Scrotal Elastography: Overview & Clinical Applications

Scrotal elastography is an advanced ultrasound technique that assesses tissue stiffness in the testes and scrotal structures. It helps differentiate benign from malignant lesions, evaluate testicular fibrosis, and detect chronic ischemia or inflammation.

Elastography measures tissue elasticity, with softer tissues appearing more deformable and stiffer tissues being less compressible—this is particularly useful in testicular tumors, chronic orchitis, and infertility-related testicular atrophy.

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Types of Scrotal Elastography

A. Strain Elastography (SE)

• Measures relative tissue deformation in response to external pressure.
• Color Map Interpretation:
  • Soft tissue → Blue/Green
  • Hard tissue → Red
• Used for focal lesion assessment (e.g., tumors vs. cysts).

B. Shear Wave Elastography (SWE)

• Provides quantitative stiffness measurements in kilopascals (kPa) or meters per second (m/s).
• More reproducible and operator-independent than SE.
• Helps assess diffuse testicular disease (e.g., fibrosis in infertility).

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Scrotal Elastography Scanning Protocol

A. Patient Preparation

• Position: Supine, with scrotum supported.
• Transducer: High-frequency linear probe (7.5–15 MHz) with elastography mode enabled.
• Settings: Adjust elastography scale to detect soft vs. stiff tissues.

B. Imaging Steps

✅ Perform conventional B-mode ultrasound first to identify normal vs. abnormal areas.
✅ Apply elastography mode (strain or shear wave) over both testes.
✅ Compare stiffness between the affected and contralateral testis.
✅ For lesions, measure stiffness in kPa and analyze the color-coded elasticity map.

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Clinical Applications of Scrotal Elastography

A. Testicular Tumors

• Malignant tumors (e.g., seminomas, non-seminomas) appear stiffer (higher kPa values) due to increased cellular density.
• Benign lesions (e.g., cysts, hydroceles, hematomas) are soft and deformable.
• Helps reduce unnecessary biopsies for non-suspicious lesions.

✅ Cutoff Values for Malignancy

• Benign lesions: ≤2.5 kPa
• Malignant lesions: ≥3.5–5.0 kPa

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B. Chronic Orchitis & Testicular Ischemia

• Chronic orchitis or fibrosis leads to increased stiffness due to scarring and inflammation.
• Helps differentiate chronic ischemia (stiff) from acute inflammation (soft).

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C. Infertility & Testicular Atrophy

• Elastography detects testicular stiffness in subfertile men with fibrosis and Sertoli-cell-only syndrome.
• Increased stiffness correlates with testicular dysfunction and sperm production impairment.

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D. Torsion vs. Epididymo-Orchitis

• Testicular torsion: Stiff due to necrosis and infarction.
• Epididymo-orchitis: Softer due to edema and inflammation.

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Summary of Elastography Findings

Condition	Elastography Appearance	Stiffness (kPa)
Normal Testis	Uniform soft tissue	1.5–2.5 kPa
Benign Cysts/Hydrocele	Soft, highly compressible	<2.5 kPa
Malignant Tumor	Stiff, less deformable	>3.5–5.0 kPa
Chronic Orchitis/Fibrosis	Increased stiffness	>2.5 kPa
Testicular Torsion (>6h)	High stiffness due to necrosis	>3.5 kPa
Epididymo-Orchitis	Softer than normal	<2.0 kPa