acute scrotum

Question 1

What is orchitis?

Answer 1

Inflammation of the testis.

Question 2

Describe the sonographic appearance of orchitis

Answer 2

There may be ipsilateral scrotal wall thickening
increased vascularity
hypoechoic
heterogeneous
enlarged
always compare to the contralateral side

Question 3

What virus is orchitis associated with ?

Answer 3

Mumps

Question 4

What is the result of severe inflammation?

Answer 4

atrophy

Question 5

What are other causes of orchitis?

Answer 5

Secondary to epididymitis

can also be seen following trauma

Question 6

Describe the sonographic appearance of focal orchitis

Answer 6

Uncommon
appears hypoechoic
poorly defined or crescent shaped peripheral focal mass
increased vasc
follow-up is required to confirm resolution as these appearances are similar to testicular neoplasm

Question 7

What are a predisposing factor of testicular torsion?

Answer 7

Ball-clapper deformity where the tunica vaginalis joins high on the spermatic cord, leaving the testis free to rotate and predisposed to torsion.

Question 8

Describe the sonographic appearances of testicular torsion

Answer 8

B-mode appearances may be normal
Using Doppler can reliably demonstrate pathology
Reversed arterial flow in diastole may be demonstrated
in subacute-chronic, the testis may appear more heterogeneous
arterial flow can become occluded

Question 9

What is intravaginal torsion?

Answer 9

○ Abnormal insertion of the tunica vaginalis on the affected testicle
○ The testicle is attached abnormally high and encircles the epididymis and distal spermatic cord (Bell-Clapper deformity)
○ Superior insertion of the tunica gives the affected testicle rotational mobility within the hemiscrotum
○ These patients will present with acute onset of unilateral scrotal pain and swelling with complaints of nausea and vomiting

Question 10

Describe the sonographic appearance of intravaginal torsion

Answer 10

Testis can appear normal during the first 6 hours of onset
After this, testis will demonstrate diffuse hypoechogenicity and enlargement compared to the contralateral side due to vascular engorgement and oedema from reduced blood flow and venous drainage.
Epididymis will demonstrate enlargement.

Question 11

What are associated signs of intravaginal torsion?

Answer 11

Enlarged epididymis that becomes hypoechoic or heterogeneous due to haemorrhage. Twisted and enlarged spermatic cord can also be seen along with scrotal thickening.
Ipsilateral hydrocele
After 24 hours, the testis develops a heterogeneous appearance due to infarction and haemorrhage. Flow can be normal, increased or absent

Question 12

What optimisation techniques for assessment of blood flow in the testis?

Answer 12

Increase gain
Decrease PRF
Using a small colour sample window
Use spectral

Question 13

What are the common causes of testicular trauma?

Answer 13

MVA
Athletic injury
straddle injuries
pelvic fracture
blunt trauma
penetrating injury

Question 14

Name some types of testicular trauma

Answer 14

Haematoma
Fracture
Rupture
Foreign bodies- it is important to ascertain whether foreign bodies are intra or extra testicular

Question 15

What indicates testicular rupture?

Answer 15

Disruption of the tunica albuginea indicates testicular rupture
90% of ruptured testes can be saved in the first 72 hours
Sonographic features: focal areas of altered testicular echogenicity corresponding to areas of hemorrhage or infarction and hematocele formation
Heterogeneity of the testis with testicular contour irregularity
Scrotal pain, swelling and thickening

Question 16

Describe the appearance of a testicular fracture

Answer 16

Testicular fracture refers to discontinuity of normal testicular parenchyma which may be present in the absence of disruption of the tunica albuginea
Hematoma or hematocele may be present
Fracture will appear as linear, hypoechoic, avascular band extending across the testicular parenchyma

Question 17

What sign is suspicious for testicular rupture?

Answer 17

Diffuse hyper or hypoechogenicity with an accompanying haematoma

Question 18

Describe the sonographic appearance of a haematocele

Answer 18

Collection of blood between the tunica vaginalis caused by intra or extra testicular bleeding
acutely- echogenic
subacute- hypoechoic fluid containing septations
Large haematoceles are suspicious for testicular rupture
Small haematoceles have little risk for rupture

Question 19

What is a seminoma?

Answer 19

Germ cell tumour
most common
cryptorchidism is a risk factor
highly sensitive to radiation and chemo
appear homogeneously hyperechoic
mostly demonstrated increased flow on colour
entire testicle can be replaced by tumour
primary is usually confined to tunica albuginea on discovery.
larger tumour appear more heterogeneous
at presentation, 25% of patients have evidence of metastatic disease either by lymphatic or haematogeneous spread.

Question 20

What are non-seminomatous germ cell tumours?

Answer 20

Includes
teratoma
embryonal cell tumour
choriocarcinoma
mixed germ cell tumour
yolk sac tumour

These tumours demonstrate a heterogeneous echotexture with irregular or ill-defined margins
echogenic foci can represent areas of haemorrhage, calcification or fibrosis

Question 21

When are teratomas most common seen?

Answer 21

In paediatric patients

Question 22

What are the sonographic features of embryonal carcinoma?

Answer 22

Present in 87% of mixed germ cell tumours
Occur in younger patients
Sonographic features of a pure embryonal cell carcinoma are nonspecific, with the only finding being testicular enlargement without a defined mass.
They tend to distort the testicle and invade the tunica albuginea

Question 23

What is the most common germ cell tumour in infants <2?

Answer 23

Most common germ cell tumour in infants younger than 2 is a yolk sac tumour and is 80% of childhood testicular neoplasms

Question 24

What is the sonographic appearance of a teratoma?

Answer 24

Usually a well defined, markedly heterogeneous mass containing cystic and solid areas of various sizes and appears similar to other NSGCTs
Can have echogenic foci due to focal calcification, cartilage, immature bone, fibrosis and noncalcific scarring

Question 25

What is a choriocarcinoma?

Answer 25

Accounts for less than 1% of malignant primary testicular tumours in its pure form but occurs in 8% of mixed germ cell tumours Peak incidence in 2nd and 3rd decades Highly malignant and metastasize early by hematogenous and lymphatic routes Primary tumour and metastases are often hemorrhagic and patients have many symptoms resulting from hemorrhagic metastases including hemoptysis, hematemesis, and CNS symptoms

Question 26

What are signs and symptoms of choriocarcinoma?

Answer 26

Focal necrosis of tumour Elevated human chorionic gonadotropin are elevated and cause gynecomastia Worst prognosis of any germ cell tumour

Question 27

What is a Leydig tumour?

Answer 27

occurs in predominantly patients aged 20-50 years Patients often present with a painless testicular enlargement or a palpable mass Gonadal tumours are usually small, solid, homogenous hypoechoic masses on sonography and may have peripheral flow Foci of hemorrhage and necrosis are present in 25% of tumours and cystic spaces

Question 28

Where do testicular metastases arise from?

Answer 28

In adults: non hodgkin's lymphoma In paeds: leukemia also renal, prostate and lung

Question 29

Which tumours are related to orchitis?

Answer 29

seminomas and testicular lymphoma

Question 30

Describe testicular lymphoma

Answer 30

Usually presents as an enlarged testicle Diffuse non-hodgkin's lymphoma is most common Infiltrative Involve the entire testis, extending to the epididymis and spermatic cord

Question 31

Describe the sonographic appearance of testicular lymphoma

Answer 31

Homogeneously, hypoechoic testicle or multifocal hypoechoic lesions Increased vasc on colour

Question 32

Why is testicular leukaemia not responsive to chemotherapy?

Answer 32

In leukemia, the blood-testis barrier prevents chemotherapeutic agents from reaching the testicle, so it continues to grow. Similar appearance to lymphoma

Question 33

What are stromal and sex-cord tumours?

Answer 33

Non-specific appearance Rare Most common types are Sertoli and Leydig cell tumours Histologically benign, but increases oestrogen secretion

Question 34

Describe a sex-cord tumour.

Answer 34

Most common symptom is a painless intratesticular mass May occur in undescended testes and Peutz Jergher’s syndrome Typically well circumscribed, unilateral, rounded to lobulated masses Might appear heterogenous due to hemorrhage Large cell calcifying Sertoli cell tumour is often bilateral, multifocal and may be completely calcified

Question 35

What can mimic malignancy?

Answer 35

Haematomas Orchitis Abscesses

Question 36

What is the acute scrotum

Answer 36

Term used to encompass clinical conditions characterised by the sudden onset of pain, swelling and reddening of the scrotum. Can occur in isolation or secondary.

Question 37

Causes of acute scrotum

Answer 37

``` inflammation torsion of testes torsion of appendages trauma incarcerated inguinal hernia underlying testicular tumour ```

Question 38

Complications of epididymitis

Answer 38

``` ○ Orchitis ○ Testicular infarct ○ Scrotal abscess ○ Chronic epididymitis ○ Testicular atrophy ○ Infertility ```

Question 39

Non-specific causes of epididymitis

Answer 39

§ Usually sequelae of infections in the genito-urinary system particularly the bladder, urethra, prostate or seminal vesicles § Pathogens reach the epididymis through retrograde migration via the vas deferens or lymphatic pathways of the spermatic cord

Question 40

Specific causes of epididymitis

Answer 40

gonorrhoea chlamydia syphillis tuberculosis

Question 41

Chemical causes of epididymitis

Answer 41

results from retrograde flow of urine from an overdistended bladder with increased abdominal pressure

Question 42

Traumatic causes of epididymitis

Answer 42

Trauma itself or trauma activating a dormant infection

Question 43

Post-vasectomy causes of epididiymitis

Answer 43

Extravasation of sperm into local tissues causing focal epididymitis in area of luminal rupture

Question 44

Describe the sonographic appearance of acute epididymitis

Answer 44

Enlarged, hypoechoic Can appear hyperechoic in some cases increased vasc

Question 45

Describe the sonographic appearance of sub-acute to chronic epididymitis

Answer 45

As inflammation progresses, associated haemorrhage and microabscess formation occurs. More complex and heterogeneous scrotal wall thickening secondary hydrocele formation pyoecele chronic epididymitis appears enlarged and hyperechoic hard, bulky tail of the epididymis is a strong marker for chronic scarring post-epididymitis

Question 46

Which part of the epididymis is most likely to be affected by infection?

Answer 46

Tail | Also the most resistant to abx

Question 47

Which occult primary tumours present as echogenic foci with or wihtout shadowing?

Answer 47

avascular burnt out tumour | azzopardi tumour

Question 48

what is the role of colour Doppler in assessing tumour lesions?

Answer 48

○ Can help distinguish haematomas and testicular infarcts ○ Not a huge role in assessing malignant from benign tumours due to overlap in appears ○ Tumours less than 16mm tend to be hypovascular' ○ Those greater than 16mm tend to be hypervascular ○ If vessels are arrange in an irregular pattern, then this is suspicious for malignancy

Question 49

Describe the sonographic appearance of metastases

Answer 49

hypoechoic | single or multiple

Question 50

Describe testicular sarcoidosis

Answer 50

Non infectious, chronic, granulomatous disease that may involve the genital tract Clinical presentation is acute or recurrent epididymitis or painless enlargement of the testis or epididymis Sarcoid lesions are irregular, hypoechoic solid masses in the testis or epididymis