Received: 28 March 2021 Revised: 12 May 2021 Accepted: 24 May 2021

DOI: 10.1111/andr.13057

REVIEW ARTICLE

Use of contrast enhanced ultrasound in testicular diseases:

A comprehensive review

Marta Tenuta Franz Sesti Ilaria Bonaventura Paola Mazzotta Riccardo Pofi
Daniele Gianfrilli Carlotta Pozza

Department of Experimental Medicine, Sapienza University, Rome, Italy

Correspondence
Carlotta Pozza, Department of Experimental Abstract
Medicine, Sapienza University of Rome, Viale
Regina Elena 324, 00161 Rome, Italy.
Background: Contrast-enhanced ultrasound (CEUS) is a sonographic technique that
Email: carlotta.pozza@uniroma1.it increases the diagnostic accuracy of ultrasound and color Doppler ultrasound (CDUS)
when studying testicular abnormalities. However, its role in clinical practice is still
debatable because there are no accepted standards regarding how and when this tech-
nique should be used for patients with testicular disease.
Objectives: To perform a nonsystematic review of the current literature to highlight
the strength and flaws of performing CEUS and to provide a critical overview of current
research evidence on this topic.
Materials and methods: A thorough search of published peer-reviewed studies in
PubMed was performed using proper keywords.
Results: Strong enhancement of neoplastic lesions (both benign and malignant) dur-
ing CEUS aids in differential diagnosis with non-neoplastic lesions, which usually
appears either nonenhanced or enhanced in a manner similar to that of the surround-
ing parenchyma. CEUS enhancement has a high predictive value in the identification
of neoplastic lesions, whereas a similar or complete absence of enhancement may
be interpreted as strong evidence of benignity, although there are exceptions. Liter-
ature on quantitative analysis is still scarce, though promising, particularly in distin-
guishing benign from malignant neoplasms. Furthermore, CEUS may be useful in many
emergency situations, such as acute scrotum, blunt scrotal trauma, and focal infarc-
tion of the testis. Finally, CEUS can help increase the probability of sperm recovery in
azoospermic males.
Discussion and conclusion: CEUS is a safe, easy-to-perform, and cost-effective diag-
nostic tool that can provide a more accurate diagnosis in testicular lesions and acute
scrotal disease. However, further studies with larger cohorts are required to refine the
differential diagnosis between benign and malignant neoplasms. Finally, these prelim-
inary results can instigate the development of innovative research on pre-testicular
sperm extraction to increase the chances of sperm recovery.

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided
the original work is properly cited.
© 2021 The Authors. Andrology published by Wiley Periodicals LLC on behalf of American Society of Andrology and European Academy of Andrology

Andrology. 2021;9:1369–1382. wileyonlinelibrary.com/journal/andr 1369

1370 TENUTA ET AL.

KEYWORDS
acute scrotum, CEUS, infertility, testicular tumor, testis

1 INTRODUCTION the number of allergic reactions reported is lower than those arising
with CT and MRI contrast medium.21–23 The overall reporting rate
Testicular ultrasound (US) currently represents a routine and manda- for all adverse events is 0.125% (only 0.0086% for serious ones)23
tory investigation for patients with scrotal symptoms and is considered including itching, mild dizziness, moderate hypotension, headache, and
the first-line imaging modality in the evaluation of the testis and adja- nausea which resolved spontaneously. Second, CEUS is neither car-
cent structures, in addition to physical examination. Since its introduc- diotoxic nor nephrotoxic and can be safely administered in patients
tion, US has become an integral diagnostic tool in clinical settings that with renal insufficiency because the contrast medium is not excreted
has been further enhanced by continuous developments to improve the via the kidney, but it is cleared by the lungs.20,24 Consequently, and
resolution of US machines and probes.1–3 due to all the other advantages offered, this diagnostic tool can
Although grayscale US, color Doppler US (CDUS), and power also be used on children.25,26 Finally, compared to MRI, CEUS offers
Doppler US (PDUS) demonstrate high diagnostic accuracy for detect- higher spatial resolution (especially using new high frequency probes,
ing most testicular pathologies, interpretation of the acquired images up to 18 MHz), allowing for a dynamic assessment even of smaller
is not well standardized and may rely on the operators’ expertise. lesions.
Recently, the use of certain techniques such as tissue elastography and Over the last years, CEUS has proved to be particularly useful in tes-
magnetic resonance imaging (MRI)4–10 has been explored in terms of ticular setting: microbubbles trace normal parenchymal microcircula-
overcoming this limitation, as well as superb microvascular imaging tion and are able to highlight intraparenchymal abnormalities within
(SMI), which specifically aims to visualize low velocity and small diame- the testicle. This is particularly useful in the characterization of tes-
ter blood vessel flow.11–13 However, their strength is still debatable. ticular lesions7–10,27–33 and acute scrotum.34–36 Recent studies have
In the last few decades, the use of intravascular contrast-enhanced also focused on the utility of CEUS in evaluating testicular perfusions
US (CEUS) has grown considerably and has proved to be a useful tool in prior to testicular sperm extraction (TESE) in infertile men.37,38 How-
many diagnostic fields.14–18 ever, to date, there are no well-established and accepted standards
US contrast medium consists of US-detectable microbubbles, which with respect to how and when this technique should be used when
are very small-sized (<10 μm) organic shells that are filled with gas. dealing with patients suffering from testicular disease.
Over the years, many US contrast agents have been approved for clin- The purpose of this study was to perform a comprehensive, up-
ical use,17,19 such as sulfur hexafluoride (SonoVue® , Bracco, Milan, to-date review of the current literature to highlight the strength and
Italy), octafluoropropane, (Definity® , Lantheus Medical Imaging, North flaws of performing CEUS, and to provide a critical overview of current
Billerica, MA, USA), perfluorobutane (Sonazoid™, GE Healthcare, Oslo, research evidence on this topic to inform and guide clinicians’ choices
Norway), and perflutren protein-type A microsphere (Optison™, GE of performing CEUS in certain conditions, and to provide them support
Health care, Oslo, Norway). in the interpretation of the exam.
A dedicated machine-setting with a low mechanical index (0.05– A computerized literature search was performed using the follow-
0.08) is needed to avoid early microbubble destruction.20 The local- ing keywords: “CEUS,” “testicle,” “testicular tumor,” “testicular lesion”,
ization of microbubbles is exclusively intravascular because they are “seminoma”, “Leydig cell tumor”, “scrotal trauma,” “testicular torsion”,
small enough to pass through the lumina of capillaries, yet large enough and “infertility”. Keywords were properly combined with Boolean oper-
to prevent extravasation from vessels. Due to their high impedance, ators to optimize the search strategy.
they reflect the majority of US waves with a higher echo than the
parenchyma. In fact, unlike CDUS and PDUS, CEUS provides a reliable
representation of blood perfusion and parenchymal microcirculation 2 TESTICULAR CEUS TECHNIQUE
in various organs, using intravascular blood tracers. After injection of
the contrast medium, two phases are described in organs with a single CEUS can depict parenchymal disorders on the basis of vascularity,
arterial blood supply20 : the first is the arterial phase (10–40 s), which thus mostly helping in the differential diagnosis of traumatic changes
shows a progressive enhancement; the second one is the venous phase and scrotal lesions. For testicular studies, the most frequently used
(30–45 s), which starts after injection and exhibits a plateau followed contrast agent in Europe is sulfur hexafluoride (SonoVue® ). SonoVue
by a progressive decrease, until the microbubble signal completely dis- is injected as two intravenous boluses of 2.4 mL (for a total of 4.8 mL)
appears. in an antecubital vein. The second dose should be injected 5–10 min
CEUS offers a number of advantages: it is easy to perform, cost- after the first injection, and both should be followed immediately
effective, safe, and does not have any harmful effects compared to by 10 mL of 0.9% saline solution. After contrast medium and saline
other complementary imaging methods such as CT and MRI. First, solution flush, microbubbles are usually observed within the testicle
TENUTA ET AL. 1371

F I G U R E 1 Qualitative analysis of CEUS. B-mode US demonstrates a small hypoechoic lesion, with hyperechoic and well-defined margins,
resulted a Leydig cell tumor at histology. Color Doppler US demonstrates vascularity within the lesion. With contrast-enhanced US, the lesion
demonstrates marked hyperenhancement, a characteristic that has the potential to differentiate neoplastic from nonneoplastic lesions

after a mean time of 20 s,20 thus enabling clinicians to draw an exact uptake phase of the contrast medium (wash-in) up to the maxi-
vascular map of the examined testis. The enhancement of testicular mum peak of intensity, and a subsequent release phase (washout)
and epididymal arteries occurs rapidly, followed by a subsequent (Figure 2).
parenchymal enhancement. Wash-in and washout of the contrast agent can be quantified by cal-
Typically, the contrast medium is no longer visible after an aver- culating intensity and temporal parameters (quantitative parameters).
age of 3–5 min.20 The entire examination needs to be recorded for Normal testicular parenchyma time-intensity curve values are lacking
subsequent analyses. Recording should be initiated at the end of each in literature, and existing studies focus on focal lesion kinetics. How-
contrast-enhancement injection and should be concluded after at least ever, depending on the software used, the parameters obtained may be
90 s. The first evaluation that can be performed involves a qualita- different, and different units of measurement could also be employed,
tive analysis: after each injection, it is possible to observe whether particularly for intensity data. In general, it is possible to identify cer-
the contrast medium enhances the area of interest, and subsequently tain standard values, which are essential for the subsequent quantita-
evaluate the intensity and timing of the uptake (wash-in), and release tive analysis7,28,29,31,38,39 (Figure 3):
(washout) of microbubbles compared with parenchyma. The area of
interest can be defined as hyper-enhancing (Figure 1), hypo-enhancing, 1. Wash-in time (W-in): the time when testicular enhancement occurs
or non-enhancing compared with the surrounding parenchyma, and the first, measured in seconds
wash-in and washout can be defined as faster, similar, or slower than 2. Time to peak (TTP): the time needed to reach the peak intensity,
parenchyma.7,9,27–29,31 However, qualitative analysis is subjective and measured in seconds
operator-dependent. In contrast, quantitative analysis using appropri- 3. Mean transit time (MTT) or rise time (RT): the difference between
ate software generally integrated in the US machine is a significantly the time needed to reach the peak intensity and the time since the
less biased approach. beginning of ROI enhancement, measured in seconds
Time-intensity curves can be obtained by manually placing a 4. Peak intensity (PI) or peak enhancement (PE): the maximum ROI
region of interest (ROI) to entirely cover the area to be examined. enhancement, measured in decibel (dB) or acoustic units (au)
Another identical ROI should be placed on the adjacent parenchyma 5. Washout time (T-out): the time difference between the 50% PI val-
for comparison.28 Within the ROI, the mean intensity of contrast ues in the washout and PI value, measured in seconds. Several stud-
enhancement can be described as a function of time with time- ies also consider T-out as the time needed for the descending slope
intensity curves: they are bell-shaped curves that describe an initial to reach a contrast signal intensity of zero
1372 TENUTA ET AL.

F I G U R E 2 Time intensity curves (TIC). They are bell-shaped curves that describe an initial uptake phase of the contrast medium (wash-in) up
to the maximum peak of intensity, and a subsequent release phase (washout). Lesion and parenchyma kinetics can be measured, and the resulting
curves can be compared. In the figure the blue curve describes the wash-in and wash-out phases of a Leydig cell tumor, the orange curve describes
the phases of the adjacent, normal parenchyma

3 CEUS AND TESTICULAR LESIONS

One of the most successful uses of CEUS reported in the literature

involves the differential diagnosis of intratesticular lesions.33 Males
presenting a palpable testis nodule are likely to have malignant
germ-cell tumor in > 90% of cases. However, the increased use of
testicular US as a diagnostic tool in most andrological pathologies and
the recent developments of high-frequency probes in ultrasonography
have allowed for an increase in the detection of small, incidental
intratesticular lesions that are thought to be benign in > 30% of cases.
Thus, a radical orchiectomy should be considered as overtreatment.40
The first step for clinicians is to distinguish whether a lesion is
neoplastic or non-neoplastic. If a neoplastic lesion is suspected, the
F I G U R E 3 Graphic representation of the time/intensity curve and second step is to differentiate between benign and malignant tes-
the calculated perfusion parameters—wash-in time (W-in): the time
ticular tumors (TTs). Clinical history (genetic syndromes, history of
when testis enhancement first occurs, measured in seconds; time to
cryptorchidism, previous surgery, infertility, previous contralateral
peak (TTP): the time needed to reach the peak intensity (PI), measured in
seconds; mean transit time (MTT) or rise time (RT): the time difference tumor, and familiarity for testicular cancer), symptoms (sudden or
between the time needed to reach the PI and the time since the chronic pain and swelling), and laboratory data (serum tumoral mark-
beginning of ROI enhancement, measured in seconds; PI or peak ers) can significantly assist this process. However, in certain cases, the
enhancement (PE): the maximum ROI enhancement, measured in differential diagnosis can still be challenging. During the last decades,
decibel (dB) or acoustic units (au); washout time (T-out): the time
CEUS has become a very useful method to improve the characteriza-
difference between the 50% PI values in the washout and peak
intensity value, measured in seconds (several studies also consider tion of nonpalpable testicular lesions, and its use is recommended by
T-out as the time needed for the descending slope to reach a contrast the European Federation of Societies for Ultrasound in Medicine and
signal intensity of zero); area under the curve (AUC): intensities of the Biology (EFSUMB) guidelines.20,41
entire enhancement period, measured in dB or au. Several studies also
differentiate wash-in AUC (before PI) and washout AUC (after PI);
slope in or β: the coefficient of the wash-in slope, it reflects the mean
blood flow velocity in the region of interest, measured in dB or au
3.1 CEUS in the differential diagnosis between
non-neoplastic and neoplastic intratesticular lesions
6. Area under the curve (AUC): intensities throughout the entire time
of enhancement, measured in dB or au. Several studies also differ- Non-neoplastic intratesticular lesions include simple cyst, epidermoid
entiate wash-in AUC (before PI) and washout AUC (after PI) cyst, segmental ischemia, abscess, hematomas, post biopsy scars, orchi-
7. Slope in or β: the coefficient of the wash-in slope, which reflects the tis, adrenal rest tumors, and sarcoidosis. Their US and CDUS char-
mean blood flow velocity in the ROI, measured in dB or au acteristics are reported in Table 1. The use of CDUS alone can be
TENUTA ET AL. 1373

TA B L E 1 Ultrasound, CDUS and CEUS characteristic of principal non-neoplastic intratesticular lesions

Non-neoplastic intratesticular lesions

Grayscale ultrasound CDUS CEUS CEUS literature
Simple cyst Rounded anechoic lesions with Avascular Unenhanced Auer et al., 201110
hyperechoic rim Isidori et al., 201424
Epidermoid cyst Well-circumscribed rounded lesion with Avascular Unenhanced/perilesional Auer et al., 201110
“onion ring” aspect (with concentric rim enhancement Lock et al., 201123
rings of hypoechogenicity and Patel et al., 201241
hyperechogenicity) or densely calcified Isidori et al., 201424
mass or cyst with peripheral Schroder et al., 20168
rim/central calcification or mixed Anheuser et al., 201942
atypical pattern Schwarze et al., 20207
Lung et al., 202083
Segmental Hypoechoic area with undefined margins, Avascular Unenhanced/perilesional Auer et al., 201110
infarction generally with a lobular shape rim enhancement Parenti et al., 201273
Isidori et al., 201424
Patel et al., 201471
Lorenz et al., 201975
Lung et al., 202083
Abscess Complex heterogeneous fluid collection Avascular/vascular Unenhanced/perilesional Isidori et al., 201424
with irregular walls, low level internal rim rim enhancement Schroder et al., 20168
echoes Lung et al., 202083
Post biopsy scar Oval or triangular hypoechoic area Avascular Unenhanced Auer et al., 201110
beneath the albuginea Schroder et al., 20168
Hematoma Well-circumscribed hypoechoic lesions Avascular Unenhanced/perilesional Lobianco et al., 201131
with areas of high reflectivity. Size rim enhancement (rarely) Hedayati et al., 201268
decrease in time is typical Yusuf et al., 201572
Lung et al., 202083
Focal orchitis Single or multiple hypoechoic areas Vascularized Hyperenhanced Auer et al., 201110
Isidori et al., 201424
Lung et al., 202083
Adrenal rest Hypoechoic lesions with irregular Vascularized Hyperenhanced Corcioni et al., 202152
margins, hyperechogenic foci, typically
localized in the mediastinum testis
(generally bilateral)
Sarcoidosis Hypoechoic lesions with irregular Vascularized Hypoenhanced Lung et al., 202083
margins (often bilateral)

CDUS: color Doppler ultrasound; CEUS: contrast-enhanced ultrasound.

adequate to perform a differential diagnosis, because the majority of The first study in this field dates back to 2011.27 The authors
non-neoplastic testicular lesions are nonvascular, with the exception of prospectively described the feasibility of CEUS in the differential diag-
focal orchitis, sarcoidosis, and adrenal rest tumors (TART).42,43 How- nosis of testicular masses. Findings revealed that in 50 out of the
ever, particularly in the case of small lesions, CDUS alone can often 51 patients examined, focal lesions demonstrated a different contrast
fail to depict internal vascularization. Blood flow, indeed, cannot be enhancement compared to the surrounding testicular tissue. In detail,
detected if the transducer is not positioned at a right angle to the testicular lesions in 39 (76.5%) patients revealed hyperenhancement,
vessels, or in case of very small vessels with low volume blood flow. of which 38 (97.4%) were diagnosed histologically as neoplasms. It is
CEUS can overcome these limitations, thus providing a reliable rep- noteworthy that early arterial hyperenhancement was predictive of a
resentation of lesion’s microcirculation. This is because US contrast neoplastic lesion, with a sensitivity of 88.4% (95% CI: 74.1–95.6%) and
medium can reach even smaller vessels,10 therefore confirming the a positive predictive value of 97.4% (95% CI: 84.9–99.9%).27 Hyper-
presence of vascularity or the nonenhancement of a lesion.44 enhancement was not found in 7/8 lesions, which proved to be non-
According to several published studies, neoplastic lesions (both neoplastic. These results were confirmed by a subsequent prospective
benign and malignant) tend to be strongly enhanced during CEUS, study on 67 patients in which hyperenhancement in CEUS showed a
thus facilitating the differential diagnosis with non-neoplastic lesions, sensitivity of 93% and a predictive positive value of 96% for detect-
which, in general, are either nonenhanced or enhanced in a similar man- ing testicular neoplasms.8 Subsequent retrospective studies confirmed
ner to that of the surrounding parenchyma (Figure 4). the high sensitivity, specificity, and positive predictive value of CEUS in
1374 TENUTA ET AL.

examination are essential for reaching a correct diagnosis. According

to CEUS kinetics, wash-in and washout, similar or delayed to the
parenchyma, can be suggestive of non-neoplastic lesions.

3.2 CEUS in the differential diagnosis between

benign and malignant neoplastic lesions

TTs are rare neoplasms that account for approximately 1–1.5% of

all human cancers. However, TTs represent the most common neo-
plasm in males between 15 and 44 years who are in full reproductive
age.47 TT can be primarily distinguished into germ-cell tumors and non-
germ-cell tumors.48 Germ-cell tumors are almost always malignant,
whereas non-germ-cell tumors are most commonly stromal tumors
with a benign behavior. Recent evidence has shown that the frequency
of stromal tumors is probably underestimated, particularly when they
are small. In fact, according to recent series, the incidence could be
significantly higher (3–22%)28,31,40,49–51 than the one reported in pre-
vious research studies. In certain cases, malignant tumors can also
undergo regression, necrosis, and scarring while spreading with distant
metastasis, as forBOT.51 Finally, although rarer, tumors of lymphatic
or hematopoietic origin with intratesticular localization should also be
described.30,52
Conventional US demonstrates high sensitivity for TT detection,
yet this diagnostic method offers low specificity in differentiating
F I G U R E 4 CEUS in the differential diagnosis between
benign from malignant lesions.53 The appearance of TTs in US may
non-neoplastic and neoplastic intratesticular lesions. (a) A
hyperenhanced lesion compared to the adjacent parenchyma, turned change according to histology. A classification of TTs48 and their
out to be a seminoma at histology. (b) A hysoenhanced lesion most commonly associated B-mode and CDUS features is provided in
compared to the parenchyma resulted a Leydig cell hyperplasia at Table 2. In most cases, stromal cell tumors are Leydig cell tumors (LCT),
histology. (c) A hypoenhanced lesion, resulted focal fibrosis at which usually appear as a small, unique, hypoechoic, homogeneous,
definitive histology
and well-demarcated lesion. Sertoli cell tumors are much less common
and can appear as both hypo- and hyper-echoic lesions, with possible
identifying neoplastic lesions,10,32 which were significantly higher than intralesional calcifications. Among malignant testicular neoplasms,
those of CDUS alone. More specifically, according to Auer et al., CDUS seminomatous tumors usually appear as focal lesions, hypoechoic to
showed a sensitivity of 66.7%, a specificity of 88.4%, a correct classifi- the normal surrounding parenchyma, with irregular margins, whereas
cation rate of 83.6%, and a positive likelihood ratio of 5.7 (p < 0.001).10 nonseminomatous tumors are usually heterogeneous with internal
In case of testicular epidermoid cysts, CEUS validated the complete calcification or cystic areas. However, large seminomatous tumors can
absence of contrast bubbles within the lesion and consequently the also appear inhomogeneous and can involve the whole parenchyma
pathognomonic absence of internal vascularization.45,46 of the testicle. Moreover, US features such as intralesional calcifica-
A description of the uptake kinetics was performed for the first time tions, irregular/infiltrating margins, and the presence of parenchymal
by Isidori et al. on 115 patients consisting of 38% patients with malig- microlithiasis are usually associated with malignancy.7,28
nant tumors, 37% with benign tumors, and 25% with non-neoplastic According to previous reports, increased vascularization (with
lesions. Non-neoplastic lesions revealed a wash-in that was similar or arborization and branches) has been considered to be a malignant
more delayed to the parenchyma compared to all tumors (76% vs. 35%, tumor characteristic.54,55 Nonetheless, vascularization is not spe-
p < 0.001) as well as a similar washout (76% vs 21%, p < 0.001).28 cific for malignant diagnosis because it can also be increased in
To sum up, lesions that were more enhanced compared to the stromal tumors,40 focal orchitis,10 TARTs,56 or benign mesenchymal
surrounding parenchyma seem to have a higher predictive value in tumors such as capillary hemangioma57–59 and leiomyoma.60 Partic-
identifying neoplastic lesions, whereas similar enhancement or its com- ularly, LCTs can appear as having a more intense blood flow than
plete absence can be interpreted as strong evidence for benignity.10,42 seminomas.9,29
However, there are some exceptions, represented by epidermoid cysts For this reason, distinguishing a malignant tumor from a benign
(Figure 5), necrotic embryonal carcinoma, and burned out tumors neoplasm between incidental lesions is a significantly challenging
(BOT), all neoplastic lesions that are typically not vascularized inter- task, particularly for small, hypoechoic, and well-vascularized masses
nally. In the latter conditions, B-mode imaging, clinical history, and with regular margins. In particular, LCTs and seminomas can be very
TENUTA ET AL. 1375

F I G U R E 5 Epidermoid cyst. B-mode US demonstrates a well-circumscribed, solid, mixed-reflectivity lesion with high-reflectivity “onion-skin”
peripheral rims. Contrast-enhanced US demonstrates a clear lack of enhancement within the lesion

similar on nonenhanced US.61,62 Performing an accurate and careful were distinctive characteristics of malignant lesions (77% vs. 25%,
differential diagnosis is imperative because both benign and malignant p < 0.001), whereas similar or delayed wash-in (compared with the
tumors have a very different clinical course. Patients suspected of parenchyma) were appropriate signs of benign lesions (both neoplas-
benign lesions can be addressed to tissue-sparing surgery enucle- tic and non-neoplastic) (61% vs. 20.5%, p < 0.001). Subsequent quanti-
ation or, in selected cases, to clinical and US strict surveillance, thus tative analysis revealed that TTP, MTT, and T-out were all significantly
preserving the testicle instead of performing total orchiectomy,63,64 shorter in malignant tumors than in benign ones, as wash-out time
which is suggested in case of malignancies. appeared to be slower in benign lesions.
In this perspective, CEUS could represent as an additional and effec- The authors also performed a comparison between the two largest
tive tool. To date, there have been only a few prospective studies that histologically proved homogeneous groups (malignant seminomas and
tried to evaluate whether the use of CEUS could help in the differen- stromal tumors) obtaining similar results28 (Figure 6). In this prospec-
tial diagnosis between benign and malignant TTs.7,28,29,31 Results are tive study, CEUS application supported the authors in selecting the
promising, however, the available data are not always in agreement, appropriate patient intervention, since 25 of 115 patients underwent
and the majority of reports are based on qualitative rather than a more US strict surveillance with serial investigations every 3 months for a
objective quantitative assessment. minimum of 18 months, instead of surgery, without any disease pro-
As reported earlier, hyperenhancement is the most common fea- gression at the final follow-up. The same was described in the study by
ture observed in TT on CEUS.28,29,31 The current literature underlines Pozza et al., where 32 of 83 patients did not undergo surgery because
that benign lesions are characterized by lower enhancement; how- CEUS, ES, MRI and clinical findings were suggestive for LCTs, therefore
ever, in these reports, both neoplastic and non-neoplastic lesions are US strict surveillance was performed. All patients were disease-free
included in the benign group.7,10,32 It must be considered, though, that at the final visit, thus suggesting that in compliant patients, active
some malignant lesions have an architecture that does not allow the surveillance through clinical and radiological follow-up could be a safe
uptake of the contrast medium. In fact, this is the case in BOT, where alternative option for small nonpalpable lesions suspicious for LCTs
malignant cells are rapidly replaced by fibrotic tissue.28,31,51 Luzurier at CEUS.40
et al. demonstrated how CEUS could help differentiate BOT from vas- More recently, Drudi et al. performed a comparative analysis on
cularized TTs.31 Similarly, some malignant tumors with large intrale- seminoma and LCT.29 Interestingly, LCT showed a faster TTP and
sional necrotic areas or embryonal carcinoma with calcific margins may greater PI and WiR. Similar findings have been previously reported in
demonstrate hypo-enhancing features.3,28,65 a series of 13 LCTs9 and in one case report.66 The authors attributed
As already pointed out, qualitative analysis can guide the clinician’s these results to the vascular architecture of LCT, which is charac-
evaluation. However, this process is based heavily upon the operator’s terized by a wider and more regular vascular bed and a greater
experience; thus, the subjective interpretation of US images can be microvessel density compared to seminomas. In fact, according to
biased. In contrast, quantitative analysis can provide more objective Samson et al., LCT has a vessel density that is 3.2-fold higher than
data, yet research in this field is still substantially limited, and studies seminoma. This could be explained by the expression of endocrine
performed have used small sample sizes and have results that are not gland-derived vascular endothelial growth factor (EG-VEGF), which
reproducible and/or not always comparable because of the use of dif- is strongly expressed in Leydig cells, and specifically in LCT, as
ferent measurement units.33 opposed to germ-cell tumors which do not express this angiogenic
Isidori et al. were the first to compare the kinetic parameters factor.67
between malignant and benign lesions (both neoplastic and non- According to Schwarze et al., PI was greater in malignant tumors,
neoplastic). According to the authors, rapid wash-in and washout whereas wash-in was found to be faster in benign lesions. However,
1376 TENUTA ET AL.

TA B L E 2 Ultrasound, CDUS, and CEUS characteristic of principal neoplastic intratesticular lesions

Neoplastic intratesticular lesions

Grayscale ultrasound CDUS CEUS CEUS Literature
Leydig cell tumor Hypoechoic, homogeneous Hypervascularized Homogeneously Auer et al., 201110 Schroder et al., 20168
well-demarcated lesion hyperenhanced Lock et al., 201123 Luzurier et al., 201927
Lock et al., 20149 Lerchbaumer et al., 2019
Cantisani et al., 201262 Pozza et al., 201936
Isidori et al., 201424 Lung et al., 202083
Drudi et al., 2015, 20165 Schwarze et al., 20207
Sertoli cell tumor Both hypo- and Hypervascularized Homogeneously Auer et al., 201110 Lerchbaumer et al., 2019
hyper-echoic lesions, hyperenhanced Isidori et al., 201424 Lung et al., 202083
with possible Luzurier et al., 201927 Schwarze et al., 20207
calcifications
Seminoma Hypoechoic round or oval Hypervascularized Homogeneously Auer et al., 201110 Schroder et al., 20168
lesion, occasionally hyperenhanced Lock et al., 201123 Peil Grum et al., 201848
multinodular or with Isidori et al., 201424 Lerchbaumer et al., 2019
polycyclic lobulated Luzurier et al., 201927 Schwarze et al., 20207
margins Drudi et al., 2015, 201625 Lung et al., 202083
Embryonal cell Hypoechoic heterogeneous Hypervascularized/ Hyper-hypo- Isidori et al., 201424 Lung et al., 202083
carcinoma lesions which can avascular unenhanced Lerchbaumer et al., 2019 Schwarze et al., 20207
present internal cystic
areas or calcific margins
and distal acoustic
shadowing
Teratoma Heterogeneous lesions, Hypervascularized Inhomogeneously Isidori et al., 201424 Lung et al., 202083
well-circumscribed, hyperenhanced
predominantly cystic
with hyperechoic spots
Choriocarcinoma Heterogeneous lesions Hypervascularized Hyperenhanced Schwarze et al., 20207
Yolk sak tumor with hypo-anechoic
areas (hemorrhage,
necrosis) and
calcifications
Mixed germ-cell Different aspect in regard Hypervascularized Homogeneously/ Lock et al., 201123 Lung et al., 202083
tumor to main histological inhomogeneously Isidori et al., 201424 Schwarze et al., 20207
component hyperenhanced
Burned out Highly echogenic foci or Hypovascularized Unenhanced Lock et al., 201123 Rocher et al., 201647
tumor gross calcifications/ Isidori et al., 201424 Luzurier et al., 201927
hypoechoic irregular
areas
Lymphoma Hypoechoic lesions with Hypervascularized Hyperenhanced Lock et al., 201123 Peil Grum et al., 201848
diffuse infiltration or Isidori et al., 201424 Schwarze et al., 20207
multifocal hypoechoic Lock et al., 2016 Lung et al., 202083
lesions of various size Schroder et al., 20168
Leukemia Diffuse or focal, Hypervascularized Hyperenhanced Schwarze et al., 20207
hypoechoic or
hyperechoic with
infiltrating pattern

CDUS: color Doppler ultrasound; CEUS: contrast-enhanced ultrasound.

it should be emphasized that the authors of this study included both size of this work remained significantly small (out of 31 lesions, 15 were
neoplastic and non-neoplastic among benign lesions.7 Finally, accord- malignant and 13 were benign).31
ing to Luzurier et al., CEUS failed in providing an effective differen- The results are hardly comparable due to the heterogeneity of the
tial diagnosis between benign and malignant tumors, as no differences examined lesions (even within the same subgroup) and to the software
were found in any parameter during the quantitative analysis. How- used to obtain kinetic parameters, which produced results that were
ever, when excluding BOTs (considered a separate group), the sample expressed in different and noncomparable scales.33
TENUTA ET AL. 1377

F I G U R E 6 Quantitative analysis comparison of a seminoma and a Leydig cell tumor. A rapid wash-in and wash-out are distinctive
characteristics of seminomas, as demonstrated by the blue curve in panel (a) that shows a wash-in that begins approximately at 18 s and a
wash-out starting at 30–35 s, whereas a rapid wash-in (20 s) and a delayed wash-out (starting at 38–40 s) are appropriate signs of a Leydig cell
tumor (panel b, blue curve). The orange curves belong to the adjacent normal parenchyma

4 CEUS BEYOND TESTICULAR LESIONS testis with decreased echogenicity and increased vascularity at CD.70
Other lesions such as abscess, hematoma, and infarction appear as
4.1 Acute scrotal pain hypoechoic lesions with absent vascularity (Figure 8),70 and their
differential diagnosis should be done with testicular neoplasm, as
Acute scrotal pain is a common urological emergency that requires previously reported.
a prompt diagnosis to determine the most appropriate treatment Due to its ability to visualize microcirculation, CEUS can be help-
approach. Pain can be due to several causes, including epididymo- ful in various emergency situations. In 2009, Moschouris et al. pub-
orchitis, testicular torsion, testis’ appendix or epididymis torsion, lished a preliminary research study that investigated the use of CEUS
intratesticular abscess, focal infarction, neoplasm, and trauma.36,68 in patients with acute scrotum.71 On the basis of their 19 cases,
At first, diagnosis of clinical and medical history, associated with authors concluded that CEUS had generally no advantages over CDUS
symptoms and biochemical assessment, is mandatory. Indeed, patients and that this method could only be useful in patients with trauma.
with testicular torsion usually present with symptoms of severe acute Recently, in a prospective study that included 50 patients with acute
unilateral scrotal pain, nausea, and vomiting.69 US diagnostic images scrotum, CEUS was found to be more accurate in definitive diagno-
pertaining to testicular torsion are characterized by the absence of sis showing higher sensibility and specificity compared to conven-
intratesticular blood flow at CD evaluation70 (Figure 7). In other cases, tional US.36 Conventional US provided a definitive tumor diagnosis in
symptoms and clinical presentation might be similar among all causes 34/50 patients, whereas CEUS provided the same diagnosis in 48/50
of acute scrotal pain, whereas physical examination and laboratory patients; the sensitivity was 76% for CDUS and 96% for CEUS, respec-
evaluation may often not be exhaustive.36 Thus, CDUS could be helpful tively, whereas the specificity was 45% for CDUS and 100% for CEUS,
in investigating the underlying pain etiology.68,70 Epididymitis and respectively.36
orchitis can be diagnosed by CDUS as a result of their typical clinical Among all causes of acute scrotal pain, CEUS seems to be particu-
features. More specifically, epididymitis appears as an enlarged epi- larly helpful in blunt scrotal trauma.35,71,72 Lobianco et al. examined 40
didymis with distinct inflammatory signs such as increased vascularity consecutive patients for blunt scrotal trauma with CDUS and CEUS.
CD and hydrocele.70 In contrast, orchitis is represented by an enlarged In 24 patients with positive findings (including interruption of the
1378 TENUTA ET AL.

F I G U R E 7 Testicular torsion. CEUS showed complete lack of enhancement of testis and spermatic cord in a patient with chronic (missed)
torsion. Peri-testicular tissues displayed increased vascularity on CEUS

F I G U R E 8 Intratesticular hematoma. CEUS appearances of intratesticular hematoma after blunt trauma. Dual-display image showing
contrast-specific (left) and low MI B-mode image (right). B-mode image shows an intratesticular bilobated hypoechoic, avascular lesion. CEUS
confirmed the absence of internal vascularity. Note the peri-lesional hyperemia and the presence of internal echoes, representing artifact from
echogenic content

tunica albuginea, testicular fracture, lacerocontusion, total testicular identification and recognition of ischemic lobules.34 Moreover, a per-
ischemia, incomplete ischemia, hamartomatosis, arteriovenous mal- ilesional rim enhancement was also identified by CEUS, which may rep-
formation, and hematocele), CEUS demonstrated a greater sensitivity resent a specific sign of subacute segmental testicular infarction.34,75
toward the detection of testicular lesions caused by blunt scrotal The ability of CEUS in assessing the complete absence of vasculariza-
trauma. This was particularly true for small lesions.35 Also, CEUS could tion with a rim enhancement has been used to distinguish a testicu-
efficiently help depict fracture lines which could usually not be seen lar hematoma76 or segmental testicular infarction77–79 from a tumor,
using grayscale US.16 in asymptomatic patients. Out of all the causes of scrotal pain, the use
Another interesting field of application of CEUS in acute scrotal of CEUS has also been described in the diagnosis of spontaneous sper-
pain involves focal testicular infarction. In CDUS examination, testic- matic vein thrombosis, a rare condition which can lead to testicular pain
ular infarction typically appears as an avascular wedge-shaped hypoe- and testicular swelling.80
choic lesion.73 However, segmental testicular infarction can be round
and resembling a TT,74 and sometimes presents a rim enhancement,
probably due to granulation tissue in response to ischemic processes.34 4.2 Infertility
In such cases, the patient’s clinical history can help the clinician in the
differential diagnosis process (Figure 9). Nowadays, approximately 10% of infertile males are affected by
In a retrospective study, 20 men with acute scrotal pain, suspected nonobstructive azoospermia (NOA), which is characterized by a com-
of testicular infarction, were examined with CEUS. Compared with plete absence of spermatozoa in the seminal fluid due to minimal or no
CDUS, CEUS facilitated improved lesion conspicuity, leading to the spermatogenesis.81 In some cases, the only therapeutic option in these
TENUTA ET AL. 1379

F I G U R E 9 Focal ischemia. CEUS appearances of focal ischemia, confirmed at definitive histology. Dual-display image showing
contrast-specific (left) and low MI B-mode image (right). B-mode image shows an intratesticular, well-defined markedly hypoechoic, avascular
lesion. CEUS confirmed the complete absence of internal vascularity and the patient, monorchid, underwent tissue sparing surgery

patients is TESE. Unfortunately, sperm retrieval using conventional titative CEUS features could have a negative predictive value on sperm
TESE has only proved to be successful in a subset of patients, approx- retrieval.38
imately 50%, regardless of the cause of azoospermia (obstructive or
nonobstructive).39,82–84 Spermatogenesis is not equally distributed
throughout the testis, and it would appear that sperm quality is better 5 CONCLUSIONS
in areas with high tissue perfusion.85 The high accuracy of CEUS in
assessing blood perfusion and microvascular architecture of the testes In conclusion, the literature underlines that CEUS is a safe, easy-to-
may suggest that this technique could help increase the probability of perform, and cost-effective diagnostic tool that is able to provide an
sperm retrieval. accurate diagnosis in testicular lesions and in acute scrotal diseases
To the best of our knowledge, a case report described for the first when US findings are unclear. CEUS can increase diagnostic confidence
time that sperm quality and quantity depend on tissue perfusion within levels, particularly in less experienced investigators. Therefore, CEUS
the testis.86 Since then, only two recent studies have focused on deter- should be proposed in every case where US diagnosis remains incon-
mining the usefulness of CEUS in infertility, by investigating whether it clusive, namely in the differential diagnosis of small testicular lesions
could be used to predict the success rate of testicular sperm retrieval to facilitate greater confidence in terms of selecting the appropriate
techniques in infertile men.37,38 Zhang et al. evaluated whether CEUS patient intervention. Lesion enhancement indeed seems to have a high
could be considered as a noninvasive approach for detecting the testic- predictive value in the identification of neoplastic lesions. Similarly, the
ular area where spermatogenesis is most likely to be found in nonob- complete absence of enhancement can be interpreted as strong evi-
structive azoospermic testes. Among the 187 testes that underwent dence for benignity, although some exceptions must be carefully con-
microdissection TESE, the sperm retrieval rates of the best perfusion sidered. Literature on quantitative analysis is still scanty, particularly
area over the maximal longitudinal section were higher than those with when distinguishing benign from malignant neoplasms. Further stud-
the poorest perfusion area and conventional area where TESE is usu- ies with larger cohorts are definitively required to refine the differen-
ally performed (63.1% vs. 34.7% and 47.1% respectively, p < 0.05). tial diagnosis between benign and malignant neoplasms. CEUS can also
These findings suggest that spermatogenesis is not uniformly dis- play an essential role in cases of acute scrotum, by excluding infarction
tributed throughout the testis because sperm quality is better in areas and trauma, when testicular torsion cannot be defined. Finally, these
with high tissue perfusion. Moreover, the subsequent ROC analysis interesting preliminary results can instigate the development of inno-
showed that W-in ≤27 s, TTP ≤45 s, and PI ≥11 dB in the selected vative research studies on pre-TESE testicular perfusion to increase the
area could be considered the best cut-off values for predicting positive chances of sperm recovery.
sperm retrieval.37
In contrast, Xue et al. did not observe significant differences in the CONFLICT OF INTEREST
success rates of SR between the major and minor perfused areas in The authors declare no conflict of interest regarding the publication of
the 46 nonobstructive azoospermic patients examined. However, TESA this article.
had a very little chance of success in patients with NOA in case of:
decreased intensity of the main perfusion area (defined as decreased AUTHOR CONTRIBUTION
intensity within 30 s after reaching the peak for both the main perfu- All authors contributed to the conception and design of the review.
sion area and whole testis) with values < 8.6 dB; TTP of the whole testis Marta Tenuta, Franz Sesti, Ilaria Bonaventura, and Paola Mazzotta
> 9.0 s; slope-in of the whole testis < 1.7 dB/s. Therefore, these quan- revised the literature and acquired the respective data. Marta Tenuta,
1380 TENUTA ET AL.

Franz Sesti, and Ilaria Bonaventura wrote the first draft and designed 14. Faccioli N, Dietrich CF, Foti G, Santi E, Comai A, D’Onofrio M. Activity-
this study’s tables and figures. Carlotta Pozza and Marta Tenuta per- based cost analysis of including contrast-enhanced ultrasound (CEUS)
in the diagnostic pathway of focal pancreatic lesions detected by
formed a first revision and synthesis of the manuscript. Riccardo Pofi
abdominal ultrasound. Ultraschall Med. 2019;40(5):618–624.
and Paola Mazzotta were involved in a second critical revision of data. 15. Tanaka H, Iijima H, Nouso K, et al. Cost-effectiveness analysis
Carlotta Pozza and Daniele Gianfrilli performed the last critical revi- on the surveillance for hepatocellular carcinoma in liver cirrho-
sion for important intellectual content and granted the final approval sis patients using contrast-enhanced ultrasonography. Hepatol Res.
2012;42(4):376–384.
of the version to be published. All authors are accountable for the accu-
16. Cantisani V, Bertolotto M, Weskott HP, et al. Growing indications for
racy and integrity of the work, and they all reviewed and approved the CEUS: the kidney, testis, lymph nodes, thyroid, prostate, and small
final manuscript. bowel. Eur J Radiol. 2015;84(9):1675–1684.
17. Appis AW, Tracy MJ, Feinstein SB. Update on the safety and efficacy
of commercial ultrasound contrast agents in cardiac applications. Echo
ORCID
Res Pract. 2015;2(2):R55–62.
Franz Sesti https://orcid.org/0000-0003-3850-627X 18. Puliani G, Sesti F, Feola T, et al. Natural history and management of
Daniele Gianfrilli https://orcid.org/0000-0002-2682-8266 familial paraganglioma syndrome type 1: long-term data from a large
Carlotta Pozza https://orcid.org/0000-0002-1147-6114 family. J Clin Med. 2020;9(2).
19. Zhai HY, Liang P, Yu J, et al. Comparison of Sonazoid and SonoVue in
the diagnosis of focal liver lesions: a preliminary study. J Ultrasound
REFERENCES
Med. 2019;38(9):2417–2425.
1. Lotti F, Frizza F, Balercia G, et al. The European Academy of Andrology 20. Sidhu PS, Cantisani V, Dietrich CF, et al. The EFSUMB guidelines and
(EAA) ultrasound study on healthy, fertile men: scrotal ultrasound ref- recommendations for the clinical practice of contrast-enhanced ultra-
erence ranges and associations with clinical, seminal, and biochemical sound (CEUS) in non-hepatic applications: update 2017 (long version).
characteristics. Andrology. 2021;9(2):559–576. Ultraschall Med. 2018;39(2):e2–e44.
2. Pozza C, Kanakis G, Carlomagno F, et al. Testicular ultrasound score: 21. Rubenthaler J, Kim SH, Kunz WG, et al. Should we use contrast-
a new proposal for a scoring system to predict testicular function. enhanced ultrasound (CEUS) for the characterization of nonpalpable
Andrology. 2020;8(5):1051–1063. testicular lesions? An analysis from a cost-effectiveness perspective.
3. Dieckmann KP, Frey U, Lock G. Contemporary diagnostic work-up of Ultraschall Med. 2020;41(6):668–674.
testicular germ cell tumours. Nat Rev Urol. 2013;10(12):703–712. 22. Tang C, Fang K, Guo Y, et al. Safety of sulfur hexafluoride microbub-
4. Pozza C, Gianfrilli D, Fattorini G, et al. Diagnostic value of qualita- bles in sonography of abdominal and superficial organs: retrospective
tive and strain ratio elastography in the differential diagnosis of non- analysis of 30,222 cases. J Ultrasound Med. 2017;36(3):531–538.
palpable testicular lesions. Andrology. 2016;4(6):1193–1203. 23. Piscaglia F, Bolondi L, Italian Society for Ultrasound in Medicine and
5. Manganaro L, Saldari M, Pozza C, et al. Dynamic contrast-enhanced Biology (SIUMB) Study Group on Ultrasound Contrast Agents. The
and diffusion-weighted MR imaging in the characterisation of small, safety of Sonovue in abdominal applications: retrospective analysis of
non-palpable solid testicular tumours. Eur Radiol. 2018;28(2):554– 23188 investigations. Ultrasound Med Biol. 2006;32(9):1369–1375.
564. 24. Jakobsen JA, Oyen R, Thomsen HS, Morcos SK, Members of Con-
6. Manganaro L, Vinci V, Pozza C, et al. A prospective study on contrast- trast Media Safety Committee of European Society of Urogenital
enhanced magnetic resonance imaging of testicular lesions: distinc- Radiology (ESUR). Safety of ultrasound contrast agents. Eur Radiol.
tive features of Leydig cell tumours. Eur Radiol. 2015;25(12):3586– 2005;15(5):941–945.
3595. 25. Mao M, Xia B, Chen W, et al. The safety and effectiveness of intra-
7. Schwarze V, Marschner C, Sabel B, et al. Multiparametric ultrasono- venous contrast-enhanced sonography in Chinese children—a single
graphic analysis of testicular tumors: a single-center experience in a center and prospective study in China. Front Pharmacol. 2019;10:1447.
collective of 49 patients. Scand J Urol. 2020;54(3):241–247. 26. Knieling F, Strobel D, Rompel O, et al. Spectrum, applicability and diag-
8. Schroder C, Lock G, Schmidt C, Loning T, Dieckmann KP. Real-time nostic capacity of contrast-enhanced ultrasound in pediatric patients
elastography and contrast-enhanced ultrasonography in the evalua- and young adults after intravenous application—a retrospective trial.
tion of testicular masses: a comparative prospective study. Ultrasound Ultraschall Med. 2016;37(6):619–626.
Med Biol. 2016;42(8):1807–1815. 27. Lock G, Schmidt C, Helmich F, Stolle E, Dieckmann KP. Early experi-
9. Lock G, Schroder C, Schmidt C, Anheuser P, Loening T, Dieckmann ence with contrast-enhanced ultrasound in the diagnosis of testicular
KP. Contrast-enhanced ultrasound and real-time elastography for the masses: a feasibility study. Urology. 2011;77(5):1049–1053.
diagnosis of benign Leydig cell tumors of the testis—a single center 28. Isidori AM, Pozza C, Gianfrilli D, et al. Differential diagnosis of
report on 13 cases. Ultraschall Med. 2014;35(6):534–539. nonpalpable testicular lesions: qualitative and quantitative contrast-
10. Auer T, De Zordo T, Dejaco C, et al. Value of multiparametric US in enhanced US of benign and malignant testicular tumors. Radiology.
the assessment of intratesticular lesions. Radiology. 2017;285(2):640– 2014;273(2):606–618.
649. 29. Drudi FM, Valentino M, Bertolotto M, et al. CEUS time intensity curves
11. Lee YS, Kim MJ, Han SW, et al. Superb microvascular imaging for the in the differentiation between Leydig cell carcinoma and seminoma: a
detection of parenchymal perfusion in normal and undescended testes multicenter study. Ultraschall Med. 2016;37(2):201–205.
in young children. Eur J Radiol. 2016;85(3):649–656. 30. Lock G, Schmidt C, Schroder C, Loning T, Dieckmann KP. Straight ves-
12. Ayaz E, Ayaz M, Onal C, Yikilmaz A. Seeing the unseen: evaluating sel pattern and rapid filling time: characteristic findings on contrast-
testicular vascularity in neonates by using the superb microvascular enhanced sonography of testicular lymphoma. J Ultrasound Med.
imaging ultrasound technique. J Ultrasound Med. 2019;38(7):1847– 2016;35(7):1593–1599.
1854. 31. Luzurier A, Maxwell F, Correas JM, et al. Qualitative and quantita-
13. Ates F, Durmaz MS, Sara HI, Kara T. Comparison of testicular vascular- tive contrast-enhanced ultrasonography for the characterisation of
ity via superb microvascular imaging in varicocele patients with con- non-palpable testicular tumours. Clin Radiol. 2018;73(3):322.e321–
tralateral normal testis and healthy volunteers. J Ultrasound. 2021. 322.e329.
TENUTA ET AL. 1381

32. Lerchbaumer MH, Auer TA, Marticorena GS, et al. Diagnostic perfor- mendations of the ESUR scrotal imaging subcommittee. Eur Radiol.
mance of contrast-enhanced ultrasound (CEUS) in testicular patholo- 2016;26(7):2268–2278.
gies: single-center results. Clin Hemorheol Microcirc. 2019;73(2):347– 52. Peil-Grun A, Trenker C, Gorg K, Neesse A, Haasenritter J, Gorg C. Diag-
357. nostic accuracy and interobserver agreement of contrast-enhanced
33. Pinto SPS, Huang DDY, Dinesh AA, Sidhu PPS, Ahmed MK. A sys- ultrasound in the evaluation of residual lesions after treatment for
tematic review on the use of qualitative and quantitative contrast- malignant lymphoma and testicular cancer: a retrospective pilot study
enhanced ultrasound in diagnosing testicular abnormalities. Urology. in 52 patients. Leuk Lymphoma. 2018;59(11):2622–2627.
2021. 53. Muller T, Gozzi C, Akkad T, Pallwein L, Bartsch G, Steiner H. Manage-
34. Bertolotto M, Derchi LE, Sidhu PS, et al. Acute segmental testicu- ment of incidental impalpable intratesticular masses of < or = 5 mm in
lar infarction at contrast-enhanced ultrasound: early features and diameter. BJU Int. 2006;98(5):1001–1004.
changes during follow-up. AJR Am J Roentgenol. 2011;196(4):834–841. 54. Aigner F, De Zordo T, Pallwein-Prettner L, et al. Real-time sonoe-
35. Lobianco R, Regine R, De Siero M, Catalano O, Caiazzo C, Ragozzino A. lastography for the evaluation of testicular lesions. Radiology.
Contrast-enhanced sonography in blunt scrotal trauma. J Ultrasound. 2012;263(2):584–589.
2011;14(4):188–195. 55. Goddi A, Sacchi A, Magistretti G, Almolla J, Salvadore M. Real-
36. Valentino M, Bertolotto M, Derchi L, et al. Role of contrast enhanced time tissue elastography for testicular lesion assessment. Eur Radiol.
ultrasound in acute scrotal diseases. Eur Radiol. 2011;21(9):1831– 2012;22(4):721–730.
1840. 56. Corcioni B, Renzulli M, Marasco G, et al. Prevalence and ultrasound
37. Zhang S, Du J, Tian R, Xie S, Li F, Li Z. Assessment of the use of con- patterns of testicular adrenal rest tumors in adults with congenital
trast enhanced ultrasound in guiding microdissection testicular sperm adrenal hyperplasia. Transl Androl Urol. 2021;10(2):562–573.
extraction in nonobstructive azoospermia. BMC Urol. 2018;18(1):48. 57. Spiesecke P, Fischer T, Stephan C, Maxeiner A, Hamm B, Lerchbaumer
38. Xue H, Wang SY, Cui LG, Hong K. Can contrast-enhanced ultrasound M. Multiparametric ultrasound (mpUS) of a rare testicular capillary
increase or predict the success rate of testicular sperm aspiration in hemangioma. Case Rep Radiol. 2019;2019:7568098.
patients with azoospermia? AJR Am J Roentgenol. 2019:1–6. 58. He Y, Liao H, Xiang X, Cai D, Qiu L. High-frequency ultrasonog-
39. Zhang HL, Zhao LM, Mao JM, et al. Sperm retrieval rates and clini- raphy and contrast-enhanced ultrasound for the evaluation of tes-
cal outcomes for patients with different causes of azoospermia who ticular capillary hemangioma: a case report. Medicine (Baltimore).
undergo microdissection testicular sperm extraction-intracytoplasmic 2019;98(11):e14779.
sperm injection. Asian J Androl. 2021;23(1):59–63. 59. Bernardo S, Konstantatou E, Huang DY, et al. Multiparametric sono-
40. Pozza C, Pofi R, Tenuta M, et al. Clinical presentation, management graphic imaging of a capillary hemangioma of the testis: appearances
and follow-up of 83 patients with Leydig cell tumors of the testis: a on gray-scale, color Doppler, contrast-enhanced ultrasound and strain
prospective case-cohort study. Hum Reprod. 2019;34(8):1389–1403. elastography. J Ultrasound. 2016;19(1):35–39.
41. Piscaglia F, Nolsoe C, Dietrich CF, et al. The EFSUMB guidelines and 60. Asanad K, Remulla D, Nassiri N, Ghodoussipour S. Leiomyoma of the
recommendations on the clinical practice of contrast enhanced ultra- testis: case report, review of literature, and discussing the role of
sound (CEUS): update 2011 on non-hepatic applications. Ultraschall contrast-enhanced ultrasound. Urol Case Rep. 2020;31:101168.
Med. 2012;33(1):33–59. 61. Woodward PJ, Sohaey R, O’Donoghue MJ, Green DE. From the
42. Huang DY, Sidhu PS. Focal testicular lesions: colour Doppler ultra- archives of the AFIP: tumors and tumorlike lesions of the testis:
sound, contrast-enhanced ultrasound and tissue elastography as adju- radiologic-pathologic correlation. Radiographics. 2002;22(1):189–216.
vants to the diagnosis. Br J Radiol. 2012;85(Spec No 1):S41–53. 62. Marko J, Wolfman DJ, Aubin AL, Sesterhenn IA. Testicular seminoma
43. De Zordo T, Stronegger D, Pallwein-Prettner L, et al. Multiparametric and its mimics: from the radiologic pathology archives. Radiographics.
ultrasonography of the testicles. Nat Rev Urol. 2013;10(3):135–148. 2017;37(4):1085–1098.
44. Rafailidis V, Robbie H, Konstantatou E, et al. Sonographic imag- 63. Giannarini G, Dieckmann KP, Albers P, Heidenreich A, Pizzocaro
ing of extra-testicular focal lesions: comparison of grey-scale, G. Organ-sparing surgery for adult testicular tumours: a systematic
colour Doppler and contrast-enhanced ultrasound. Ultrasound. review of the literature. Eur Urol. 2010;57(5):780–790.
2016;24(1):23–33. 64. Scandura G, Verrill C, Protheroe A, et al. Incidentally detected testicu-
45. Patel K, Sellars ME, Clarke JL, Sidhu PS. Features of testicular epi- lar lesions <10 mm in diameter: can orchidectomy be avoided? BJU Int.
dermoid cysts on contrast-enhanced sonography and real-time tissue 2018;121(4):575–582.
elastography. J Ultrasound Med. 2012;31(1):115–122. 65. Valentino M, Bertolotto M, Martino P, Barozzi L, Pavlica P. Incidentally
46. Anheuser P, Kranz J, Stolle E, et al. Testicular epidermoid cysts: a detection of non-palpable testicular nodules at scrotal ultrasound:
reevaluation. BMC Urol. 2019;19(1):52. what is new? Arch Ital Urol Androl. 2014;86(4):378–382.
47. Park JS, Kim J, Elghiaty A, Ham WS. Recent global trends in 66. Cantisani V, Olive M, Di Segni M, et al. Contrast-enhanced ultrasono-
testicular cancer incidence and mortality. Medicine (Baltimore). graphic (CEUS) and elastosonographic features of a case of testicular
2018;97(37):e12390. Leydig tumor. Ultraschall Med. 2012;33(5):409–410.
48. Williamson SR, Delahunt B, Magi-Galluzzi C, et al. The World Health 67. Samson M, Peale FV, Jr., Frantz G, Rioux-Leclercq N, Rajpert-De Meyts
Organization 2016 classification of testicular germ cell tumours: a E, Ferrara N. Human endocrine gland-derived vascular endothelial
review and update from the International Society of Urological Pathol- growth factor: expression early in development and in Leydig cell
ogy Testis Consultation Panel. Histopathology. 2017;70(3):335–346. tumors suggests roles in normal and pathological testis angiogenesis.
49. Lagabrielle S, Durand X, Droupy S, et al. Testicular tumours discovered J Clin Endocrinol Metab. 2004;89(8):4078–4088.
during infertility workup are predominantly benign and could initially 68. Pavlica P, Barozzi L. Imaging of the acute scrotum. Eur Radiol.
be managed by sparing surgery. J Surg Oncol. 2018;118(4):630–635. 2001;11(2):220–228.
50. Leonhartsberger N, Ramoner R, Aigner F, et al. Increased incidence of 69. Sharp VJ, Kieran K, Arlen AM. Testicular torsion: diagnosis, evaluation,
Leydig cell tumours of the testis in the era of improved imaging tech- and management. Am Fam Physician. 2013;88(12):835–840.
niques. BJU Int. 2011;108(10):1603–1607. 70. Dogra VS, Gottlieb RH, Oka M, Rubens DJ. Sonography of the scrotum.
51. Rocher L, Ramchandani P, Belfield J, et al. Incidentally detected non- Radiology. 2003;227(1):18–36.
palpable testicular tumours in adults at scrotal ultrasound: impact of 71. Moschouris H, Stamatiou K, Lampropoulou E, Kalikis D, Mat-
radiological findings on management radiologic review and recom- saidonis D. Imaging of the acute scrotum: is there a place for
1382 TENUTA ET AL.

contrast-enhanced ultrasonography? Int Braz J Urol. 2009;35(6):692– 80. Liu M, Luo L, Zhou A, Liu J. Ultrasonography assessment of sper-
702. Discussion 702–695. matic vein thrombosis. Am J Emerg Med. 2018;36(12):2339.e2331–
72. Hedayati V, Sellars ME, Sharma DM, Sidhu PS. Contrast-enhanced 2339.e2333.
ultrasound in testicular trauma: role in directing exploration, debride- 81. Jarow JP, Espeland MA, Lipshultz LI. Evaluation of the azoospermic
ment and organ salvage. Br J Radiol. 2012;85(1011):e65–e68. patient. J Urol. 1989;142(1):62–65.
73. Bilagi P, Sriprasad S, Clarke JL, Sellars ME, Muir GH, Sidhu PS. Clini- 82. Pavan-Jukic D, Stubljar D, Jukic T, Starc A. Predictive factors for sperm
cal and ultrasound features of segmental testicular infarction: six-year retrieval from males with azoospermia who are eligible for testicular
experience from a single centre. Eur Radiol. 2007;17(11):2810–2818. sperm extraction (TESE). Syst Biol Reprod Med. 2020;66(1):70–75.
74. Gianfrilli D, Isidori AM, Lenzi A. Segmental testicular ischaemia: pre- 83. Ichioka K, Matsui Y, Terada N, Negoro H, Goto T, Ogawa O. Three-
sentation, management and follow-up. Int J Androl. 2009;32(5):524– dimensional simulation analysis of microdissection testicular sperm
531. extraction for patients with non-obstructive azoospermia. Andrology.
75. Patel KV, Huang DY, Sidhu PS. Metachronous bilateral segmen- 2020;8(5):1214–1221.
tal testicular infarction: multi-parametric ultrasound imaging with 84. Corona G, Pizzocaro A, Lanfranco F, et al. Sperm recovery and ICSI out-
grey-scale ultrasound, Doppler ultrasound, contrast-enhanced ultra- comes in Klinefelter syndrome: a systematic review and meta-analysis.
sound (CEUS) and real-time tissue elastography (RTE). J Ultrasound. Hum Reprod Update. 2017;23(3):265–275.
2014;17(3):233–238. 85. Herwig R, Tosun K, Schuster A, et al. Tissue perfusion-controlled
76. Yusuf G, Konstantatou E, Sellars ME, Huang DY, Sidhu PS. Multipara- guided biopsies are essential for the outcome of testicular sperm
metric sonography of testicular hematomas: features on grayscale, extraction. Fertil Steril. 2007;87(5):1071–1076.
color Doppler, and contrast-enhanced sonography and strain elastog- 86. Herwig R, Tosun K, Pinggera GM, et al. Tissue perfusion essential for
raphy. J Ultrasound Med. 2015;34(7):1319–1328. spermatogenesis and outcome of testicular sperm extraction (TESE)
77. Parenti GC, Sartoni M, Gaddoni E, Zago S, Campioni P, Mannella P. for assisted reproduction. J Assist Reprod Genet. 2004;21(5):175–
Imaging of segmental testicular infarction: our experience and litera- 180.
ture review. Radiol Med. 2012;117(7):1161–1175.
78. Lung PF, Jaffer OS, Sellars ME, Sriprasad S, Kooiman GG, Sidhu
PS. Contrast-enhanced ultrasound in the evaluation of focal testic-
ular complications secondary to epididymitis. AJR Am J Roentgenol. How to cite this article: Tenuta M, Sesti F, Bonaventura I, et al.
2012;199(3):W345–354. Use of Contrast Enhanced Ultrasound in Testicular Diseases: a
79. Lorenz N, Schuster F, Steinbach F, Heubner G. Segmental testic-
Comprehensive Review. Andrology. 2021;9:1369–1382.
ular infarction after methamphetamine abuse in a 16-year-old—
diagnosis by using contrast-enhanced ultrasound (CEUS). Ultraschall https://doi.org/10.1111/andr.13057
Med. 2019;40(2):253–254.