Pathologic Conditions at Imaging of the Spermatic Cord

Role of Funiculitis in Sonographic Diagnosis of Acute Epididymitis

ABSTRACT

Ultrasonography is the gold standard for diagnosing acute epididymitis. However, it is not well understood if the simultaneous inflammation of the spermatic cord (funiculitis) is a helpful imaging finding in diagnosing acute epididymitis. This study aimed to investigate the frequency of funiculitis in cases of epididymitis and determine its sensitivity and specificity. This retrospective study included 50 consecutive patients with acute epididymitis. Funiculitis was defined as increased echogenicity of the spermatic cord fat with mass-like cord thickening. All scrotal ultrasound examinations were reviewed for the size of the spermatic cord and surrounding fat, indistinct margins between the spermatic cord and epididymis, similar findings on the contralateral side, and scrotal wall thickening. Spermatic cord inflammation was present in 96% (48/50) of patients with acute epididymitis, significantly higher than in the asymptomatic side (18%, n = 9/50, P < 0.0001). The presence of funiculitis had a sensitivity of 95.9% (confidence interval [CI] 86-99.5%), a specificity of 81.6% (CI 68-91.2%), a positive predictive value of 83.9% (CI 71.7-93%), and a negative predictive value of 95.2% (CI 84-99%) for diagnosing acute epididymitis. The sonographic presence of funiculitis in the setting of acute scrotal pain is a sensitive marker for concomitant acute epididymitis.

Encysted spermatic cord hydrocele: A case series

INTRODUCTION AND IMPORTANCE

Encysted spermatic cord hydrocele is a rare anomaly characterized by obstruction of processus vaginalis closure. Clinically, it presents as a swelling in the inguinal region extending to the upper scrotum and does not communicate with the peritoneal cavity. It is often mistaken for indirect inguinal hernias, inguinal lymphadenopathy, undescended testis, and primary tumors of the cord in infants and children, making the diagnosis challenging.

CASE PRESENTATION

We report the cases of five male patients aged nine months to 12 years who presented with painless swelling on the right side of the scrotal region. Physical examination revealed firm masses in the right inguinal region with positive transillumination, negative cough impulse tests, and irreducibility. Inguinal and scrotal ultrasonography showed an anechoic cystic lesion with thin walls, without any signs suggestive of a hernia. Patients were diagnosed with encysted spermatic cord hydrocele and advised to undergo cyst excision. The postoperative periods were uneventful, and expected recovery was observed at one-week and one-month follow-ups.

CLINICAL DISCUSSION

Encysted spermatic cord hydroceles are rare causes of painless inguinal swelling. The medical history and clinical findings can be used to establish a diagnosis, which can be confirmed using ultrasonography. Management depends on differentiating between spermatic cord hydrocele and scrotal hydrocele and involves considering the type. Treatment options range from conservative measures to surgery, particularly for non-communicating hydroceles that persist beyond 12-18 months or enlarge in size.

CONCLUSION

Encysted hydrocele of the cord is rare and is often mistaken for indirect inguinal hernias in infants and children. This similarity makes the diagnosis challenging and necessitates vigilance from clinicians. Surgical intervention results in optimal outcomes, especially in cases where the hydrocele persists beyond 12-18 months or with size progression.

Gamut of Extratesticular Scrotal Masses: Anatomic Approach to Sonographic Differential Diagnosis

The commonly taught tenet that intratesticular lesions are always malignant and extratesticular scrotal lesions are always benign is a simplistic statement that erroneously minimizes the significance of extratesticular scrotal masses and their diagnosis. Yet, disease in the extratesticular space is commonly encountered by clinicians and radiologists and is often a source of uncertainty in diagnosis and management. Given the embryologically rooted complex anatomy of this region, a wide range of pathologic conditions is possible. Radiologists may not be familiar with some of these conditions; further, many of these lesions can have a specific sonographic appearance, allowing accurate diagnosis that can minimize surgical intervention. Lastly, malignancies can occur in the extratesticular space-although this is less common than in the testicles-and proper recognition of findings that warrant additional imaging or surgery is critical in optimizing outcomes. The authors present a compartmental anatomic framework for differential diagnosis of extratesticular scrotal masses and provide a comprehensive illustrative display of many of the pathologic conditions that can be encountered to familiarize radiologists with the sonographic appearances of these lesions. They also review management of these lesions and scenarios where US may not be definitive in diagnosis and selective use of scrotal MRI can be helpful. ^© RSNA, 2023 Quiz questions for this article are available in the supplemental material.