 Hi friends, having understood acute scrotum quite in detail, now let's shift our discussion to an organ which is quite neglected in scrotal ultrasound imaging and that is epididymis. So you all have learned the sononatomy of epididymis and one of the most common presentation in day to day practice is of epididymitis. So let's see this case where a 32 year old male patient who had an underlying urinary tract infection was sent for ultrasound. These are the images, the B mode where you can see a normal looking left epididymis but look at the right epididymis it's enlarged, heterogeneous and inhomogeneous in ecotexture. When you switch on color Doppler there is increased vascularity in that inhomogeneous area. Whenever you see something like this epididymis with increased vascularity unless food otherwise this is epididymitis. Now epididymitis is very commonly seen condition especially in post pubertal men where the common culprit is either a lower urinary tract infection caused by E. coli, pseudomonas or very commonly they're also seen with sexually transmitted diseases mainly gonorrhea being culprit. Ultrasound signs are very classical, thicken enlarged inhomogeneous epididymis with increased vascularity on Doppler with a reactive hydrocele. Having seen this this epididymitis can spread down into the testes and cause epididymorchitis or it can go up in the cord and it can cause associated funiculitis. So you could have an overlapping presentation of each of this. So this talks about acute epididymitis but what about chronic epididymitis? The way there are acute inflammatory pathologies of epididymis can you have chronic pathology of epididymis? Yes you know that long-standing epididymitis not getting treated and having resistance can present to you as chronic epididymitis but in India genitourinary tuberculosis is very very common and can present to you in day-to-day practice where you get this thickened irregular epididymis or an epididymal mass you see calcifications within this epididymis which is one of the clue clincher to pick up chronic epididymitis. So see this case given by my fellow colleague Shreyas where he was flummoxed that the testes on one side was normal and this quite this was the enlarged testes which showed a permeative pattern like this. You promptly feel this is looking like leukemia and lymphoma but when we scanned his epididymis his epididymide there was gross epididymitis with increased vascularity. We did work up of this patient and this indeed is been described as tuberculosis epididymitis. In fact that appearance is called as biliary pattern of testicular involvement in TB where epididymis as well as the testes both get infected in coughs. Then see this case testes was completely normal and epididymis was normal but lying within this test epididymis was this focal hypoechoic area increased vascularity. We thought whether this is a testicular torgen of the testicular appendage but patient did not have any pain and there was this silent asymptomatic lesion lying there. The surgeon did an FNA of this lesion and indeed this turned out to be coughs. So coughs can have bizarre presentations in human body but sometimes ecopore legions within the epididymis or the permeative pattern the way we saw in testes both can have present as coughs in India and very commonly see. Before concluding with this part of the lecture unusual case outcome I want to show in this case. So this was one young guy with severe UTI infection. We saw this kind of picture so now by now I've trained you to see that epididymis is enlarged, ecogenic, bulky. You know this is epididymitis. Then we put in color we knew there is increased vascularity. We confidently called up the surgeon and said that it's a straightforward case of an epididymocorchitis. The patient was put on heavy antibiotics and sent home because we made a confident diagnosis of epididymocorchitis. Patient was followed up after three weeks of antibiotics and the surgeon called me up and said Rajesh I can feel that this whole legion has increased in size and in fact I can feel a lump within these testes kindly revaluate. So simple epididymocorchitis four weeks of antibiotics. A big googly. What had happened is that this whole testes which was normally initially had turned out into a large collection with ecopore areas within it moving internal echos. What looking at this what do you think this is looking like an abscess or a scrotal wall collection. Now testes was completely replaced by this ecopore collection. When we studied about this this is nothing but in all diagnosed cases of epididymocorchitis patient had so much severe infection that it led to venous outflow obstruction at the level of epididymis which lead to testicular infarction and this lead to complete liquefaction necrosis within this testes. Therefore now in our every patient of epididymocorchitis we write that please follow up after four weeks of antibiotics because sometimes there can be googly cases like this where the testes are completely undergone infarction because of severe bad epididymocorchitis. Now having finished testes and epididymis the acute pathologies there can be legions seen depending upon where the area is like epididym is called or tunica vaginal is and let's look at it which are simpler cases to diagnose in day to day practice. So one is anechoic cystic legion lying at the head of the epididym is good acoustic enhancement you know like any cyst in human body looks like this this is nothing but an epididymal cyst. Sometimes same in that area you see a multi-locular appearance thin wall septae like this. Now there is a debate whether this is a epididymal cyst multiple or whether this is a spermatocele. So now they say that if you see thin wall septae multi-locular appearance like this lying at the head of the epididymis majority of the times this leads to a spermato most of the times these are spermatocele but trust me is difficult to differentiate one from another but we in our practice we write if it is a single legion as epididymal cyst but if it is multi-locular multi-septated like this we say that this is most probably a spermatocele. Many of these patients in fact have undergone vasectomy and they show this kind of spermatocele where this case clearly shows this on the video. Having said that can there be a tumor within the epididymis yes one of the most commonest tumor of the epididymis has an overlapping appearance with the origin of the testicular appendage. Now how are you going to diagnose that one asymptomatic versus symptomatic epididymal tumors the commonest tumor is a adenomertal tumor of the epididymis which typically lies in the tail of the epididymis echogenic mass. Now that's a difficult diagnosis to make but you will see that adenomertal tumor is a silent legion as against a torgen of testicular appendage or an epididymal appendage is going to have an acute presentation by making the torgen best way to differentiate is silent versus an symptomatic legion. So typically an ecogenic mass well circumscribed hyper-echoic than testis unless true otherwise these are epididymal adenomertal tumors. There is a huge list of legions lying within the epididymis depending upon the connective tissue structures fat lying there we are not going to go into the details of the same but there can be legions lying in the cord pediatric age group anechoic cystic legion you know that this is a bayonet ship entrapped within the cord unless proved otherwise these are nothing but insisted hydrocele of the cord but in India filariasis is very very common so many a times you will see that the cord area is replaced with this multiple anechoic cystic structures which is not picking up vascularity on ultrasound and Doppler these are nothing but lymph anjectasia in the cord so whenever you see lymph anjectasia in the cord you need to report this that they will show no color flow on imaging but always in anemic areas of India the most common pathology is filariasis so you should go and search didactically in all areas of lymph anjectasia for this filarial dance which you are in samil ghani sir's case we saw there was lymph anjectasia but we could pick up this filarial dance so whenever you see some filarial dance like this and lymph anjectasia putting two and two in India we write a confident diagnosis of filariasis but the western countries don't accept our school of thinking because they say that their filariasis is not very common they say that this kind of appearance happens because of brownian motion because of macroagglutinated or macrosperms which undergo agglutination and these also show brownian motion and show these kind of filarial dance so they say that there is nothing called as filarial dance but i still feel in our Indian scenario with filariasis is being still so common whenever you see lymph anjectasia with filarial dance you should make a prompt diagnosis of filariasis but in abroad countries they write it as a brownian motion artifact so this is the video showing the same in cord the most common is benign pathology is lipoma in fact in 18 years i am yet to see these all rare malignant legions within the cord the commonest one is lipoma in fact see this surgeon who himself presented with a paratesticular legion where testes epididymis were completely normal and what we picked up in this paratesticular area is this ecogenic mass completely lying in the region of the spermatic cord on the left side right spermatic cord normal epididymis normal see this was the case it actually looks like a testes being there but this is an ecogenic mass unless food otherwise if it is in the cord area fibular pattern which gives a signature sign of lipomas anywhere in body unless food otherwise these turn out lipomas