acute scrotum Flashcards
What is orchitis?
Inflammation of the testis.
Describe the sonographic appearance of orchitis
There may be ipsilateral scrotal wall thickening increased vascularity hypoechoic heterogeneous enlarged always compare to the contralateral side
What virus is orchitis associated with ?
Mumps
What is the result of severe inflammation?
atrophy
What are other causes of orchitis?
Secondary to epididymitis
can also be seen following trauma
Describe the sonographic appearance of focal orchitis
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
What are a predisposing factor of testicular torsion?
Ball-clapper deformity where the tunica vaginalis joins high on the spermatic cord, leaving the testis free to rotate and predisposed to torsion.
Describe the sonographic appearances of testicular torsion
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
What is intravaginal torsion?
○ 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
Describe the sonographic appearance of intravaginal torsion
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.
What are associated signs of intravaginal torsion?
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
What optimisation techniques for assessment of blood flow in the testis?
Increase gain
Decrease PRF
Using a small colour sample window
Use spectral
What are the common causes of testicular trauma?
MVA Athletic injury straddle injuries pelvic fracture blunt trauma penetrating injury
Name some types of testicular trauma
Haematoma
Fracture
Rupture
Foreign bodies- it is important to ascertain whether foreign bodies are intra or extra testicular
What indicates testicular rupture?
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
Describe the appearance of a testicular fracture
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
What sign is suspicious for testicular rupture?
Diffuse hyper or hypoechogenicity with an accompanying haematoma
Describe the sonographic appearance of a haematocele
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
What is a seminoma?
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.
What are non-seminomatous germ cell tumours?
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
When are teratomas most common seen?
In paediatric patients
What are the sonographic features of embryonal carcinoma?
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
What is the most common germ cell tumour in infants <2?
Most common germ cell tumour in infants younger than 2 is a yolk sac tumour and is 80% of childhood testicular neoplasms
What is the sonographic appearance of a teratoma?
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
What is a choriocarcinoma?
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
What are signs and symptoms of choriocarcinoma?
Focal necrosis of tumour
Elevated human chorionic gonadotropin are elevated and cause gynecomastia
Worst prognosis of any germ cell tumour
What is a Leydig tumour?
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
Where do testicular metastases arise from?
In adults: non hodgkin’s lymphoma
In paeds: leukemia
also renal, prostate and lung
Which tumours are related to orchitis?
seminomas and testicular lymphoma
Describe testicular lymphoma
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
Describe the sonographic appearance of testicular lymphoma
Homogeneously, hypoechoic testicle or multifocal hypoechoic lesions
Increased vasc on colour
Why is testicular leukaemia not responsive to chemotherapy?
In leukemia, the blood-testis barrier prevents chemotherapeutic agents from reaching the testicle, so it continues to grow. Similar appearance to lymphoma
What are stromal and sex-cord tumours?
Non-specific appearance
Rare
Most common types are Sertoli and Leydig cell tumours
Histologically benign, but increases oestrogen secretion
Describe a sex-cord tumour.
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
What can mimic malignancy?
Haematomas
Orchitis
Abscesses
What is the acute scrotum
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.
Causes of acute scrotum
inflammation torsion of testes torsion of appendages trauma incarcerated inguinal hernia underlying testicular tumour
Complications of epididymitis
○ Orchitis ○ Testicular infarct ○ Scrotal abscess ○ Chronic epididymitis ○ Testicular atrophy ○ Infertility
Non-specific causes of epididymitis
§ 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
Specific causes of epididymitis
gonorrhoea
chlamydia
syphillis
tuberculosis
Chemical causes of epididymitis
results from retrograde flow of urine from an overdistended bladder with increased abdominal pressure
Traumatic causes of epididymitis
Trauma itself or trauma activating a dormant infection
Post-vasectomy causes of epididiymitis
Extravasation of sperm into local tissues causing focal epididymitis in area of luminal rupture
Describe the sonographic appearance of acute epididymitis
Enlarged, hypoechoic
Can appear hyperechoic in some cases
increased vasc
Describe the sonographic appearance of sub-acute to chronic epididymitis
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
Which part of the epididymis is most likely to be affected by infection?
Tail
Also the most resistant to abx
Which occult primary tumours present as echogenic foci with or wihtout shadowing?
avascular burnt out tumour
azzopardi tumour
what is the role of colour Doppler in assessing tumour lesions?
○ 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
Describe the sonographic appearance of metastases
hypoechoic
single or multiple
Describe testicular sarcoidosis
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
