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acute scrotum Flashcards

1
Q

What is orchitis?

A

Inflammation of the testis.

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2
Q

Describe the sonographic appearance of orchitis

A 
There may be ipsilateral scrotal wall thickening
increased vascularity
hypoechoic
heterogeneous
enlarged
always compare to the contralateral side
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3
Q

What virus is orchitis associated with ?

A

Mumps

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4
Q

What is the result of severe inflammation?

A

atrophy

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5
Q

What are other causes of orchitis?

A

Secondary to epididymitis

can also be seen following trauma

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6
Q

Describe the sonographic appearance of focal orchitis

A

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

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7
Q

What are a predisposing factor of testicular torsion?

A

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

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8
Q

Describe the sonographic appearances of testicular torsion

A

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

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9
Q

What is intravaginal torsion?

A

○ 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

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10
Q

Describe the sonographic appearance of intravaginal torsion

A

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.

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11
Q

What are associated signs of intravaginal torsion?

A

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

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12
Q

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

A

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

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13
Q

What are the common causes of testicular trauma?

A 
MVA
Athletic injury
straddle injuries
pelvic fracture
blunt trauma
penetrating injury
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14
Q

Name some types of testicular trauma

A

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

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15
Q

What indicates testicular rupture?

A

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

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16
Q

Describe the appearance of a testicular fracture

A

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

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17
Q

What sign is suspicious for testicular rupture?

A

Diffuse hyper or hypoechogenicity with an accompanying haematoma

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18
Q

Describe the sonographic appearance of a haematocele

A

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

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19
Q

What is a seminoma?

A

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.

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20
Q

What are non-seminomatous germ cell tumours?

A 
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

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21
Q

When are teratomas most common seen?

A

In paediatric patients

22
Q

What are the sonographic features of embryonal carcinoma?

A

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

23
Q

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

A

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

24
Q

What is the sonographic appearance of a teratoma?

A

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

25
Q

What is a choriocarcinoma?

A

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

26
Q

What are signs and symptoms of choriocarcinoma?

A

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

27
Q

What is a Leydig tumour?

A

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

28
Q

Where do testicular metastases arise from?

A

In adults: non hodgkin’s lymphoma
In paeds: leukemia

also renal, prostate and lung

29
Q

Which tumours are related to orchitis?

A

seminomas and testicular lymphoma

30
Q

Describe testicular lymphoma

A

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

31
Q

Describe the sonographic appearance of testicular lymphoma

A

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

32
Q

Why is testicular leukaemia not responsive to chemotherapy?

A

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

33
Q

What are stromal and sex-cord tumours?

A

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

34
Q

Describe a sex-cord tumour.

A

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

35
Q

What can mimic malignancy?

A

Haematomas
Orchitis
Abscesses

36
Q

What is the acute scrotum

A

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.

37
Q

Causes of acute scrotum

A 
inflammation
torsion of testes
torsion of appendages
trauma
incarcerated inguinal hernia
underlying testicular tumour
38
Q

Complications of epididymitis

A 
○ Orchitis
○ Testicular infarct
○ Scrotal abscess
○ Chronic epididymitis
○ Testicular atrophy
○ Infertility
39
Q

Non-specific causes of epididymitis

A

§ 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

40
Q

Specific causes of epididymitis

A

gonorrhoea
chlamydia
syphillis
tuberculosis

41
Q

Chemical causes of epididymitis

A

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

42
Q

Traumatic causes of epididymitis

A

Trauma itself or trauma activating a dormant infection

43
Q

Post-vasectomy causes of epididiymitis

A

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

44
Q

Describe the sonographic appearance of acute epididymitis

A

Enlarged, hypoechoic
Can appear hyperechoic in some cases
increased vasc

45
Q

Describe the sonographic appearance of sub-acute to chronic epididymitis

A

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

46
Q

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

A

Tail

Also the most resistant to abx

47
Q

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

A

avascular burnt out tumour

azzopardi tumour

48
Q

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

A

○ 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

49
Q

Describe the sonographic appearance of metastases

A

hypoechoic

single or multiple

50
Q

Describe testicular sarcoidosis

A

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

Gynae (12 decks)

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