uni- or bilateral tumours, status of the contralateral testis, and CDUS characteristics, with solid lesions displaying vascularity and hypoechogenicity being more suspicious for malignancy. The consensus statements are prone to a bias, and some may not reflect robust, randomised evidence.

CONCLUSIONS AND CLINICAL IMPLICATIONS

The expert panel has produced consensus recommendations on the management of STMs, and TSS should be considered in patients with an STM. The recommendations could aid in the dissemination of best practice.

PATIENT SUMMARY

There are no clear guidelines on the management of small testicular masses. Excising the whole testicle (radical orchidectomy) with a small or an indeterminate mass may affect fertility and hormonal function. A panel of experts was formed, and consensus recommendations were developed on how to deal with small and indeterminate testicular masses, which include surveillance or testis-sparing surgery.

Follow-up of non-palpable testicular incidentalomas under 1 cm: does growth rate differentiate malignant and non-malignant lesions?

OBJECTIVE

To determine whether small, incidentally detected testicular lesions can be safely followed up, by assessing growth rate and volume threshold for benign vs. malignant lesions.

METHODS

This retrospective observational study includes a consecutive series of 130 testicular incidentalomas < 1 cm and with negative tumour markers identified from October 2001 to November 2022, which were initially followed up with ultrasound. A total of 39 cases proceeded to surgery during the study period, either due to lesion growth (n = 28) or patient preference/recommendation by the referring urologist (n = 11). For the lesions that were growing, specific growth rate (SGR) and doubling time (DT) were calculated assuming an exponential growth pattern. In addition, the velocity of increase of the average diameter (∆Dav) and of the maximum diameter (∆Dmax) were calculated.

RESULTS

Of the 130 nodules that were initially followed up, six disappeared, eight were reduced in size, eighty-eight were stable, and twenty-eight increased in size. For operated nodules all 18 malignant tumours, 8/9 benign tumours, and 2/12 surgically proved non-neoplastic lesions were growing. The best cut-off values of the growth indicators to differentiate between malignant and non-malignant histology were 3.47 × 10-3%volume/day, ≤ 179 days, > 10 × 10-3 mm/day, and > 5 × 10-3 mm/day for SGR, DT, ∆Dmax, ∆Dav, respectively.

CONCLUSIONS

Malignant and non-malignant small incidentalomas can be effectively differentiated based on growing parameters, even though overlap exists. An increase of the maximum diameter of about 1 mm and 2 mm in three months and in six months, respectively, suggests malignancy.

CLINICAL RELEVANCE STATEMENT

Growing parameters allow an educated assessment of benign and malignant small testicular incidentalomas. Non-aggressive management is justified and safe when follow-up includes self-examination and tumour marker assessment to reduce the risk of interval tumour growth.

KEY POINTS

Small, non-palpable and asymptomatic testicular nodules < 1 cm are unexpectedly discovered during scrotal ultrasound. Growth indicators estimate the potential malignancy, even though overlap with non-malignant lesions exists. Non-growing incidentalomas can be safely followed up.

Shear Wave Elastography Evaluation of Testicular Stiffness in Dogs Affected by Testicular Pathology

Shear wave elastography (SWE) is an advanced ultrasound technique that assesses tissue stiffness by measuring shear wave speed (SWS) produced after an acoustic impulse. It includes bidimensional (2D-SWE) and focal point (pSWE) methods, allowing qualitative and quantitative analysis of tissue stiffness. This study aimed to describe the elastographic features of testicular abnormalities in dogs, supported by histological findings. Eighteen dogs with testicular abnormalities underwent B-mode ultrasound, power and color Doppler ultrasound, 2D-SWE, and pSWE before orchiectomy. Five cryptorchid testes were excluded and thirty-one testes (12 normal, 7 with leydigomas, 6 with seminomas, 1 with a round cell tumor, and 5 with orchitis) were examined. Normal testes, lesions, and adjacent healthy tissues (no evident ultrasound changes, NEUC) were sampled. Testicular abnormalities presented SWS values of 1.05-4.89 m/s (2D-SWE) and 1.35-5.31 m/s (pSWE). Significant differences were observed among normal testes, NEUC areas, and those with orchitis, leydigomas, and seminomas by both 2D-SWE and pSWE. Normal testes were significantly softer than ones with leydigomas, seminomas, and orchitis, and NEUC areas also had different SWS values compared to those with tumors and orchitis (p < 0.05). However, SWE techniques lacked specificity in differentiating between orchitis and tumors. Diagnostic accuracy of SWE techniques for testicular lesions remains challenging and requires further investigation to fully address its clinical potential.

Abdominopelvic imaging in the follow-up of testicular germ-cell tumors in adults: recommendations of the Scrotal and Penile Imaging Working Group of the European Society of Urogenital Radiology

OBJECTIVES

The Scrotal and Penile Imaging Working Group (SPIWG) of the European Society of Urogenital Radiology (ESUR) aimed to formulate recommendations on the imaging modalities and minimal technical requirements for abdominopelvic imaging in the follow-up of adult patients treated for testicular germ-cell tumors (TGCT).

METHODS

The SPIWG members performed an extensive literature search, reviewed the current clinical practice, and reached a consensus based on the opinions of experts in the field.

RESULTS

Recurrence in patients treated for TGCT mainly occurs in retroperitoneal lymph nodes (LNs). Abdominopelvic CT and MRI are equivalent assessing retroperitoneal LNs. MRI has the advantage of avoiding radiation exposure, and moreover, diffusion-weighted images (DWI) may increase the detection rates without the need for contrast administration. In patients treated for stage I TGCT, the ESUR-SPIWG recommends MRI over CT for the detection of retroperitoneal LNs during the follow-up after treatment. CT, however, remains the follow-up imaging of choice in patients with advanced disease. When MRI is used, the recommended minimal requirements are at least one high-quality anatomical sequence (T1-WI or T2-WI) in axial and coronal planes, and DWI in the same axial plane, ≤ 4 mm contiguous slices from the diaphragm to the perineum. When CT is used, the recommended minimal requirement is a standard-dose contrast-enhanced CT in the portal-venous phase, scanned from the diaphragm to the perineum.

CONCLUSIONS

In this paper, the ESUR-SPIWG provides recommendations on the imaging modalities and minimal technical requirements for abdominopelvic imaging in the follow-up of adult patients treated for TGCT.

KEY POINTS

Question There are no recommendations on the preferred imaging modality or scan sequences required for abdominopelvic imaging in the follow-up after treatment for testicular cancers. Findings The European Society of Urogenital Radiology Scrotal and Penile Imaging Working Group (ESUR-SPIWG) provides recommendations for abdominopelvic imaging in follow-up after treatment for testicular cancers. Clinical relevance Recurrence of testicular germ-cell tumors mainly occurs in retroperitoneal lymph nodes. Both CT and MRI provide similar morphological assessments, but radiation exposure can be avoided by using MRI instead of CT.

Updates on Imaging of Common Urogenital Neoplasms

Urogenital neoplasms represent some of the most common malignancies [...].

Elastography of the Male Pelvic Region-Perspectives on Malignant Lesions

Ultrasound elastography is widely used to assess tissue stiffness for lesion characterization, including differentiation between benign and malignant lesions. This study focuses on the use of elastography in the male pelvis, including the prostate, testicles, and rectum, by comparing elastography types (shear wave and strain). This article provides a summary of the existing literature on the use of elastography in the male pelvic region and outlines the clinical perspective. Ultrasound elastography is a good technique for evaluating and monitoring lesions in the male pelvic region.

Assessment of testicular stiffness in fertile dogs with shear wave elastography techniques: a pilot study

Ultrasound of the testes is important in the evaluation of breeding dogs, and recently advanced techniques such as Shear Wave Elastography (SWE) have been developed. This study focused on evaluation of normal testicular stiffness in healthy and fertile male dogs, employing both qualitative (2D-SWE) and quantitative (pSWE, 2D-SWE) techniques. Nineteen dogs of various medium-large breeds aged 3.39 ± 2.15 years, and with a history of successful reproduction were included after clinical, B-mode and Doppler ultrasound of testes and prostate, and semen macro and microscopic evaluations. pSWE involved square regions of interest (ROIs) placed at six different points in the testicular parenchyma, while 2D-SWE depicted stiffness with a color scale ranging from blue (soft) to red (stiff), allowing a subsequent quantification of stiffness by the application of 4 round ROIs. The results showed a mean Shear Wave Speed (SWS) of 2.15 ± 0.39 m/s using pSWE, with lower values above the mediastinum compared to below, and in the center of the testis compared to the cranial and caudal poles. 2D-SWE demonstrated a uniform blue pattern in the parenchyma, and a mean SWS of 1.65 ± 0.15 m/s. No significant differences were found between left and right testes, above and below the mediastinum, or among breeds. No correlations were observed between mean SWS and body condition score, age, testicular and prostatic volume. Weight was positively correlated with mean SWS only by 2D-SWE. By performing semen analysis and enrolling only healthy and fertile adult dogs, we ensured both structural and functional integrity of the testes. This pilot study represents a valuable baseline data for testicular stiffness by both pSWE and 2D-SWE with a Mindray US machine in medium-large sized healthy and fertile dogs, pointing out the potential role of SWE in the non-invasive fertility assessment and management of breeding dogs.

Multiparametric ultrasound-based assessment of overt hyperthyroid diffuse thyroid disease

Introduction

Hyperthyroidismis a prevalent condition affecting global populations, with an overall prevalence of 1.2%. Our research aimed to establish a systematic diagnostic approach using multiparametric ultrasound (MPUS) to diagnose hyperthyroid diffuse thyroid disease (DTD).

Methods

We conducted a retrospective study from June 2021 to June 2023 at a specialized endocrinology center in Timisoara, Romania, enrolling subjects presenting with clinical hyperthyroidism. Using the Mach 30 Aixplorer ultrasound equipment, evaluations were performed initially in B-mode US, followed by Color Doppler and Spectral Doppler measurements, and finally, 2D Shear wave elastography (SWE).

Results

From the 218 patients analyzed, the diagnosis of DTD with hyperthyroidism was confirmed through biochemical assessment, subgrouping various pathologies such as subacute thyroiditis, Graves' disease, painless thyroiditis, Hashimoto's thyroiditis, iatrogenic, as well as healthy controls. In the first step, B-mode hypoechogenicity had an AUC of 0.951 for DTD detection. In the second step, the peak systolic velocity differentiated Graves' disease with a median of 42.4 cm/s and an AUC of 1. Lastly, the third step consisted of SWE evaluation, revealing a mean elasticity index in the SAT subgroup significantly higher from other subgroups (p<0.001) with an AUC of 1.

Conclusion

Our study offers a step-by-step evaluation algorithm for DTD diagnosis, with a very good overall diagnostic performance (AUC of 0.946).

Multiparametric Ultrasound for Diagnosing Testicular Lesions: Everything You Need to Know in Daily Clinical Practice

BACKGROUND

Ultrasonography (US) represents the gold standard imaging method for the assessment of testicular lesions (TL). The gray-scale (GSUS) and color-Doppler (CDUS) ultrasound examination allow sonographers to investigate the size, margins, echotexture, and vascular features of TLs with the aim to differentiate benign from malignant lesions. Recently, the use of contrast-enhanced US (CEUS) and sonoelastography (SE) has led to further improvements in the differential diagnosis of TL. Although GSUS and CDUS are often sufficient to suggest the benign or malignant nature of the TL, CEUS can be decisive in the differential diagnosis of unclear findings, while SE can help to strengthen the diagnosis. The contemporary combination of GSUS, CDUS, CEUS, and SE has led to a new diagnostic paradigm named multiparametric US (mp-US), which is able to provide a more detailed characterization of TLs than single techniques alone. This narrative and pictorial review aimed to describe the mp-US appearance of several TLs.

METHODS

An extensive Medline search was performed to identify studies in the English language focusing on the mp-US evaluation of TLs.

RESULTS

A practical mp-US "identity card" and iconographic characterization of several benign and malignant TLs is provided herein.

CONCLUSIONS

The mp-US characterization of TL reported herein can be useful in daily clinical practice.

Cytological spectrum of testicular malignancies with histopathological correlation: A retrospective analysis

BACKGROUND

Testicular malignancy is the most common solid organ cancer occurring in young men. The most common testicular malignancy is germ cell tumor. Extragonadal malignancies such as lymphomas are rare. Testicular fine-needle aspiration cytology (FNAC) in cancer is a bit controversial amidst fear of tumor seeding along the needle tract. Nevertheless, its largely safe, cost-effective technique providing a quick and fairly reliable diagnosis.

METHODS

A retrospective analysis of testicular malignancies on FNAC over a period of 9 years with cyto-histological correlation wherever possible was carried out. FNAC slides and cell blocks with immunocytochemistry wherever done were retrieved.

RESULTS

A total of 74 cases were obtained. The age ranged from 1 year to 65 years. Infiltration by leukemia was the most common malignancy detected in pediatric population, while germ cell tumors were common amongst young adults and middle-aged men. In elderly, metastatic carcinoma, infiltration by lymphoma were identified. On FNAC, 38 cases were of leukemic infiltration, 27 of germ cell tumors (subtyped as mixed germ cell tumors-15 cases, seminoma-11 cases, and yolk sac tumor-1 case) with two cases each of non-Hodgkin lymphoma, Leydig cell tumor, metastatic adenocarcinoma, and one case each of metastatic small cell carcinoma, rhabdomyosarcoma, and malignant neoplasm. Histological correlation was available in 15/74 cases. Only 3 cases were discordant. Seeding of tumor along the needle tract was not seen.

CONCLUSION

The current study deciphers the cytological spectrum of testicular malignancies on FNAC and highlights its importance as a reliable modality for a prompt diagnosis of testicular tumors guiding patient management.

Sonoelastography for Testicular Tumor Identification: A Systematic Review and Meta-Analysis of Diagnostic Test Accuracy

The objective of this review was to summarize the applications of sonoelastography in testicular tumor identification and inquire about their test performances. Two authors independently searched English journal articles and full conference papers from CINAHL, Embase, IEEE Xplore®, PubMed, Scopus, and Web of Science from inception and organized them into a PIRO (patient, index test, reference test, outcome) framework. Eleven studies (n = 11) were eligible for data synthesis, nine of which (n = 9) utilized strain elastography and two (n = 2) employed shear-wave elastography. Meta-analyses were performed on the distinction between neoplasm (tumor) and non-neoplasm (non-tumor) from four study arms and between malignancy and benignity from seven study arms. The pooled sensitivity of classifying malignancy and benignity was 86.0% (95%CI, 79.7% to 90.6%). There was substantial heterogeneity in the classification of neoplasm and non-neoplasm and in the specificity of classifying malignancy and benignity, which could not be addressed by the subgroup analysis of sonoelastography techniques. Heterogeneity might be associated with the high risk of bias and applicability concern, including a wide spectrum of testicular pathologies and verification bias in the reference tests. Key technical obstacles in the index test were manual compression in strain elastography, qualitative observation of non-standardized color codes, and locating the Regions of Interest (ROI), in addition to decisions in feature extractions. Future research may focus on multiparametric sonoelastography using deep learning models and ensemble learning. A decision model on the benefits-risks of surgical exploration (reference test) could also be developed to direct the test-and-treat strategy for testicular tumors.

An Overview of the Role of Multiparametric MRI in the Investigation of Testicular Tumors

Simple Summary

Although conventional ultrasonography remains the primary imaging modality for the assessment of testicular tumors, multiparametric MRI of the scrotum, which combines morphologic and functional data, serves as a powerful adjunct. Based on the recommendations issued by the Scrotal and Penile Imaging Working Group of the European Society of Urogenital Radiology, scrotal MRI is strongly recommended after equivocal US findings. In cases of testicular masses, the main clinical indications are as follows: lesion characterization when sonographic findings are non-diagnostic, discrimination between germ-cell and non-germ-cell testicular tumors, local staging of testicular tumors in patients who are candidates for testis-sparing surgery, and preoperative histological characterization of testicular germ-cell tumors in selected cases. This article aims to provide an overview of the role of multiparametric MRI in the investigation of testicular tumors.

Abstract

Conventional ultrasonography represents the mainstay of testis imaging. In cases in which ultrasonography is inconclusive, scrotal MRI using a multiparametric protocol may be used as a useful problem-solving tool. MRI of the scrotum is primarily recommended for differentiating between benign and malignant testicular masses when sonographic findings are ambiguous. This technique is also accurate in the preoperative local staging of testicular tumors and, therefore, is recommended in patients scheduled for testis-sparing surgery. In addition, MRI may provide valuable information regarding the histological characterization of testicular germ-cell tumors, in selected cases. Scrotal MRI may also help in the differentiation between testicular germ-cell neoplasms and non-germ-cell neoplasms. Axial T1-weighted imaging, axial and coronal T2-weighted imaging, axial diffusion-weighted imaging, and coronal subtracted dynamic contrast-enhanced imaging are the minimum requirements for scrotal MRI. A variety of MRI techniques—including diffusion tensor imaging, magnetization transfer imaging, proton MR spectroscopy, volumetric apparent diffusion coefficient histogram analysis, and MRI-based radiomics—are being investigated for testicular mass characterization, providing valuable supplementary diagnostic information. In the present review, we aim to discuss clinical indications for scrotal MRI in cases of testicular tumors, along with MRI findings of common testicular malignancies.

Ultrasonography of the scrotum: Revisiting a classic technique

Conventional US is the primary imaging modality for the evaluation of the scrotum, due to its high resolution, availability, cost-effectiveness and absence of ionizing radiation. Grayscale and color Doppler US provide a comprehensive assessment of scrotal diseases. The technique represents the mainstay for imaging of acute scrotum. US is highly accurate in the detection, localization and characterization of scrotal masses. Multiparametric US, including conventional US, contrast-enhanced US and tissue elastography has improved the diagnostic performance of the technique in the assessment of testicular diseases. MRI represents a valuable supplemental imaging tool for the investigation of scrotal pathology, mainly recommended in cases of indeterminate US findings. Recommendations recently issued by the European Society of Urogenital Radiology Scrotal and Penile Imaging Working Group (ESUR-SPIWG) refer to the use of scrotal sonography for the evaluation of pathologic entities, including testicular microlithiasis, small, non-palpable incidentally detected testicular masses, varicocele and scrotal trauma. In this review, the technical specifications for scrotal US and the normal sonographic findings are presented. Grayscale and color Doppler US findings of common acute scrotal diseases and scrotal masses are discussed. The complimentary role of multiparametric US and scrotal MRI is addressed. ESUR-SPIWG's guidelines are also reviewed.