CASE 18491 Published on 15.03.2024

A polyorchidism mimic in imaging of scrotum


Uroradiology & genital male imaging

Case Type

Clinical Case


Ali S. F. Fadhil 1, Sahar Al-Talqani 1, Sumit Jagani 2

1 NHS Workforce, Training and Education – East Midlands, Nottingham, United Kingdom

2 Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom


6 years, male

Area of Interest Genital / Reproductive system male ; Imaging Technique Ultrasound
Clinical History

A 6-year-old male presented with scrotal swelling with minimal pain, which was relieved with analgesia. There were no associated fevers or vomiting, nor history of trauma. Examination identified a non-tender 2cm x 3cm rounded firm rubbery mass anterior to the left testicle. There were no abnormal skin changes, normal cremasteric reflex, no hydrocele nor examination findings of hernia.

Imaging Findings

US was performed with an 18–24MHz linear probe demonstrating normal appearances of the right hemiscrotum; fine granular echotexture of pre-pubertal testes measuring 13x7x8mm and relatively hypoechoic epididymis (Figure 1).

In the left hemiscrotum, there was a trilobed, ovoid structure with fine granular echotexture separated by thing hypoechogenic linear band (Figure 2). The lobes were isoechogenic to each other and similar to the right testes. There were mediastinum testes present in one of the lobules measuring 12x7mm in association with a relatively hypoechogenic epididymal head, thought to be the left testicle (Figure 3). The body and tail of the epididymis were distorted by the other lobules. The remaining ovoid structure 13x16x18mm had a central hyperechogenic band resembling mediastinum (Figure 4) but no communication to the epididymis. The findings were concerning for polyorchidism; however, on closer inspection, cine loop imaging demonstrated fine to-and-fro movement of echogenic material within the larger of the ovoid structure, favouring fluid content rather than testicular tissue, albeit incongruous with clinical findings. In light of this, the patient underwent surgical exploration and was found to have a haemorrhagic cyst containing old blood.


Polyorchid is the condition of having more than 2 testes [13]. While the majority of cases are asymptomatic, a small number of patients may experience pain as their sole symptom [4]. The left side is more commonly affected by polyorchidism. Among all cases of supernumerary testes, triorchidism is the most frequently observed condition [5].

Sonography is usually sufficient for diagnosis in the majority of instances. However, an MRI may be useful in cases of complex polyorchidism [6]. Histology is the gold standard confirmation modality [7,8].

The typical imaging appearance of polyorchid involves normal echogenicity of the testes on scrotal ultrasonography. The supernumerary testis/testes can be observed as a solid nodule that is isoechoic to the testes and has the same echotexture [1,8]. Colour Doppler or power Doppler ultrasonography shows normal blood flow in the supernumerary testis, with the same characteristics as in the two normal ones [1,3,9]. Polyorchidism mimics or differentials include minor lobulation, para testicular dermoid cyst, hydroceles, varicoceles, spermatoceles, lipomas, tumours, hernia, and splenogonadal fusion [3,4,10,11].

In this case, it demonstrates that the blood could give a high echo signal which mimicked the polyorchidism picture radiologically [12]. The brief medical history exhibited atypical characteristics for polyorchidism, yet the absence of a triggering event such as trauma, combined with suspicious ultrasound features, raised concerns.

The management of polyorchidism remains a subject of debate, depending on factors such as testis location, reproductive potential, size, and age. Conservative surveillance is an option for orthotopic supernumerary testes, while surgical exploration is recommended for extra-scrotal testes or complications [13]. Conservative surveillance is now being accepted, particularly in pediatric cases with normal radiological findings and negative tumour markers [6,9,14,15].

Written informed patient consent for publication has been obtained.

Differential Diagnosis List
Testicular haemorrhagic cyst
Para testicular dermoid cyst
Final Diagnosis
Testicular haemorrhagic cyst
Case information
DOI: 10.35100/eurorad/case.18491
ISSN: 1563-4086