Pathologic Conditions at Imaging of the Spermatic Cord 精索成像时的病理状况
Niloofar Karbasian, MDNicole SegaranNadia Solomon, Gohn S. Pellerito, Douglas S. Katz, MDMariam Moshiri, MDMargarita V Revzin, MD Niloofar Karbasian，MDNicole SegaranNadia Solomon， Gohn S. Pellerito， Douglas S. Katz，MDMariam Moshiri，MDMargarita V Revzin，MD
Abstract 抽象的
Abbreviations: IC inguinal canal, sper matic cord 缩写：IC 腹股沟管， 精索
From the Department of Radiology and Biomedical Imuging, Yale University School of Med icine, 333 Cedar St, PO Box 208042, Room TE 2, New Haven, CT 06520 N.K, N. Solomon, M. V.R.); Stanford University, Stanford, Calif (N Segaran); Zucker School of Medicine at Hofstra Northwell, Department of Radiology, Northwel Health System, Manhasset, NY (J.S.P); Depart ment of Radiology, NYU Winthrop University Hospital, Mincola, NY (D.S.K.); and Department of Radiology, University of Washington Medical Center, Seattle, Wash (M.M.). Recipien of a Certificate of Merit award for an education exhibit at the 2020 RSNA Annual Meeting. Re ceived May 22, 2021; revision requested June 28 and received September 13; accepted Septembe 16. For this journal-based SA-CME activity, the authors D.S.K. and M.V.R. have provided disclosures (see end of article); all other authors, the editor, and the reviewers have disclosed no rel evant relationships. Address correspondence to M.V.R. (e-mail: margurita.revain(ayale.edu) 来自耶鲁大学医学院放射学和生物医学成像系，地址：333 Cedar St, PO Box 208042, Room TE 2, New Haven, CT 06520 N.K, N. Solomon, M. V.R.）；斯坦福大学，斯坦福，加利福尼亚州（N Segaran）；霍夫斯特拉诺斯韦尔 Zucker 医学院，诺斯韦尔卫生系统放射科，曼哈塞特，纽约 (J.S.P)；纽约大学温思罗普大学医院放射科，纽约州明科拉 (D.S.K.)；和华盛顿大学医学中心放射科，华盛顿州西雅图（M.M.）。因 2020 年 RSNA 年会上的教育展览而获得优异奖。 2021 年 5 月 22 日收到； 6月28日提出修改要求，9月13日收到； 9 月 16 日接受。对于这项基于期刊的 SA-CME 活动，作者 D.S.K.和 M.V.R.已提供披露（见文章末尾）；所有其他作者、编辑和审稿人均未披露任何相关关系。与 M.V.R. 的通信地址（电子邮件：margurita.revain（ayale.edu）
'Current address: Department of Radiology, Univernity of Texas Health Science Center, Houston, Texas '当前地址：德克萨斯州休斯顿德克萨斯大学健康科学中心放射科
RSNA, 2022 北美放射学会，2022
SA-CME LEARNING OBJECTIVES SA-CME 学习目标
After complering this joumal-based SA-CME activity, participants will be able to: 完成此基于期刊的 SA-CME 活动后，参与者将能够：
Describe the relevant SC anatomy and its contents, review its relationships to the IC and scrotum, and discuss associ ated physiologic characteristics. 描述相关的 SC 解剖结构及其内容，回顾其与 IC 和阴囊的关系，并讨论相关的生理特征。
Explain the role of imaging in evaluation of emergency and nonemergency pathologic conditions: 解释影像学在紧急和非紧急 病理状况评估中的作用：
Discuss the characteristic imaging features of various SC abnormalities. 讨论各种 SC 异常的特征性影像学特征。
A wide range of benign and malignant processes can affect the spermatic cord (SC). Familiarity with and recognition of the characteristic imaging features of these entities are imperative for accurate diagnosis and optimal clinical care. While some SC diseases are self-limiting, others can result in infertility and potentially life-threatening infection or bleeding if they are left untreated. Therefore, correct diagnosis is important for life-saving treatment and preservation of fertility. Disorders including anomalies of the vas deferens and the processus vaginalis, arterial and venous diseases (torsion of the SC and varicoceles), infection, trauma, and neoplasms are the most pertinent entities with which radiologists should be familiar when assessing the SC. Knowing what to expect in a patient who has undergone SC interventions is imperative. US has a fundamental role in the initial examination of patients who present with symptoms that indicate abnormalities of the SC, such as suspected posttraumatic testicular retraction or SC torsion. Other imaging techniques including abdominal and pelvic MRI and CT have their own importance. For correct interpretation of the findings and to establish an accurate diagnosis, it is crucial to have a thorough knowledge of the anatomy, the utility and limitations of various imaging modalities, optimal imaging and scanning techniques, and the imaging features of various benign and malignant pathologic conditions that can involve the SC. 多种良性和恶性过程都会影响精索 (SC)。熟悉和识别这些实体的特征性影像学特征对于准确诊断和最佳临床护理至关重要。虽然一些 SC 疾病是自限性的，但其他疾病如果不及时治疗，可能会导致不孕以及可能危及生命的感染或出血。因此，正确诊断对于挽救生命的治疗和保留生育能力具有重要意义。包括输精管和阴道突异常、动脉和静脉疾病（SC 扭转和精索静脉曲张）、感染、创伤和肿瘤在内的疾病是放射科医生在评估 SC 时应熟悉的最相关实体。了解接受 SC 干预的患者会发生什么情况至关重要。对于出现 SC 异常症状（例如疑似创伤后睾丸回缩或 SC 扭转）的患者，超声检查在初步检查中发挥着重要作用。其他成像技术，包括腹部和盆腔 MRI 和 CT，也有其重要性。为了正确解释所发现的结果并建立准确的诊断，至关重要的是全面了解解剖学、各种成像方式的实用性和局限性、最佳成像和扫描技术以及各种良性和恶性病理的成像特征。可能涉及 SC 的条件。
Online supplemental material is available for this article. 本文提供在线补充材料。
Pathologic conditions that affect the spermatic cord (SC) are relatively common in everyday clinical practice. These conditions range from asymptomatic abnormalities that are incidentally discovered to common causes of emergency medicine visits. Visits for male genitourinary complaints comprise of all emergency medicine visits . In many cases, various pathologic entities that affect either the scrotal contents or the prostate indirectly involve the SC. Although US is the primary imaging modality in assessment of the SC, abdominal and pelvic CT and MRI also are important. It is critical for the radiologist be familiar with SC anatomy and the imaging features of conditions that affect the SC to ensure correct diagnosis and proper patient care. 影响精索 (SC) 的病理状况在日常临床实践中相对常见。这些病症的范围从偶然发现的无症状异常到急诊就诊的常见原因。男性泌尿生殖系统疾病就诊占所有急诊医疗就诊 的 。在许多情况下，影响阴囊内容物或前列腺的各种病理实体间接涉及 SC。尽管超声是评估 SC 的主要成像方式，但腹部和盆腔 CT 和 MRI 也很重要。对于放射科医生来说，熟悉 SC 解剖结构和影响 SC 的病症的成像特征至关重要，以确保正确诊断和适当的患者护理。
In this article, we discuss the anatomy and physiology of the SC, review the available conventional and advanced imaging modalities used for SC assessment, and discuss the imaging appearance and differentiating features of various benign and malignant SC conditions. 在本文中，我们讨论 SC 的解剖学和生理学，回顾用于 SC 评估的现有常规和先进成像方式，并讨论各种良性和恶性 SC 病症的影像学表现和鉴别特征。
Figure 20. SC fibrous pseudotumor in a 45 -yearold man with a palpable suprascrotal mass. (A) Sagittal color Doppler US image of the groin shows a hypoechoic solid mass ( ), with posterior acoustic shadowing (black arrow) in the suprascrotal segmen of the SC (white arrows), which are findings that are most consistent with a leiomyoma. (B) Corresponding coronal fat-saturated T2-weighted MR image shows a solid hypointense well-defined mass (*). A smal left hydrocele is noted and is likely physiologic. (C) Contrast-enhanced TI-weighted MR image shows enhancement of the mass (arrowhead). Note that the fibrous pseudotumor has a similar appearance at al cross-sectional imaging to that of a leiomyoma. 图 20. 一名 45 岁男性的 SC 纤维性假瘤，可触及阴囊上肿块。 (A) 腹股沟矢状彩色多普勒超声图像显示低回声实性肿块 ( )，在 SC 的阴囊上段（白色箭头）中有后声阴影（黑色箭头），这些发现与平滑肌瘤最为一致。 (B) 相应的冠状脂肪饱和 T2 加权 MR 图像显示固体低信号明确的质量 (*)。注意到左侧有小鞘膜积液 ，可能是生理性的。 (C) 对比增强 TI 加权 MR 图像显示质量增强（箭头）。请注意，纤维性假瘤在所有横截面成像中具有与平滑肌瘤相似的外观。
Figure 21. Cystic lymphatic malformation in a 55 -year-old man with a groin and scrotal mass that has been stable for 30 years. (A) Sagittal power Doppler US image of the scrotum in the supratesticular location shows a multiloculated cystic complex mass in the SC (white arrows), with a mild amount of flow (arrowhead) in the thin and thick septa (black arrow). Note that the testis is located inferior to the mass. (B) Correlative sagittal fat-saturated T2-weighted MR image shows a multilocular mass (white arrows) with thin and thick septa (black arrow). Some of the loculations demonstrate a hemorrhagic component, which is evidenced by a T2 shading artifact (arrowhead). The septa demonstrated faint contrast enhancement on delayed images (not shown). 图 21. 一名 55 岁男性的囊性淋巴管畸形，腹股沟和阴囊肿块已稳定 30 年。 (A) 睾丸上位置阴囊的矢状功率多普勒超声图像显示 SC 中存在多房性囊性复合体肿块（白色箭头），薄厚隔膜（黑色箭头）中有少量血流（箭头）。请注意，睾丸 位于肿块下方。 (B) 相关矢状脂肪饱和 T2 加权 MR 图像显示多房性肿块（白色箭头），具有薄而厚的隔膜（黑色箭头）。一些部位表现出出血成分，T2 阴影伪影（箭头）证明了这一点。隔片在延迟图像上表现出微弱的对比度增强（未显示）。
typically demonstrates increased internal vascularity (31,57). MRI is essential in differentiation of liposarcomas from lipomas because it demonstrates enhancing soft-tissue components that suggest liposarcoma (58). Metastatic disease or local invasion can also occur. CT is reserved for staging (Fig 22). Although liposarcomas dominate cases of adult SC tumors, rhabdomyosarcomas are the most common paratesticular subtype in children and are mainly seen in patients aged years ). At CT, rhabdomyosarcoma manifests as an infiltrative mass around the SC (31). US and MRI findings are generally nonspecific and can mimic more prevalent paratesticular neoplasms (Fig 23). 通常表现出内部血管分布增加（31,57）。 MRI 对于区分脂肪肉瘤和脂肪瘤至关重要，因为它显示提示脂肪肉瘤的软组织成分增强 (58)。也可能发生转移性疾病或局部侵袭。 CT 保留用于分期（图 22）。虽然脂肪肉瘤在成人 SC 肿瘤中占主导地位，但横纹肌肉瘤是儿童中最常见的睾丸旁亚型，主要见于年龄 岁 的患者。在 CT 上，横纹肌肉瘤表现为 SC 周围的浸润性肿块 (31)。 US 和 MRI 结果通常是非特异性的，可以模仿更常见的睾丸旁肿瘤（图 23）。
Figure 3. Unilateral congenital agenesis of the vas deferens in a 57 -year-old man with a history of cystic fibrosis who presented for evaluation of infertility. (A) Sagittal color Doppler US image of the left IC shows the absence of the SC, with only fat contents seen in the IC (arrows). (B) Corresponding transverse color Doppler US image of the scrotum shows an empty left hemiscrotum ( Scrotum). The right testis (RT) shows normal echogenicity. (C) Coronal contrast-enhanced CT image shows the absence of the SC in the left groin (arrowhead) and a normal right SC (arrow). There was no associated left renal or seminal vesicle agenesis. 图 3. 一名 57 岁男性，患有囊性纤维化病史，因单侧先天性输精管发育不全而前来接受不孕症评估。 (A) 左侧 IC 的矢状彩色多普勒超声图像显示不存在 SC，仅在 IC 中看到脂肪含量（箭头）。 (B) 相应的阴囊横向彩色多普勒超声图像显示左半阴囊空虚（ 阴囊）。右侧睾丸 (RT) 显示正常回声。 (C) 冠状对比增强 CT 图像显示左侧腹股沟处没有 SC（箭头），右侧 SC 正常（箭头）。没有相关的左肾或精囊发育不全。
Figure 4. Vasa deferentia calcifications in a 44-year-old man with a history of diabetes. (A) Coronal precontrast CT image of the pelvis shows bilateral symmetric parallel linear calcifications (arrows) along the walls of the vasa deferentia at the level of the ampulla and seminal vesicles. (B) Sagittal color Doppler US image of the SC shows similar findings in the vas deferens (arrows). 图 4. 一名有糖尿病史的 44 岁男性的输精血管钙化。 (A) 骨盆的冠状预对比 CT 图像显示，壶腹和精囊水平沿输精管壁出现双侧对称平行线性钙化（箭头）。 (B) SC 的矢状彩色多普勒超声图像显示输精管中的类似发现（箭头）。
patients with it typically present with a completely necrotic testis at birth (15). In this type of SC torsion, twisting of the SC takes place outside the sac of the tunica vaginalis. The intensity of clinical symptoms varies according to the duration and degree of torsion. Common findings include nausea, vomiting, scrotal swelling and pain, a high-riding testicle, and the absence of cremasteric reflex . Because SC torsion may be difficult to distinguish clinically from other scrotal abnormalities including epididymo-orchitis, acute epididymitis, and torsion of the appendix testis, gray-scale and Doppler US are vital to establishing the diagnosis (14). Although the testicular appearance may remain normal during early phases of torsion (ie, within the first 1-3 hours), eventual enlargement and heterogeneous echogenicity are frequently observed. At US, a spiral appearance of the twisted SC (ie, "torsion knot" or "whirlpool pattern") is seen in of cases (Fig 5, Movie 1) (17). An edematous cord can also manifest as a round or ovoid echogenic supratesticular 患有该病的患者通常在出生时就出现睾丸完全坏死的情况 (15)。在这种类型的 SC 扭转中，SC 的扭转发生在阴道膜囊的外部。临床症状的强度根据扭转的持续时间和程度而变化。常见症状包括恶心、呕吐、阴囊肿胀和疼痛、睾丸高位以及提睾反射消失 。由于 SC 扭转在临床上可能难以与其他阴囊异常（包括附睾睾丸炎、急性附睾炎和睾丸附件扭转）区分开，因此灰阶和多普勒超声对于诊断至关重要 (14)。尽管睾丸外观在扭转的早期阶段（即最初的 1-3 小时内）可能保持正常，但经常观察到最终增大和异质回声。在美国，在病例 中可以看到扭曲SC的螺旋外观（即“扭结”或“漩涡图案”）（图5，电影1）（17）。水肿性脊髓也可表现为圆形或卵圆形的睾丸上回声
Figure 1. Illustration shows an overview of the spermatic cord (SC) as it exits (left) and passes through (middle) the inguinal canal (IC) and the cross-sectional anatomy of the SC (right). Note that the SC starts at the level of the deep (internal) inguinal ring, where the vas deferens enters the IC, and leaves the IC through the superficial (external) inguinal ring. The distal (scrotal) portion of the SC is not included in the illustration. The cross-sectional anatomy of the SC includes the genital branch of the genitofemoral nerve (from the lumbar plexus); the vas deferens and its artery (a branch of the inferior vesicle artery); the testicular artery (which originates from the infrarenal aorta); the testicular veins (ie, the pampiniform plexus), with the left testicular vein draining into the left renal vein and the right testicular vein draining directly into the inferior vena cava; the cremasteric artery (a branch of the inferior epigastric artery); the lymphatic vessels; and connective tissue. Three fascial layers cover the SC: the internal and external spermatic fascia and the cremasteric fascia. 图 1. 图示显示精索 (SC) 离开（左）并穿过（中）腹股沟管 (IC) 时的概览以及 SC 的横截面解剖结构（右）。请注意，SC 起始于腹股沟深环（内），输精管在此进入 IC，并通过腹股沟浅环（外）离开 IC。图中未包括 SC 的远端（阴囊）部分。 SC 的横截面解剖结构包括生殖股神经的生殖分支（来自腰丛）；输精管及其动脉（下囊泡动脉的分支）；睾丸动脉（起源于肾下主动脉）；睾丸静脉（即蔓状丛），左睾丸静脉流入左肾静脉，右睾丸静脉直接流入下腔静脉；提睾动脉（腹壁下动脉的分支）；淋巴管；和结缔组织。 SC 覆盖三层筋膜：精索内筋膜、精索外筋膜和提睾筋膜。
vessels, marks the most proximal end of the SC (7). Assessment of the distal (ie, scrotal) segment of the SC, which begins at the epididymal tail and courses cranially toward the superficial ring of the IC, completes the examination. 血管，标记 SC 的最近端 (7)。对 SC 远端（即阴囊）部分的评估完成了检查，该部分从附睾尾部开始，向颅内延伸至 IC 的浅环。
Special maneuvers such as the Valsalva maneuver, with the patient in supine and/or standing positions during the examination, can be helpful in evaluation of various SC abnormalities, particularly varicoceles (7). 特殊的操作，例如 Valsalva 操作，在检查期间患者处于仰卧和/或站立位置，有助于评估各种 SC 异常，特别是精索静脉曲张 (7)。
Imaging Appearance of the Normal SC 正常 SC 的影像表现
The SC, which contains the vas deferens and testicular vessels, appears relatively hypoechoic when compared with echogenic fat in the IC. In the longitudinal plane, the vas deferens appears as a hypoechoic cordlike structure with two parallel linear reflectors that reflect the echogenic mucosa of the lumen. These are surrounded by a thick, hypoechoic, and mostly muscular wall. In the transverse plane, the vas deferens shows a targetlike appearance (Fig 2). The vas deferens normally measures 1-3 mm in anteroposterior diameter, and - in contrast to vessels - does not collapse during external compression by the transducer because of its thick muscular wall (8). SC 包含输精管和睾丸血管，与 IC 中的回声脂肪相比，回声相对较低。在纵向平面中，输精管表现为低回声索状结构，具有两个平行的线性反射器，反射管腔的回声粘膜。它们被厚厚的、低回声的、大部分由肌肉构成的壁包围。在横向平面上，输精管呈靶状外观（图 2）。输精管前后径通常为 1-3 毫米，与血管不同，由于其肌肉壁较厚，在传感器外部压缩期间不会塌陷 (8)。
At color Doppler US, the testicular artery and pampiniform plexus are visualized as tubular vessels coursing along the IC. The vas deferens artery is not normally visualized at US examination of a noninflamed cord (9) (Fig 2). In some situations, the vas deferens pampiniform plexus may be mistaken for the venous plexus. The vas deferens can be differentiated from the venous plexus on the basis of the following characteristics: (a) No flow is seen in the vas deferens at color Doppler US, (b) the vas deferens is relatively straight compared with the more tortuous venous plexus, (c) the mucosa of the vas deferens appears as parallel echogenic lines, and (d) no enlargement of the vas deferens is seen with the use of the Valsalva maneuver at cross-sectional imaging such as CT and MRI. The use of CT and MRI are reserved for patients with inconclusive, equivocal, or nondiagnostic US findings and may reveal additional information such as local extension of malignant neoplasms or complications of prior instrumentation. 在彩色多普勒超声检查中，睾丸动脉和蔓状神经丛被视为沿着 IC 行进的管状血管。对未发炎的脊髓进行超声检查时，通常看不到输精管动脉 (9)（图 2）。在某些情况下，输精管蔓状丛可能会被误认为是静脉丛。输精管可根据以下特征与静脉丛区分开来：(a) 彩色多普勒超声检查中输精管未见血流，(b) 与更曲折的静脉丛相比，输精管相对笔直，（c）输精管粘膜呈平行回声线，（d）在 CT 和 MRI 等横截面成像中使用 Valsalva 动作未见输精管扩大。 CT 和 MRI 的使用仅限于超声检查结果不确定、模棱两可或无法诊断的患者，并且可能会揭示其他信息，例如恶性肿瘤的局部扩展或先前仪器的并发症。
At CT, the cord appears as a fat-containing tubular structure surrounded by a thin capsule. The vas deferens is indistinguishable from adjacent vessels under normal circumstances, although the ejaculatory duct can be identified at the level of the origin of the seminal vesicles. The pampiniform plexus appears as nondilated ( ) veins, and the testicular artery may enhance after administration of intravenous contrast material (Fig E1). 在 CT 上，脊髓显示为被薄囊包围的含脂肪管状结构。正常情况下，输精管与邻近血管无法区分，但可以在精囊起源水平识别射精管。蔓状丛表现为未扩张的 ( ) 静脉，静脉注射造影剂后睾丸动脉可能增强（图 E1）。
The MRI protocol for imaging of the SC includes T1- and T2-weighted MRI, intravenous contrast-enhanced T1-weighted MRI with fat suppression, in- and out-of-phase gradient-recalledecho MRI sequences, and diffusion-weighted MRI. The cord demonstrates intermediate signal intensity at T1- and T2-weighted MRI, with the vessels and vas deferens appearing as low-signalintensity tubular structures (Fig E1). The intra-abdominal vas deferentia are seen as bilateral tubular SC 成像的 MRI 方案包括 T1 和 T2 加权 MRI、具有脂肪抑制功能的静脉对比增强 T1 加权 MRI、同相和异相梯度回忆回波 MRI 序列以及扩散加权 MRI。脊髓在 T1 和 T2 加权 MRI 中显示出中等信号强度，血管和输精管显示为低信号强度管状结构（图 E1）。腹腔内输精管呈双侧管状
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