4. Genitourinary (Male repro)

Question 1

Normal penis anatomy (2)

Answer 1

2 Corpus Cavernosa, both surrounded by a tunica albuginea, then both surrounded by deep fascia then superficial fascia.
Urethra is beneath all this

Question 2

Fractured penis (3)

Answer 2

Common in older men, often while erect.
US or MRI will show haematoma.
Defined by fracture corpus cavernosum and surrounding tunica albuginea.

Question 3

Prostate cancer screening (2)

Answer 3

Prostate MRI is replacing biopsy,
Also can be used for high risk screening (high or rising PSA with negative biopsy) or to stage (extracapsular extension).

Question 4

Prostate anatomy (4)

Answer 4

Anterior fibromuscular zone - Dark on T1 and T2.
Central and transitional zones (together called central gland) are brighter than anterior muscular zone, but less bright than peripheral zone on T2.
Peripheral zone is T2 brightest.
70% of cancer and 70% of prostate mass is in the peripheral zone

Question 5

Prostate cancer Imaging (3)

Answer 5

MRI:
Cancer is dark on T2 (background is high). Restricts diffusion.
Enhances early, washes out (type 3 curve like breast cancer).
Bone scan is useful for prostate mets (vertebral body mets).

Question 6

Prostate cancer staging (4)

Answer 6

Stage B: Confined by capsule, abutment of capsule without bulging.
Stage C: Extension through capsule, bulging of capsule or frank extension through it.
B vs C is most important factor governing treatment.
Seminal vesicles and nerve bundle are right behind the prostate and can get invaded too (important for urology to know).

Question 7

BPH (5)

Answer 7

Common, defined as prostate volume >30ml.
Most commonly affects transitional zone (cancer is rare here).
Median lobe hypertrophies, sticks into the bladder.
Can cause bladder outlet obstruction, bladder wall thickening (detrusor hypertrophy) and bladder diverticula.
IVP buzzword is J shaped or Fishhook shaped ureter.

Question 8

BPH on MRI (4)

Answer 8

Nodules seen on MRI are usually
- In transition zone
- T2 heterogenous
- Can restrict diffusion
- May enhance and washout

Question 9

Post prostate biopsy MRI

Answer 9

T1 brightness in the gland due to subacute blood.

Question 10

Prostate lesion summary (4)

Answer 10

Peripheral zone tumour: T2 dark, ADC dark, Early enhancement and washout.
Peripheral zone haemorrhage: T2 dark (sometimes T1 bright), ADC less dark, no enhancement.
Central gland/transitional zone tumour: T2 dark, ADC dark, Early enhancement and washout.
BPH: T2 dark (well defined), ADC less dark, can enhance.

Question 11

Prostatic utricle cyst/Mullerian duct cyst (5)

Answer 11

Both look similar.
Mullerian duct cyst is an anatomic variant of caudal ends of Mullerian ducts (male equivalent of vagina/cervix).
Prostatic utricle is focal dilation in prostatic urethra.
Midline cystic structure near the bladder of a man.
Can be seen on RUG as focal out-pouching from prostatic urethra.

Question 12

Prostatic utricle cyst vs Mullerian Duct Cyst (5)

Answer 12

Prostatic utricle cyst:
- Associated with hypospadias.
- Also associated with prune belly syndrome, Downs, unilateral renal agenesis and imperforate anus.
- If large, can get infected.
Mullerian duct cyst
- Doesn’t have same associations as prostatic utricle cyst.
- Can contain cancer (endometrial, clear cell or squamous).

Question 13

Seminal vesicle cysts (3)

Answer 13

Unilateral, lateral cyst (lateral to prostate).
Cam look midline if large.
Can be congenital or acquired.

Question 14

Congenital seminal vesicle cysts - associations (4)

Answer 14

Associated with:
- Renal agenesis
- Vas deferens agenesis
- Ectopic ureter insertion
- Polycystic Kidney Disease

Question 15

Acquired seminal vesicle cysts (2)

Answer 15

Obstruction from prostatic hypertrophy, or chronic infection/scarring
Classic Hx is prior prostate surgery

Question 16

Male pelvic cysts DDx (5)

Answer 16

Midline
- Prostatic utricle
- Mullerian duct cyst
- Ejaculatory duct cyst
Lateral
- Seminal vesicle cyst
- Diverticulosis of ampulla of vas deferens

Question 17

Testicular trauma (3)

Answer 17

Important distinction is rupture vs fracture. Rupture requires surgical intervention.
Rupture: Disrupted tunica albuginea, heterogenous testicle, poorly defined testicular outline.
Fracture: Intact tunica albuginea, linear hypoechoic band across parenchyma of testicle, well defined testicular outline.

Question 18

Torsion of testicle (4)

Answer 18

Due to testis and spermatic cord twisting within the serosal space, leading to ischaemia.
Doppler: Absent or assymetrically decreased flow, asymmetric enlargement and decreased echogenicity of affected testis.
Cause: “bell clapper deformity” - abnormal high attachment of tunical vaginalis, increasing mobility and predisposing to torsion. Usually bilateral, so other side gets orchidopexy too.
Viability: Related to degree of torsion and time. Generally needs to be operated before 6 hours

Question 19

Epididymitis (5)

Answer 19

Inflammation of epididymis, most common cause of acute scrotal pain in adults.
Caused by chlamydia or gonorrhoea in sexually active men, or e.coli more often in older men from UTI.
Epididymal head is most affected.
Increased size and hyperaemia on US.
Infection of epididymis alone, or with testicle (epididymo-orchitis). Isolated orchitis is rare.

Question 20

Orchitis (3)

Answer 20

Typically progresses from epididymitis.
Isolated only really occurs with mumps.
Asymmetric hyperaemia on US.

Question 21

Epidermoid cysts (2)

Answer 21

Benign mass of testicle with onion skin appearance on US (alternating hyper and hypoechoic rings).
Non-vascular relative to rest of testicle.

Question 22

Tubular ectasia of Rete Testis (4)

Answer 22

Common benign finding, due to partial or complete obliteration of the efferent ducts.
Usually bilateral and in older men.
Cystic dilatation is next to mediastinum testis.
Essentially a normal variant. No follow-up needed.

Question 23

Calcified vas deferens

Answer 23

Commonly seen in bad diabetics.

Question 24

Testicular cancer - overview (5)

Answer 24

Hypoechoic solid intratesticular masses are cancer until proven otherwise.
Doppler is helpful if absent (suggests haematoma in the right clinical setting).
Extratesticular + cystic = probably benign.
Cryptorchidism increases risk of Ca in both testes, and risk not reduced by orchidopexy.
Most tumours met via lymphatics (retroperitoneal nodes at level of renal hilum), except choriocarcinoma, which mets via blood.
Most are germ cell subtypes (95%), of which half are seminomas.

Question 25

Testicular cancer risk factors (6)

Answer 25

Cryptorchidism,
Gonadal dysgenesis
Klinefelters
Trauma
Orchitis
Possibly testicular microlithiasis

Question 26

Testicular microlithiasis (2)

Answer 26

Multiple, small echogenic foci within the testes, usually incidentally found.
May have relationship with germ cell tumours. Follow up in 6 months, then yearly, but this recommendation is contraversial.

Question 27

Seminoma (4)

Answer 27

Commonest testicular tumour, and best prognosis (very radiosensitive).
9x more common in white men. peak age around 25.
Homogenous, hypoechoic round mass, classically replaces the entire testicle.
On MRI, usually homogenously T2 dark (not-seminomatous germ cell tuomurs are often brighter)

Question 28

Non-seminomatous germ cell tumours (3)

Answer 28

Mixed germ cell tumours, teratomas, yolk sack tumours and choriocarcinoma.
Usually at a younger age than seminomas (teens).
More heterogenous and larger calcifications

Question 29

Testicular lymphoma (5)

Answer 29

Can “hide” in testes due to blood testes barrier.
Associated with immunosuppression.
Usually non-Hodgkin B cell lymphoma.
US: normal homogenous echogenic testicular tissue is replaced focally or diffusely with hypoechoic, vascular, lymphomatous tissue.
Buzzword = Multiple Hypoechoic Masses of the Testicle

Question 30

Burned out testicular tumour (4)

Answer 30

Large dense calcifications with shadows in old man’s testicle.
Spontaneous regression of germ cell tumour, now calcified.
Can still be viable tumour in there.
Rx is controversial, many will surgically remove.

Question 31

Testicular cancer staging (3)

Answer 31

Testicular mets should spread to para-aortic, aortic, caval region.
Mets to pelvic, external iliac and inguinal nodes is non-regional (i.e. M1 disease).
Exception is if inguinal or scrotal surgery was done before the cancer manifested.

Question 32

High yield testicle tumour trivia (7)

Answer 32

Seminoma is commonest and best prognosis cancer.
Multiple hypoechoic masses = lymphoma
Homogenous and microcalcifications = seminoma
Cystic elements and microcalcifications = mixed germ cell tumour/teratoma
Most met via lymphatics, except choriocarcinoma which mets via blood
Gynaecomastia seen with Sertoli Leydig Tumours
Sertoli Cell Tumours also seen with Peutz-Jehgers

Question 33

hCG and AFP in testicular caner (2)

Answer 33

Raised hCG suggests seminoma or choriocarcinoma.
Raised AFP suggests mixed germ cell or Yolk Sac tumour

Question 34

Male infertility - causes (8)

Answer 34

Obstructive
- Congenital bilateral absence of vas deferens (e.g. CF),
- Ejaculatory duct obstruction.
- Prostatic cysts
- Associated renal anomalies (Zinner syndrome)
Non-obstructive
- Varicocele
- Cryptorchidism
- Anabolic steroid use
- Erectile dysfunction

Question 35

Varicocele (4)

Answer 35

Most common correctible cause of infertility.
Can be unilateral or bilateral.
Unilateral is much more common on left.
Isolated right varicocele - think retroperitoneal process (Ca) compressing right gonadal vein

Question 36

Cryptorchidism (8)

Answer 36

Undescended testes. Usually found within the inguinal canal.
Both testes have increased risk of cancer.
Most common in premature kids (20%)
Complications include
- Malignant degeneration of both testes
- Infertility
- Torsion
- Bowel incarceration (related to association with indirect inguinal hernia)
Not associated with increased risk of orchitis.

Question 37

Syndromes associated with male infertility (4)

Answer 37

Pituitary adenoma (making prolactin)
Kallmann’s syndrome (Can’t smell + infertile)
Klinefelters syndrome (tall + gynaecomastia + infertile)
Zinner syndrome (renal agenesis + ipsilateral seminal vesicle cyst)