 Hello everyone, I am Dr. Subhas Taylor, radiologist, Subhas Ultrasound Imaging Centre, Bheilwada, Rajasthan. My field of interest is ultrasound and today I am going to discuss ultrasound features of benign testicular cysts. We know intratesticular cystic lesions are clinically palpable or non-palpable. They can be tender, non-tender, acute or chronic in onset or can be incidentally detected on ultrasound. High-resolution color Doppler ultrasound is modality of choice for evaluation of various scrotal cysts. Most of the intratesticular cystic lesions are benign and can be identified by their anatomic locations. Diagnosis of these cysts will avoid unnecessary surgery. This presentation includes ultrasound characterization of various benign intratesticular cysts. When there is a fluid collection in the scrotal sac, we can even make 3D reconstruction of scrotal contents as we can see in these two images, beautifully, spermatic cord, appendix of the testis, epidemis and testicular outline in particular. Now, coming to sonoinatomy of the testis, testis is thoroughly examined with the help of high-resolution transducer and thoroughly in entirety from craniocaudal approach in longitudinal as well as in short axis planes. It is well-defined avoid structure with homogenic medium-level echoes. It is surrounded by an echo-genic line, here we can see by red arrows, is basically a capsule of the testis which is formed by tunica albuginia and visceral tunica vaginalis layer. This is another zoom image of the scrotal sac showing well-defined, compactly arranged two echo-genic layers of tunica albuginia and tunica vaginalis. And when there is fluid collection in the scrotal sac, we can see varietal deflection of tunica vaginalis also as we can see by this blue arrow. These are two different images of transverse and longitudinal scans of testis showing an echo-genic structure centrally located on posterior-lateral aspect is a media synompathotestis which is seen as echo-genic structure. And another important structure posterior-lateral to testis is epididymis which has head, body and tail parts and ecotexer of epididymis is almost equals to testis. And on longitudinal plane we can see head of the epididymis on abutting the upper wall of the testis in most of the time. Benign testicular cysts are commonly seen are tunica albuginia cyst, simple testicular cyst, epidermoid cyst, ectasia or cystic transformation of ratchetestis, intratesticular spermato seals, intratesticular varico seals, abscess, segmental infarcts or post-traumatic hematomas. Now coming to tunica albuginia cyst, this presents as a small palpable non-tender mass, usually affecting elderly males between 40 to 60 years of age. It is commonly seen at upper-lateral part of the testis. The cyst is simple, uni- or multi-locular in appearance and size ranges between 2-5 mm. These are testicular scans, longitudinal and transverse images showing a well-defined small, unilocular, simple cystic lesion at the periphery of the testis in the region of tunica albuginia is classical of tunica albuginia cyst. It is non-vascular structure, it is palpable as it is sitting at the periphery of the testis. Now these are two images of transfer sections of the testis of two different patients. The blue arrow is showing again a small tunica albuginia cyst and another red arrow is showing a small cystic lesion located at sub-capsular location is basically intratesticular cyst. So these are peripherally located cysts but are tunica albuginia and intratesticular cysts. Now simple cysts, simple cysts are seen mostly in elderly males and most of the time it is an incidental finding. Simple cysts are seen near mediastinum, they can be single or multiple, size varies between 2-25 mm and these cysts we are all characters of simple cysts like imperceptible wall, clear or eco-free interior, distal eco-enhancement with no internal complexities like internal eco-saptee or solid nodule. These cysts if are small are non-palpable and if eccentric or peripherally located in the testis then they are palpable. These cysts are associated with extratesticular epididymal cysts or spermetocele and causes of simple cyst can be trauma, surgical intervention, post-inflammatory and these cysts require no treatment. Simple testicular cysts are also seen associated with epididymal cyst or spermetocele and this is transfer scan of the testis and epididym is showing a small intratesticular cyst seen by red arrow and another cystic lesion C1 that is shown by red arrow is extratesticular cyst of epididymis. Now coming to another cystic lesion that is epidermoid cysts, these are uncommon germ cell tumors or cysts, size varies between 10-30 mm, these are usually palpable masses and non-tender. Azofection is variable between 20-40 years of age at ultrasound these lesions are focal rounded target like lesions with a concentric hypo and hyper-echoic layers which gives a typical onion ring appearance. This is zoomed image of the same lesion showing a typical target like an onion ring lesion. Peroperatively it was found to be an epidermoid cyst. In this case we can also see small L-defined hypoechoic heterogenic area with punctate foci is another mass like lesion was another epidermoid which was basically collapsed. So there were two epidermoids in this case, we can differentiate epidermoid from tumor by its typical target like or onion ring configuration on ultrasound and negative tumor marker status and a vascularity. Now another important condition is ectasia or cystic transformation of the retic testis. It is a diffuse dilatation or cystic changes in the retae of the testis due to obstruction in the ephrainducts. It is a benign condition usually asymptomatic and seen as incidental finding. It affects elderly males more than 40-50 years of age and it is usually bilateral. At ultrasound we can see multiple dilated clustered tubules or multi cystic mass in the region of mediastinum and associated with epidermal cysts with no internal vascularity. It should be differentiated from cystic neoplasm like teratoma or inter testicular varicoseal. The same case as we have seen previously is showing mediastinal multi cystic mass with a large supra testicular epidermal cyst which is basically a spermatocele and it is associated with ectasia of the retic testis. Now these are three different cases and three different testicular scans showing mild, moderate and gross type of ectasia of the retic testis. Now inter testicular spermatoceles. These are intraperian chimbell cystic lesions seen near the mediastinum and retic testis. These cysts usually communicate with the seminiferous tubules and contents internal echoes and permetozoa and that's why they are known as permetoceles, intra testicular spermatoceles. Mostly permetoceles are extra testicular and located in the head of the epidermal cyst but sometimes they can extend within the perian chimbell of the testis. They can be unilocular, they can be septic. So this is a transverse scan of the testis showing a well defined cystic lesion in the region of mediastinum of the testis. Now there are certain conditions simulating ectasia of the retic. These are testicular teratoma and intra testicular varicoseals. This have a look on testicular teratoma. It is rare tumor in children. It is basically intra testicular complex mass bearing solid and cystic areas and some internal vascularity can be seen with some calcific foci. And this is color Doppler scan of the same left testis showing some internal vascularity on color Doppler. This is peroperative photograph and biopsy turned out to be teratoma in this case. So this is again a multi cystic mass but it affects entire testis. It is not confined within the area of mediastinum as we can see in the retic testis. This is the differentiated point. Now coming to intra testicular varicoseals. These are basically multiple anechoic, syrupy genus or tubular structures or variable size in the testis particularly in periphery or subcaptular area. And on color Doppler color flow channels are seen with venous flow pattern. Blood flow augmentation and reversal is also seen on valsalva maneuver in these genals and usually intra testicular varicoseals are associated with extra testicular varicoseals. But in some cases intra testicular varicoseals may be isolated. Location is mostly in capsular area and subcaptular area but these lesions or these genals may also extend within testicular perinchyma up to some extent. Clinically these patients usually present with testicular swelling and mild orkelgia due to passive congestion. These lesions should be differentiated from pseudo aneurysms in which pseudo aneurysms we can see in young sign and twin flow flow on color Doppler. Testicular abscess usually secondary to apid demorcaitis and other causes of abscess include trauma and testicular infarctions. Testicular abscess can be single or multiple. At ultrasound we can see a well defined hypoechoic to eco free or complex stick mass with slightly thick or shaggy wall with internal echoes and no internal vascularity seen but we can see slightly increased peripheral vascularity around it. In the typical clinical setting we can diagnose testicular abscess. This is a small subcapsular testicular abscess. This is 3D reconstruction of the same. Another important entity is intra testicular infarct. Intra testicular infarct is basically focal or segmental infarction of the test is due to occlusion of the segmental vessels and its causes are apid demorcaitis, trauma or tumor or torsion. At ultrasound we can see a focal triangular shaped hypoechoic mass extending from periphery towards the center of the testis with no internal vascularity and rest of the testis shows normal flow or increased flow depending upon the underlying condition. It may complicate with necrosis and abscess formation or it may result to a small scar or a small calcific focus. It should be differentiated from tumor which shows basically internal vascularity and positive tumor markers whereas for intra testicular infarct usually do not show any internal vascularity and it is devoid of vascularity and in area of infarction. Now there are two sets of examples I am going to show you here. First case is post apid demorcaitis we can see thick congested cord and transverse and longitudinal images of the testis showing marked hyperemia and in testis we can see a well defined large inhomogenic focal hypoechoic area devoid of vascularity and this is zoom image of the testis showing normal vascularity with a large area devoid of vascularity is segmental infarct with areas of necrosis and breakdown in it. This is another example of torsion this is transverse image of the scrotal sac showing the testis in transverse plane with adjacent whirlpool sign and this hypoechoic area as shown by red arrow is a for segmental infarct. This is the testicular scan of the same testis longitudinal scan showing almost average or normal vascularity in the rest of the testis except this focal area hypoechoic area which is due to segmental infarct. So this is basically partial torsion with segmental infarct. Now another condition which we can see it's cyst is due to post traumatic hematoma in traumatic settings and trauma can be blunt penetrating or crushed. The nature of the testicular injury depends on type and severity of the injury and injury can be in form of confusion or some testicular disruption or laceration, fracture of the testis and rupture of the testis with associated testicular or extratesticular hematoma or testicular infarction. This is a case having history of blunt trauma, transverse and longitudinal scans of the testis. There is large focal area of hypoechoic inhomogenic ecotexture, devoid of vascularity rest of the testis shows normal vascularity. The tunica was intact in this patient. This is a focal testicular disruption with a large intratesticular hematoma with variable cystic changes due to variable age. The patient was conservatively treated because there was no disruption in the tunica. To conclude I would like to say benign intratesticular cystic lesions are very well characterized by ultrasound, by their location, by their vascular pattern and differentiation of these lesions is possible with melignin tumors. Thank you very much for your patience listening.