JULY 2007 contemporaryurology.com 9

There are many indications forscrotal US (Table 1).1 ScrotalUS is often performed when the

physical examination is inconclusiveor difficult to complete (or both) be-cause of patient discomfort or inabilityof the examiner to precisely identifythe scrotal structures on palpation.The US examination is therefore anintegral part of the physical examina-tion of the male genitalia.

Investigation of a scrotal mass is themost common indication for scrotalUS. All scrotal masses should be evalu-ated with US and the findings properlydocumented (including the location,echogenicity, size, color flow charac-teristics, and clinical impressions ofany mass). A mass should be identifiedas being testicular, epididymal, para-testicular, or part of the scrotal wall.Echogenicity and color flow character-istics should help determine whetherthe mass is vascular, fluid, or solid. Ascrotal mass can be either painful ornonpainful.

PAINFUL SCROTAL ENLARGEMENT

This condition, which may occur inpatients with epididymitis, orchitis,testicular abscess, and/or testiculartorsion, often has a variable presenta-tion. While US has the advantages ofbeing a quick, noninvasive, and sensi-tive diagnostic test, it is not alwaysspecific. For example, in the acutescrotum, increased testicular bloodflow can be noted on US in patientswith orchitis and torsion-detorsion(Figure 1). US cannot differentiate thehyperemia often seen with reperfusion

(such as in cases of torsion-detorsion)from an inflammatory etiology. Over-reliance on US findings can, therefore,be misleading at times. In my opinion,US cannot “rule out” torsion in theevaluation of the acute scrotum, sinceit can only define what exists at thetime of the examination. The diagno-sis of torsion should only be madeclinically by the urologist based uponthe history (for example, characteris-tics of onset and associated symptomssuch as dysuria, fever, and chills), find-ings on physical examination (such asrubor, dolar, tumor, and tenderness),and diagnostic studies (including urinanalysis and culture and WBCcount). Epidymitis/orchitis. The body of thenormal epididymis has slightly de-creased echogenity as compared to itshead. In patients with acute epididy-mitis (Figure 2), the epididymis may beinvolved focally (usually beginning inthe cauda) or globally, with enlarge-ment and thickening of the epididy-mis, decreased echogenicity, and an in-creased color Doppler flow. A high-flow, low-resistance pattern is seen. Areversal of flow during diastole occurswith venous infarction.2 A reactive hy-drocele is often present. Complicationsinclude infectious spread to the testis(epididymo-orchitis, Figure 3), abscessformation, testicular infarction (usual-ly secondary to obstruction of venousflow followed by testicular atrophy),and chronic pain. Color Doppler is of-ten diagnostic.

In patients with orchitis, the testisbecomes enlarged, appears inhomoge-

SCROTAL ULTRASOUNDWhen and what to look forBy Bruce R. Gilbert, MD, PhD

PART 2 OF 2

Office scrotal ultrasound (US),

when properly performed and

documented, can provide

indispensable information

regarding males with scrotal

symptoms. Part 1 of this article

(June 2007, pages 10-22) included a

primer on the underlying

principles and terminology of

scrotal US, explained why artifacts

occur (and how to avoid them),

and outlined the essential elements

of an optimal scrotal exam.

Part 2 describes proper assessment

of the various indications for

scrotal US and offers tips on

device selection.

Dr. Gilbert is AssociateClinical Professor ofUrology, and AssociateClinical Professor of MaleReproductive Medicine,Weill Cornell MedicalCollege, New York, NY.

Phot

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by G

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neous, and exhibits a decreased re-sistive index (RI). (See part 1 of thisarticle for a refresher on termi-nology.) The RI of the epididymaland testicular artery have beenshown to be significantly lower inpatients with epididymo-orchitisthan in control subjects.3

Patients with chronic epididymi-tis (Figure 4) often present withpersistent pain. In these men, USexamination reveals an enlargedepididymis with increased echogen-icity and possible areas of calcifi-cation.Testicular abscess. Persistent feverand scrotal pain and swelling can beseen in approximately 5% of pa-tients with orchitis. These are theclinical hallmarks of a testicular ab-scess. The characteristic US appear-ance of a testicular abscess usuallyappears within 1 to 7 weeks.4 Ineffec-tive treatment of epididymo-orchitismay result in a pyelocele (an abscessaround the testicle), a testicular orscrotal abscess, or testicular infarc-tion, and possibly fasciitis. While ascrotal abscess may resemble a tu-mor, the historical presentation (thatis, preceding epididymo-orchitis)together with US evidence of inflam-mation, as described above, will of-ten differentiate the 2.Torsion. While torsion of a testic-ular or epididymal appendage isthought to be more common thantorsion of the spermatic chord, thelatter represents a true urologicemergency. While irreversible tes-ticular damage is presumed after 4hours of spermatic cord torsion,5-9

only 50% of men who were de-torsed less than 4 hours after theirsymptoms began were noted tohave normal semen quality.10

Torsion is a clinical diagnosisproven at surgery. US does not diag-nose torsion—only the urologist (orpathologist) can. US should only beused to document findings. Manyconditions (such as torsion-detorsion,

intermittent torsion, persistent capsu-lar flow, and color flow artifacts) cansuggest apparent flow in cases wherenone exists.

On US, the affected testis usuallyappears hypoechoic. Testicular size

can vary from hypertrophic to atrophic. The sonographer shouldalways compare the affected testiswith the contralateral side usinglongitudinal, transverse, and coro-nal views (Figure 5). Apical viewscan be particularly informativewhen the sonographer attempts toalign the transducer parallel to flow.Spectral waveform analysis withcalculation of the RI is also helpful,but as stated previously, is not diag-nostic. In patients with acute tor-sion, the epididymis may appearhypoechoic and enlarged, similar toepididymitis.Nonpainful scrotal enlargement. Avariety of conditions can result in anonpainful scrotal mass or enlarge-ment. US is an excellent modalityfor identifying the etiology and hasalso been used intraoperatively tolocalize nonpalpable lesions.11

• Testicular tumor. The most com-mon US appearance of a testicularmalignancy—whether a germ celltumor, a non-germ cell tumor, or a metastatic lesion from a nontes-ticular source—is one of homoge-neous echogenicity that is hypo-echoic to the surrounding testicu-lar parenchyma with intralesionalvascularity (Figure 6).12 However, awide range of presentations exist,including nonpalpable lesions13

and hyperechoic lesions that areheterogeneous with areas of calci-fication, cystic changes,14 and/orvariable vascularity. Patients withwidespread metastasis may presentwith only a scar or an area of calci-fication in the testis that representsa “burned-out” testicular tumor, in which involution occurred dueto its high metabolic rate outstrip-ping its blood supply (Figure 7).

The tumor tissue type cannot be reli-ably differentiated solely by its ap-pearance on US.

• Hydrocele. Patients with a hydrocele(caused by a collection of serous fluidbetween the parietal and visceral layers

SCROTAL ULTRASOUND

10 contemporaryurology.com JULY 2007

ASSESSMENT OF SCROTAL MASS

Painful enlargement

Epididymitis/orchitis

Testicular abscess

Torsion

Nonpainful enlargement

Testicular tumor

Hydrocele

Varicocele

Spermatocele/epididymal cyst

Scrotal hernia

Cyst

EVALUATION OF SCROTAL TRAUMA

Testicular rupture

Hematocele

INVESTIGATION OF EMPTY ORABNORMAL SCROTAL SAC

Undescended testis

Thickened scrotal skin

EVALUATION OF FERTILITY ANDRELATED ISSUES

Varicocele

Atrophic testis

Measure size and intratesticularlesions

Microlithiasis

Impaired semen quality

Azoospermia

Antisperm antibody

FOLLOW-UP AFTER SCROTAL SURGERY

Varicocele

Testis biopsy

Hydrocelectomy

FOLLOW-UP OF PATIENTS WITHINDETERMINATE SCROTAL MASSES

Source: American Urological Association ConsensusStatement on Urologic Ultrasound Utilization.1

TABLE 1

Indications for scrotal US

of the tunica vaginalis) present with apainless scrotal swelling. While hydro-celes are usually anechoic, they maycontain echogenic cholesterol crystals.The presence of septations (Figure 8)is often associated with infection, trau-ma, or metastatic disease. While theetiology may be idiopathic, hydrocelesmay develop secondary to infection,trauma, torsion, or tumor, or may re-sult from a patent process vaginalis.The testis is often posteriorly displacedby the hydrocele.

• Scrotal hernia. Patients with a scrotalhernia (Figure 9) usually present withmesenteric fat and/or bowel loopsseen superior to the testis. Characteris-tic US findings include peristalis,

fluid-filled bowel loops, and highlyechogenic omental fat.

• Epididymal cyst/spermatocle. An epi-dydimal cyst (Figure 10) is a non-painful scrotal structure that, whenlarge, displaces the testis inferiorly. Aspermatocle is a benign, anechoic epi-didymal cyst that contains sperm, isusually located in the head of the epi-didymis, and often has septations.

TRAUMA

Traumatic injury to the testis hasmany etiologies .15-17 Sporting injuriesaccount for 50% of cases, and motorvehicle accidents account for 9% to17%. US is thought to have 100% sen-sitivity and 80% specificity for testicu-

lar trauma.18 Traumatic injury to thetestis should be considered a surgicalemergency when testicular rupture(discontinuity of the tunica albuginea)is identified. US characteristics of tes-ticular rupture include scrotal wallthickening, discontinuity of the tunicaalbuginea (in 17% of patients), irregu-lar testicular margins, hematocele ortesticular hematoma, and decreasedblood flow (Doppler color flow) to theaffected area (Figure 11).19

ABNORMAL SCROTUM

In patients with cryptorchidism or ab-normally thick scrotal skin, US can fa-cilitate treatment by identifying andcharacterizing the abnormality.

Undescended testis. When theabsence of a testis in the scro-tum is noted, a search is initiat-ed to confirm its presence or ab-sence. US is usually the initialdiagnostic imaging modality be-cause of its sensitivity in the in-guinal canal (where most unde-scended testes are found), itsready availability, its safety profile,and its lack of need for anesthe-sia in the infant or young child.If the absent testis is not identi-fied within the inguinal canal,CT or MRI is often used in an attemptto locate an intra-abdominal testis.Surgical exploration, however, re-mains the gold standard for identify-ing an intra-abdominal testis.

A cryptorchid testis in the inguinalcanal, identified by the presence of themediastinum testis, is usually small in

size (hypotrophic). It can be differen-tiated from an inguinal hernia by theabsence of peristalsis, the presenceor absence of highly reflective omentalfat, or both.17

Thickened scrotal skin. Palpation ofthe scrotal contents can be difficult inpatients with a thickened scrotal wall

or a retracted scrotum (Figure12). Scrotal US is particularlyuseful in the testicular evalua-tion of patients who exhibitscrotal wall changes secondaryto heart failure, lymphatic or ve-nous obstruction, an infectiousetiology (such as filariasis), oran inflammatory etiology (suchas cellulite or Fournier’s gan-grene).20-23

FERTILITY AND RELATED ISSUES

In male patients with the followingscrotal conditions, which have the po-tential to affect fertility, US can pro-vide beneficial diagnostic informationprior to and after intervention.Varicocele. The most common pres-entation of a varicocele is due to aninvestigation of male subfertility and

JULY 2007 contemporaryurology.com 13

SCROTAL ULTRASOUND

12 contemporaryurology.com JULY 2007

FIGURE 5

Right testicular torsion

Examination of the contralateral (normal) left testisallows for comparison of the echogenicity.

FIGURE 6

Testicular tumors

A and B: On 2D gray scale US, tumors may appear hypoechoic and well circumscribed (A) or not well circumscribed andmultifocal (B). C and D: 2D color flow Doppler clearly demonstrates increased tumor blood flow.

A B

C D

FIGURE 1

Increased blood flow after manual testicular detorsion

FIGURE 2

Epididymitis as demonstrated by power Doppler

FIGURE 3

Epididymo-orchitis

This 2D gray scale image demonstrates an enlarged andheterogeneous epididymis and testis.

FIGURE 4

Chronic epididymitis

In this patient with chronic epididymitis, US examinationdemonstrates increased echogenicity and microcalcificationsin the caput epididymis.

contain microliths, and the associat-ed risk of malignancy has not beenwell defined. Bennett and colleaguesdemonstrated a direct relationshipbetween the number of microlithsand the incidence of testicular tumorat initial presentation.29 Only 1 (2%)of 65 patients who had fewer than 5microliths had a concomitant testic-ular tumor, compared with 7 (18%)of 39 patients who had 5 or moremicroliths. In a study by Bach andassociates, 48 (9%) of the 528 pa-

tients referred for scrotal US had mi-crolithiasis, with 13 (27%) of the 48having testicular cancer.30 Only 38(8%) of 480 patients without TMhad testicular cancer. However, re-sults from a prospective analysisdemonstrated only a 5% to 10% riskof coexisting tumors when TM waspresent.31

The risk of subsequent develop-ment of testicular tumor in patientspresenting with TM is less clear.32,33

Data from several investigators sug-

gest that TM is a benign, nonprogres-sive condition, at least when followedfor up to 45 months.29,34,35 However,several recent case reports have docu-mented the development of testiculartumors in patients with TM whenfollow-up extended for several years,suggesting the need for close follow-up in these patients.36-40 The frequen-cy and type of exam required on follow-up is not well defined by the presentliterature, and the suggested durationof follow-up is even less clear.

Many urologists teach patientshow to perform monthly testicularself-exam, then follow them withphysical exam and scrotal US every 6to 12 months. Conditions associatedwith an increased incidence of germcell tumors (such as testicular atro-phy, infertility, cryptorchidism, pres-ence of intratubular germ cell neo-

JULY 2007 contemporaryurology.com 15

SCROTAL ULTRASOUND

infrequently due to scrotal pain. Avaricocele is present in about 15% ofnormally fertile men, in 30% to 40%of men with primary subfertility,and in as many as 80% of men withsecondary subfertility. Clinically sig-nificant varicoceles are associatedwith a couples’ subfertility and im-pairments in semen quality that caninclude a decrease in sperm count,sperm motility, and the number ofmorphologically normal sperm. Inparticular, an increased number oftapered (elongated) heads are usual-ly present with an increase in thenumber of immature (round) ger-minal forms appearing in the ejac-ulate.

Varicoceles are more often identi-fied on the left side, most likely re-lated to the angle of insertion andthe length of the left testicular vein.However, it has been found to be abilateral condition in more than80% of some series.24 UScharacteristics include thefindings of multiple, low-reflective serpiginous tubularstructures of varying diame-ters best visualized superiorand posteriolateral to thetestis.25 In patients with alarge varicocele, these dilatedveins can fill a good portionof the scrotum (Figure 13).Color flow Doppler is impor-tant in documenting the pres-ence and size of a varicocele

as well as differentiating an intrates-ticular varicocele (Figure 14) from adilated rete testis.26,27 The presenceof bilateral varicoceles is often bestidentified by scrotal US.

No standards have been set formeasurement of a varicocele. Clinicalevaluation of scrotal contents is sub-jective and influenced by several fac-tors such as patient compliance, scro-tal wall thickness, and contraction ofthe scrotum. One group’s criterion fora varicocele is measurement in thesupine position of the largest vein posterior to the testis of greater than2.5 mm and documentation of rever-sal of flow after a Valsalva maneuver.28

A color flow image of the dilated vari-cocele vein(s) should be archived fordocumentation.

In patients who experience suddenonset of a varicocele or whose varico-cele persists in the supine position, fur-ther imaging of the retroperitoneum iswarranted to identify etiologic factors.Testicular atrophy. This conditionmay be related to age, trauma, torsion,infection, or inflammation, or mayoccur secondary to hypothyroidism,drug therapy, or chronic disease. Theappearance on US is variable, andwhile related to the underlying cause,is usually characterized by decreasedechogenicity with a normal appearingepididymis.

Imaging for patients presentingwith subfertility provides documenta-tion prior to treatment and intratestic-ular evaluation for conditions such astumor (Figure 15) or testicular micro-lithiasis (TM).Testicular microlithiasis. Defined as 5or more microcalcifications within a

testicle, TM is thought to becaused by the calcification ofdegenerating cells in the semi-niferous tubule. This condi-tion, which occurs in 1% to5% of asymptomatic men, isusually symmetrical (occur-ring unilaterally 20% of thetime). Acoustic shadowing isoften absent, likely due to thesmall size of the calcifications(Figure 16).

Both benign and malig-nant tumors of the testis may

14 contemporaryurology.com JULY 2007

FIGURE 13

Large bilateral varicoceleFIGURE 14

Intratesticular varicocele

FIGURE 11

Testicular trauma

Longitudinal view(top) and transverseview (bottom) of apostoperativehematoma.

FIGURE 12

Thickened scrotal wallsecondary to scrotal edema

FIGURE 8

Septated hydrocele

The presence of septations within ahydrocele is frequently associated withinfection, trauma, or metastasis.

FIGURE 9

Scrotal hernia

FIGURE 10

Epididymal cyst

FIGURE 7

“Burned out” testiculartumor

SCROTAL ULTRASOUND

plasm on biopsy) in the presence ofTM support long-term follow-up. Impaired semen quality and azoo-spermia. Poor semen quality can be aharbinger of underlying disease. Vari-cocele, ductal obstruction, and testicu-lar tumors are examples of pathologyeasily demonstrated by US that may ormay not be identified by physical exam. US, being a noninvasive, real-time imaging modality, is often usedin the comprehensive evaluation ofmen with impaired semen quality todocument the presence or absence ofpathology, especially when the physi-cal exam is inconclusive or suggestiveof intrascrotal pathology. In men withazoospermia, US can often define theunderlying etiology (for example, con-genital bilateral absence of the vas def-erens or microlithiasis).41-43

Antisperm antibodies. About 10% ofmen presenting with subfertility arefound to have antisperm antibodies,compared with 2% or fewer of fertilemen.44-46 Several common causes

of antisperm antibodies, including obstructive azoospermia, congenitalbilateral absence of the vas deferens,epididymitis, genital trauma, andcryptorchidism, can be evaluated withscrotal US.47-51

POSTOPERATIVE FOLLOW-UP

While rarely considered, office US is asuperb modality for following patientspostoperatively. Changes in semenquality following varicocelectomy canbe correlated to US documentation indicating the absence, persistence, orrecurrence of the varicocele. US is alsoa sensitive modality for evaluating thetesticular parenchyma following testisbiopsy, testicular sperm extraction, orhydrocele repair.52,53

WHAT TO LOOK FOR IN AN US SYSTEM

The choice of an US system is uniqueto each practice. No matter what sys-tem your practice considers, be sure totry it “on site” before making a pur-

chase. Equipment manufacturers areextremely accommodating, and willlikely agree to bring the equipment toyour facility along with a trained tech-nician for a trial use of a day or more.

Here are some of the most impor-tant issues to consider before making apurchase:

• What is your budget?

• Which features are required, andwhich are optional? In my opinion,color capabilities can provide essentialinformation and therefore should beseriously considered.

• What is the intended purpose of thedevice? Will it be the only US machinefor the practice or is it being pur-chased for a particular type of exam? Ifit is being purchased for a specific pur-pose (such as for the determination ofbladder volume or for prostate biop-sy), you might consider a specificallydesigned system. The intended func-tions will help determine which trans-ducers are necessary.

• Will the machine be used at a singlesite or at multiple locations? If porta-bility is important, you might considerpurchasing one of several availableself-contained systems.

• What archival system does yourpractice employ for images? If youhave specific requirements, make surethe equipment you intend to purchasecan do what you want. Better yet, try itout in your office!Transducer selection. In my opinion,urologists should consider obtaining 3transducers at the time of initial pur-chase. A curved array transducer witha broad bandwidth (3.5 to 5 MHz) isuseful for both bladder and renal ex-amination. The same transducer canbe used to evaluate the testes in pa-tients with a thickened scrotal wall andto compare the echogenicity of the 2testes.

Also consider a linear array (smallparts) transducer with a bandwidth ofat least 7.5 mHz and a “footprint” thatcan accommodate a large size testis. Ifthe equipment has color capabilities,

16 contemporaryurology.com JULY 2007

FIGURE 16

Microlithiasis

Patients with TM may present with few (left) or many (right) microcalcifications.

FIGURE 15

Atrophic testis with nonpalpable Leydig cell tumor

This patient with an atrophictestis (left) had anonpalpableLeydig cell tumoridentified onpathologic exam(right).

SCROTAL ULTRASOUND

this probe can also be used for penileDoppler studies. An intracavitarytransducer (5 to 7.5 mHz) is used fortransrectal prostate studies.

Broad bandwidth or multifrequen-cy probes are standard on most equip-ment. You might also ask to try a bi-plane probe, which is valuable forprostate examination. This type ofprobe provides simultaneous sagittaland transverse images and is very use-ful for prostate biopsies. With thesetransducers, renal, scrotal, penile, andtransrectal US examinations and diag-nostic procedures can be appropriatelyperformed.

CONCLUSION

When armed with a comprehensiveunderstanding of the testicular anato-my, the fundamental principles of US,and the proper equipment, urologistscan perform, interpret, and documentthe results of office scrotal US in a waythat provides invaluable informationregarding the diagnosis and treatmentof many urologic conditions. Urolo-gists, uniquely qualified by trainingand experience to perform these stud-ies, should maintain a high degree ofproficiency in these.

REFERENCES

1. American Urological Association Consensus State-ment on Urologic Ultrasound Utilization. Updated bythe AUA Board of Directors, February 2007. Availableat: http://www.auanet.org/about/policy/education.cfm. Accessed June 7, 2007.2. Sanders LM, Haber S, Dembner A, et al. Signifi-cance of reversal of diastolic flow in the acute scro-tum. J Ultrasound Med. 1994;13(2):137-139.3. Jee WH, Choe BY, Byun JY, et al. Resistive index ofthe intrascrotal artery in scrotal inflammatory disease.Acta Radiol. 1997;38(6):1026-1030.4. Mevorach RA, Lerner RM, Dvoretsky PM, et al. Tes-ticular abscess: diagnosis by ultrasonography. J Urol.1986;136(6):1213-1216.5. Baker LA, Sigman D, Mathews RI, et al. An analysisof clinical outcomes using color Doppler testicular ul-trasound for testicular torsion. Pediatrics. 2000;105(3 pt 1):604-607.6. Blaivas M, Sierzenski P, Lambert M. Emergencyevaluation of patients presenting with acute scrotumusing bedside ultrasonography. Acad Emerg Med.2001;8(1):90-93.7. Dogra V, Bhatt S. Acute painful scrotum. RadiolClin North Am. 2004;42(2):349-363.8. Weber DM, Rosslein R, Fliegel C. Color Dopplersonography in the diagnosis of acute scrotum inboys. Eur J Pediatr Surg. 2000;10(4):235-241.

9. Dogra VS, Bhatt S, Rubens DJ. Sonographic evalua-tion of testicular torsion. Ultrasound Clin. 2006;1:55-66.10. Bartsch G, Frank S, Marberger H, et al. Testiculartorsion: late results with special regard to fertility andendocrine function. J Urol. 1980;124:375-378.11. Kravets FG, Cohen HL, Sheynkin Y, et al. Intraop-erative sonographically guided needle localization ofnonpalpable testicular tumors. AJR Am J Roentgenol.2006;186(1):141-143.12. Steinfeld AD. Testicular germ cell tumors: reviewof contemporary evaluation and management. Radi-ology. 1990;175(3):603-606.13. Carmignani L, Morabito A, Gadda F, et al. Prog-nostic parameters in adult impalpable ultrasono-graphic lesions of the testicle. J Urol. 2005;174(3):1035-1038.14. Cho JH, Chang JC, Park BH, et al. Sonographicand MR imaging findings of testicular epidermoidcysts. AJR Am J Roentgenol. 2002;178(3):743-748.15. Bhandary P, Abbitt PL, Watson L. Ultrasound diag-nosis of traumatic testicular rupture. J Clin Ultrasound.1992;20(5):346-348.16. Dogra VS, Gottlieb RH, Oka M. Sonography of thescrotum. Radiology. 2003;227(1):18-36.17. Dogra VS, Bhatt S. Categorical Course in Diagnos-tic Radiology: Acute Scrotal Pain: Imaging Evaluationfor a More Specific Diagnosis. Ramchandani P, ed.Oak Brook, Ill; Radiological Society of North America:Genitourinary Radiology; 2006:255-270.18. Herbener TE. Ultrasound in the assessment ofthe acute scrotum. J Clin Ultrasound. 1996;24(8):405-421.19. Haas CA, Brown SL, Spirnak JP. Penile fractureand testicular rupture. World J Urol. 1999;17(2):101-106.20. Grainger AJ, Hide, GH, Simon TE. The ultrasoundappearances of scrotal oedema. Eur J Ultrasound.1998;8(1):33-37.21. Sasso F, Nucci G, Palmiotto F, et al. Acute idio-pathic scrotal oedema: rare disorder or difficult diag-nosis? Int J Urol Nephrol. 1990;22(5):475-478.22. Najmaldin A, Burge DM. Acute idiopathic scrotaloedema: incidence, manifestations and aetiology. Br JSurg. 1987;74(7):634-635.23. Brandes SB, Chelsky MJ, Hanno PM. Adult acuteidiopathic scrotal edema. Urology. 1994;44:602-605.24. Gat Y, Bachar GN, Everaert K, et al. Induction ofspermatogenesis in azoospermic men after internalspermatic vein embolization for the treatment ofvaricocele. Hum Reprod. 2005;20(4):1013-1017.25. Cornud F, Belin X, Amar E, et al. Varicocele: strate-gies in diagnosis and treatment. Eur Radiol. 1999;9(3):536-545.26. Das KM, Prasad K, Szmigielski W, et al. Intratestic-ular varicocele: evaluation using conventional andDoppler sonography. AJR Am J Roentgenol. 1999;173(4):1079-1083.27. Tasci AI, Resim S, Caskurlu T, et al. Color Dopplerultrasonography and spectral analysis of venous flowin diagnosis of varicocele. Eur Urol. 2001;39(3):316-321.28. Schiff J, Li P, Goldstein M. Correlation of ultra-sound-measured venous size and reversal of flowwith Valsalva with improvement of semen-analysisparameters after varicocelectomy. Fertil Steril. 2006;86(1):250-252.29. Bennett HF, Middleton WD, Bullock AD, et al.Testicular microlithiasis: US follow-up. Radiology.2001; 218(2):359-363.30. Bach AM, Hann LE, Hadar O, et al. Testicular mi-crolithiasis: what is its association with testicular can-cer? Radiology. 2001; 220(1):70-75.31. Peterson AC, Bauman JM, Light DE, et al. Theprevalence of testicular microlithiasis in an asympto-matic population of men 18 to 35 years old. J Urol.2001;166(6):2061-2064.

32. Middleton WD, Teefey SA, Santillan CS. Testicularmicrolithiasis: prospective analysis of prevalence andassociated tumor. Radiology. 2002;224(2):425-428.33. von Eckardstein S, Tsakmakidis G, Kamischke A,et al. Sonographic testicular microlithiasis as an indica-tor of premalignant conditions in normal and infertilemen. J Androl. 2001;22(5):818-824.34. Whitman GJ, Hall DA, McCarthy KA, et al. Testicu-lar microlithiasis: sonographic features and signifi-cance. Radiology. 1994;193(P):335. Abstract.35. Furness PD III, Husmann DA, Brock JW III, et al.Multi-institutional study of testicular microlithiasis inchildhood: a benign or premalignant condition? J Urol. 1998;160(3 pt 2):1151-1154.36. Gooding GAW. Detection of testicular microlithia-sis by sonography. AJR Am J Roentgenol. 1997;168(1):281-282.37. Winter TC 3rd, Zunkel DE, Mack LA. Testicular car-cinoma in a patient with previously demonstratedtesticular microlithiasis. J Urol. 1996;155(2):648.38. Frush DP, Kliewer MA, Madden JF. Testicular mi-crolithiasis and subsequent development of metastat-ic germ cell tumor. AJR Am J Roentgenol. 1996;167(4):889-890.39. McEniff N, Doherty F, Katz J, et al. Yolk sac tumorof the testis discovered on a routine annual sono-gram in a boy with testicular microlithiasis. AJR Am JRoentgenol. 1995;164:971-972.40. Salisz JA, Goldman KA. Testicular calcificationsand neoplasia in a patient treated for subfertility. Urol-ogy. 1990;36(6):557-560.41. Aizenstein RI, DiDomenico D, Wilbur AC, et al.Testicular microlithiasis: association with male infertili-ty. J Clin Ultrasound. 1998;26(4):195-198.42. Jarow JP. Life-threatening conditions associatedwith male infertility. Urol Clin North Am. 1994;21(3):409-415.43. Honig SC, Lipshultz LI, Jarow J. Significant medicalpathology uncovered by a comprehensive male infer-tility evaluation. Fertil Steril. 1994;62(5):1028-1034.44. Clarke GN, Elliott PJ, Smaila C. Detection ofsperm antibodies in semen using the immunobeadtest: a survey of 813 consecutive patients. Am J Re-prod Immunol Microbiol. 1985;7(3):118-123.45. Sinisi AA, Di Finizio B, Pasquali D, et al. Preva-lence of antisperm antibodies by SpermMARtest insubjects undergoing a routine sperm analysis for in-fertility. Int J Androl. 1993;16(5):311-314.46. Gilbert BR, Witkin SS, Goldstein M. Correlation ofsperm-bound immunoglobulins with impaired se-men analysis in infertile men with varicoceles. FertilSteril. 1989;52(3):469-473.47. Fuchs EF, Alexander NJ. Immunologic considera-tions before and after vasovasostomy. Fertil Steril.1983;40(4):497-499.48. Patrizio P, Silber SJ, Ord T, et al. Relationship ofepididymal sperm antibodies to their in vitro fertiliza-tion capacity in men with congenital absence of thevas deferens. Fertil Steril. 1992;58(5):1006-1010.49. Iqbal PK, Adeghe AJ, Hughes Y, et al. Clinical char-acteristics of subfertile men with antisperm antibod-ies. Br J Obstet Gynaecol. 1989;96(1):107-110.50. Heidenreich A, Bonfig R, Wilbert DM, et al. Riskfactors for antisperm antibodies in infertile men. Am JReprod Immunol. 1994;31(203):69-76.51. Urry RL, Carrell DT, Starr NT, et al. The incidence ofantisperm antibodies in infertility patients with a histo-ry of cryptorchidism. J Urol. 1994;151(2):381-383.52. Harrington TG, Schauer D, Gilbert BR. Percuta-neous testis biopsy: an alternative to open testicularbiopsy in the evaluation of the subfertile male. J Urol.1996;156(5):1647-1651.53. Schlegel PN, Su L-M. Physiological consequencesof testicular sperm extraction. Hum Reprod. 1997;12(8):1688-1692.

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