Ch 5b (scrotum pathology) Flashcards
1
Q
What is tubular ectasia of the rete testis?
A
-A common benign condition
-M/c bilateral + seen in men with vasectomy’s
2
Q
What is a decrease in testicle size a possible cause of + possible indication of?
A
-Cause of infertility
-Indication of a pituitary or hypothalamus gland abnormality
3
Q
Hypogonadotropic hypogonadism results from the absence of which hormone?
A
Absence of gonadal-stimulating pituitary hormones causing underdeveloped testicles
4
Q
What are some causes of testicular atrophy?
A
-cryptorchidism (undescended testicles)
-missed torsion
-postsurgical procedures
-epididymo-orchitis
-trauma
5
Q
An absence of GnRH affects the size of the testis how?
A
Causes smaller testicles
6
Q
SF of testicular atrophy?
A
-Small/shrunken
-Heterogeneous
-Increased echogenicity due to fibrosis
7
Q
Where do the testicles lie in fetuses?
A
In peritoneal cavity near inguinal canal
8
Q
When do boys testes descend?
A
At birth, sometimes they descend later tho
9
Q
What is cryptorchidism?
A
Undescended testis:
Unilateral absence of a testis in the scrotum, usually located in abdominal cavity or inguinal canal
10
Q
Is malignancy higher in an undescended testis?
A
Yes, 48-50x higher than normal descended testis
11
Q
Why is infertility associated with an undescended testis?
A
B/c sperm are exposed to abnormally high temperatures within the abdomen or inguinal canal
12
Q
By what age can fertility be preserved when an undescended testis is relocated?
A
Before 2 y/o
13
Q
Is an undescended testis associated with an increased risk of testicular torsion + inguinal hernia?
A
Yes!
14
Q
What 4 things are associated with an undescended testis?
A
-malignancy
-infertility
-testicular torsion
-inguinal hernia
15
Q
80% of undescended testis are located where?
A
Inguinal canal
(20% in intra-abdominal, which is from renal hilum to inguinal canal)
16
Q
SF of cryptorchidism?
A
-oval/elongated
-well circumscribed
-hypoechoic
-homogeneous soft tissue structure
-smaller than normal descended testis
17
Q
Testicular torsion represents what % of scrotal disease in postpuberty males?
A
20%
18
Q
Torsion m/c occurs during what age?
A
Adolescence - b/w 12-18 y/o
19
Q
What is torsion caused by?
A
Developed weakness of the mesenteric attachment of the spermatic cord to the testis + epi
20
Q
The weak + faulty development with testicular torsion causes what to happen to the testis?
A
Causes them to fall forward in the scrotum + rotate freely within the tunica vaginalis
21
Q
Twisting of the spermatic cord with torsion results in what?
A
Venous congestion - prevents venous drainage
22
Q
What can venous drainage lead to in torsion?
A
-Arterial occlusion
-Scrotal edema
-Hemorrhage
-Infarction
23
Q
What is the sign for detecting a spermatic cord with torsion?
A
Torsion knot / whirlpool pattern
(shows increased + decreased echogenicity at the external inguinal canal above the testis + epi)
24
Q
What 2 things must we always use when confirming presence of arterial + venous flow in testis?
A
-Pulsed doppler
-CD
25
When surgery is performed for torsion within 6 hours after onset of pain, what is the salvage rate?
B/w 80-100%
26
When surgery is performed for torsion after 12 hours after onset of pain, what is the salvage rate?
20%
27
2 types of torsion are?
-Intravaginal
-Extravaginal
28
What is intravaginal torsion?
-When testis rotate freely in tunica vaginalis
-M/c type
29
What is extravaginal torsion?
-Only occurs in newborns
-When gubernaculum is not fixed + testis can freely rotate
30
Which type or torsion is m/c?
Intravaginal
31
Which type of torsion only occurs in newborns?
Extravaginal
32
What are the 4 clinical signs of testicular torsion?
-Sudden onset of pain
-Nausea
-Vomiting
-Low grade fever
33
After how many hours until torsion pain disappears + the testicle is dead?
After 24 - 48 hours
34
What are the 3 phases of torsion?
-Acute (within 24 hrs)
-Subacute (1 - 10 days)
-Chronic (over 10 days)
35
Can the testicle be saved if surgery is done after 24 hours?
No, almost never results in successful salvage of the testis
36
What is a missed torsion?
A missed opportunity to save the testicle before it hits the 24 hour mark
37
What does missed torsion cause?
Permanent infertility issues
38
What do SF in torsion depend on?
Duration + degree of spermatic cord rotation
39
SF of acute torsion?
-enlarged testis
-normal or decreased echogenicity
-enlarged epi (with torsic knot/whirlpool pattern)
-scrotal skin thickening
-reactive hydrocele
-lack of blood flow by CD or PD shows ischemia
(occurs within 1-6 hours)
40
SF of subacute torsion?
-enlarged testis, epi + spermatic cord with varying echogenicity
-heterogeneous testis + epi with diffuse or focal hypoechoic changes (represents necrosis, hemorrhagse + infarction)
(occurs within 24hrs - 10 days)
41
Which stage of torsion is missed torsion territory?
Subacute - may not be reversible now
42
SF of chronic torsion?
Testes:
-small + hypoechoic
-heterogeneous + fibrotic in cases of hemorrhage infarction b/c is degenerating
Epi:
-enlarged + echogenic (represents hemorrhage + necrosis)
(occurs after 10 days)
43
What is torsion-detorsion?
-Partial or transient (meaning only lasting for a short time) torsion occurs with spontaneous detorsion of testicular torsion
-Naturally detorts itself
44
Would torsion-detorsion be hard to image or diagnose?
Yes, b/c the affected structures can look normal even though the pathology is present
45
Characteristics of torsion-detorsion?
-Acute + intermittent sharp testicular pain with scrotal swelling
-Long asymptomatic intervals
46
SF of torsion-detorsion?
-Possibly enlarged testis
-Focal infarcts may or may not be present
47
How could we catch the torsion with someone experiencing torsion-detorsion?
Wait until the pt is feeling clinical symptoms until we do an u/s so we can catch it
48
Which pathology can cause acute scrotal pain that mimic's testicular torsion?
Torsion of the appendix testis or appendix epi
49
SF of a torsed appendage?
Varies:
-large, circular, hyperechoic mass with central hypoechoic area
or
-enlarged, circular, heterogeneous mass adjacent to normal testis + epi
50
Is it easy to diagnose a torsed appendage?
No, it is hard unless we saw the appendix on a previous study
51
Is testicular rupture common?
No, rare
52
What causes testicular rupture?
When the tunica albuginea is torn by trauma
(the layer surrounding the testicle is broken cause of the trauma)
53
What 2 types of injuries/accidents is testicular rupture associated with?
-Athletic injuries
-Industrial/motor vehicle accidents
54
SF of testicular rupture?
-Abnormal contour
-Extrusion of testicle contents into scrotal sac (fluid is draining into scrotum)
-Hematocele b/w tunica vaginalis + parietalis
-Intratesticular hematoma
-Infarction
55
Which pathology accounts for 75-80% of all acute inflammatory processes in the scrotum?
Epididymitis (inflammation of epi)
56
What age group is m/c affected by epididymitis?
Men 20-30 y/o
57
What can cause epididymitis?
Infections:
-STI's
-chlamydia
-gonorrhoeae
-escherichia coli + proteus mirabilis
-urinary catheters
58
Which part of the epi is affected with epididymitis?
Any part - the entire epi is affected in 50% of cases
59
What happens if epididymitis is left untreated?
-Progresses to involve the spermatic cord + testis
-Results in a spermatic cord abscess or epididymo-orchitis (inflammation of both epi + testicle)
60
Which pathology accounts for 25% of acute inflammatory processes of the scrotum?
Epididymo-orchitis (inflammation of both the epi + testicle)
61
What happens if acute epididymo-orchitis is left untreated?
Progresses to abscess, gangrene, infarct, pyocele, infertility + atrophy
62
Clinical symptoms of epididymo-orchitis?
-fever
-tenderness
-enlarged epi, testis + hemiscrotum
(hemiscrotum = 1 half of scrotum)
63
Is it common to have an inflamed testicle + a normal epi?
No, rare. M/C both are inflamed.
64
What is orchitis?
Inflammation of one or both testicles
65
SF of epididymo-orchitis?
-Hypoechoic due to edema
-Areas of hyperechogenicity
-Secondary to hemorrhage + infection
-Scrotal wall thickening
-Reactive hydrocele
-CD hypervascularity
66
Common SF's of acute epididymitis, epididymo-orchitis + orchitis?
-Enlargement
-Variable echogenicity of affected structure
67
What is the hallmark sign that indicates scrotal inflammatory disease?
CD hypervascularity of affected structures
68
SF + result of severe untreated epididymo-orchitis?
Scrotal/testicular/epi abscess! Appears as:
-Focal hypoechoic or mixed area
-Irregular walls
-Hypervascular margins
-Scrotal wall thickening
-Reactive hydrocele
69
What is a reactive hydrocele?
Type of non-communicating hydrocele that results from inflammation in scrotum due to trauma, infection or testicular torsion
70
What is a hydrocele?
Abnormal accumulation of serous fluid in potential space b/w visceral + parietal layers of the tunica vaginalis (which surrounds the testis)
71
What is the m/c cause of painless scrotal swelling?
Hydroceles
72
Difference b/w congenital + acquired hydroceles?
Congenital: is fluid communicating b/w abdominal cavity + scrotum
Acquired: is fluid secondary to infection or trauma
73
What is the classic SF of a hydrocele?
Anechoic simple fluid collection surrounding the testis
74
Should we be concerned if we see a hydrocele?
If it is small it's fine, unless it grows to become larger
75
What could chronic hydroceles contain?
Calcifications (produces shadowing)
76
What are calcifications in a chronic hydrocele called?
Scrotoliths or scrotal pearls
77
SF of scrotoliths?
-Multiple or singular
-Fills potential space b/w layers of tunica vaginalis testis
78
How are scrotoliths m/c found?
Incidentally
79
What are the 2 m/c epi lesions?
-Spermatoceles
-Epi cysts
80
Symptoms of spermatoceles + epi cysts?
-Asymptomatic
or
-Painless scrotal masses
81
Size of spermatoceles + epi cysts?
Varies, from 0.2 - 9 cm
82
Cause of spermatoceles + epi cysts?
Dilatation of epi tubules - whether secondary to vasectomy, scrotal surgery, trauma or epididymitis
83
Which part of epi is m/c location for spermatoceles/epi cysts?
Epi head
84
What do spermatoceles contain?
-Nonviable spermatozoa
-Cellular debris
-Lymphoceles
85
What do epi cysts contain?
Lined wtih epithelium + contain ONLY serous fluid
86
Are spermatoceles + epi cysts hard to distinguish on u/s?
Yes, b/c they look almost identical on u/s
87
SF of epi cysts?
-Anechoic
-Thin walled
-M/C in head
88
SF of spermatoceles?
-Low level echoes
-Thin walled
-Hypoechoic
89
Could spermatoceles + epi cysts contain septations?
Yes, they might. Usually unilocular as well.
90
What is tubular ectasia of the rete testis?
Dilatation of the efferent ductules
91
What age would we m/c see tubular ectasia of the rete testis?
Men over 50 y/o
92
SF of tubular ectasia of the rete testis?
-M/C bilateral
-Multiple tiny cystic tubules located within or adjacent to the mediastinum testis
93
Which procedure m/c causes tubular ectasia of the rete testis?
Post vasectomy
94
How is a varicocele formed?
By dilatation of the pampiniform plexus veins to a width greater than 3 mm
95
Which pathology is the reason why we assess scrotal veins with a valsalva?
Varicoceles
96
Where would dilated + tortuous veins be located on the testis?
Superior + posterior to the testis
97
What causes dilated + tortuous veins in testicles?
From incomplete valves in the testicular vein
98
2 types of varicoceles?
-Primary (idiopathic)
-Secondary
99
Lightbulbs for primary varicoceles?
-M/C left sided (due to length + pathway of left testicular vein)
-M/C in men aged 15-25
100
Cause of secondary varicoceles?
Pressure on testicular vein due to compression
(ex. nutcracker syndrome, RCC, cirrhosis, etc)
101
What pathology is the m/c correctable cause of infertility?
Varicoceles
(occurs in 21-39% of men at infertility clinics)
102
Measurement of varicocele?
Over 3mm
103
Varicoceles are m/c seen after which procedure?
Post vasectomy
104
Are primary or secondary varicoceles m/c?
Primary
105
Are varicoceles m/c on right or left testis?
Left - b/c has longer path to go
106
Do we perform a valsalva on every scrotum scan?
Yes!
107
Generally what causes varicoceles?
If valves don't close properly + flow goes backwards
108
Clinical signs of varicoceles?
-Scrotal mass
-Infertility
-Abnormally warm scrotum
109
SF of varicoceles?
-Multiple hypoechoic, tortuous, tubular structures
-Measure over 3mm when doing valsalva (must be in supine)
110
What are scrotal hernias?
Inguinal hernias that descend into the scrotum
111
What are inguinal hernias?
Protrusion of peritoneal contents (bowel or omentum/fat) through the processus vaginalis (canal that connects the peritoneal to tunica vaginalis)
112
Do we need u/s to diagnose a scrotal hernia?
No, a clinical exam can diagnose it. Pt will feel bowel slipping down into scrotal sac.
113
Clinical symptoms of scrotal hernias?
-Scrotal mass (constant or intermittent)
-Abdominal pain (very painful)
-Blood in stool
(others may have a hard, nonreducible mass that can't distinguish from a primary scrotal mass)
114
How to treat scrotal hernia?
May need to surgically remove the bowel, pay close attention to these pt's
115
SF of bowel hernia?
-Fluid/air filled loops of bowel will peristalse in scrotum or inguinal canal
-Herniated bowel can become strangulated + no longer peristalse, becoming ischemic
(very painful, can lose segment of bowel)
116
SF of omentum/fat hernia?
Diffusely echogenic paratesticular mass
117
Can scrotal hematomas be intratesticular + extratesticular?
Yes! Extratesticular can involve the scrotal wall, tunica vaginalis + the epi.
118
Cause of scrotal hematomas?
Trauma - injury to scrotum
119
Are scrotal hematomas m/c singular or multiple?
Singular
120
3 physical symptoms of scrotal hematomas?
-Swollen
-Painful
-Can be discolored
121
SF of scrotal hematomas?
Varies, but typically has avascular areas with mixed echogenicities
122
What is a hematocele?
Accumulation of blood b/w visceral + parietal layers of tunica vaginalis
123
What 4 things can causes a hematocele?
-Trauma
-Surgery
-Tumor
-Torsion
124
SF of a hematocele?
Complex, heterogeneous collection within tunica vaginalis
(similar to hematoma, except hematoceles have fresher blood appearing more anechoic)
125
What is a pyocele?
Pus in the space b/w the parietal + visceral layers of the tunica vaginalis
126
Physical signs of a pyocele?
Mimic's signs of an infection + inflammation, along with hemiscrotal pain + swelling
127
Lightbulb for pyocele?
Infection - think fever (pt will be sick)
128
SF of a pyocele?
-Thick hemiscrotal wall
-Echogenic fluid with septations
-Can have focal mural calcifications
129
How can we differentiate b/w a pyocele + a hematocele?
Must use clinical signs to tell - pyocele the pt will be sick
130
What is granulomatous disease?
Disease of testis + epi due to retrograde spread of TB from prostate, seminal vesicles + kidneys OR from hematogenous spread (meaning from the bloodstream)
131
Lightbulb for granulomatous disease?
Spread of TB
132
What age m/c gets granulomatous disease?
Men aged 20-50
133
What do pt's present with when having granulomatous disease?
Scrotal swelling, often epididymitis or epididymo-orchitis
134
SF of granulomatous disease?
-Either diffusely enlarged OR nodular + enlarged
-Hypervascular
-Scrotal wall thickening
-Hydrocele
-Scrotal abscess
-Intrascrotal, extratesticular calcifications
135
Are tunica albuginea cysts common?
Nope
136
How do tunica albuginea cysts clinically present?
Painless scrotal lump
137
Which decade are tunica albuginea cysts m/c seen?
B/w 5-6 decades
138
SF of tunica albuginea cysts?
-well circumscribed
-anechoic
-measures 2-5mm
-located along tunica albuginea (shell of testicle)
139
Would a pt know if they have an intratesticular cyst?
No, asymptomatic + an incidental finding
140
SF of an intratesticular cysts?
-Anechoic
-Smooth walls
-Posterior enhancement
-Measures b/w 2-20mm
141
What is a sperm granuloma?
Ball of dead sperm following trauma, vasectomy or infection. Occurs if sperm is floating around.
(sperm may enter surrounding tissues + produce necrosis, resulting in granulomatous formation)
142
Sperm granulomas occur in what % of pt's post vasectomy?
40%
143
SF of a sperm granuloma?
-Well defined
-Solid
-Hypoechoic
-Heterogeneous mass
-Located anywhere in ductal system
-M/C in epi tail
144
M/c part of epi where sperm granulomas occur?
Epi tail
145
M/c location for benign adenomatoid tumors?
Epi tail
146
Are benign adenomatoid tumors common?
Represent 30% of extratesticular benign lesions
147
Clinical finding of a benign adenomatoid tumor?
Painless mass or incidental finding
148
What age is m/c to find a benign adenomatoid tumor?
B/w ages 20-50
149
SF of benign adenomatoid tumors?
-Well circumscribed solid mass
-Variable echgenicity
(indistinguishable from other benign tumors)
150
Which pathology is the 2nd m/c primary benign neoplasm of the epi?
Leiomyoma / fibroid
151
M/c location for a leiomyoma?
Epi tail
152
SF of a leiomyoma?
-M/c unilateral
-M/c epi tail
-Well circumscribed
-Homogeneous
-Solid mass with variable echogenicity
(indistinguishable from other benign tumors)
153
Another name for leydig cell tumors?
Gonadal stromal tumors
154
M/c neoplasm of the testis?
Leydig cell tumors (a non-germ cell neoplasm)
155
Are leydig cell tumors benign or malignant?
In the benign group, however up to 15% are malignant
156
M/c age to have a leydig cell tumor?
B/w 20-50
157
Clinical signs of leydig cell tumors?
-Endocrine imbalance
-Impotence
-Decreased libido
-Gynecomastia
158
SF of benign leydig cell tumors?
-Small, less than 1cm
-Well circumscribes masses
(small hypoechoic lesion in slide)
159
SF of malignant leydig cell tumors?
-Larger, over 5cm
-Less well defined borders
160
Can u/s determine if a leydig cell tumor is benign or malignant?
Nope, need biopsy
161
M/c malignant tumor of epi + spermatic cord?
Rhabdomyosarcomas
162
Which age group m/c gets rhabdomyosarcomas?
Children + adolescents
163
SF of a rhabdomyosarcoma?
-Circumscribed
-Unilateral
-Hypoechoic lesion w/o a capsule
-Measures 1-2cm
-Poorly defined borders
164
Why do cancerous masses have no capsule?
B/c they are trying to invade the body. If mass appears large + w/o clear borders, think malignancy.
165
List other malignant neoplasms that have similar appearances?
-Leiomyosarcoma
-Liposarcoma
-Fibrosarcoma
-Mesenchymoma
166
What is an epidermoid cyst?
Benign teratoma of testicle
(think hair, teeth, skin, nails, etc like the ovaries)
167
Are epidermoid cysts common?
Nope, 1-2% of all testicular neoplasms
168
M/c age to get an epidermoid cyst?
B/w 20-40
169
Clinical finding of an epidermoid cyst?
Painless scrotal mass + asymptomatic
170
SF of epidermoid cysts?
-Target/bulls eye/rings of tree appearance
-Sharply circumscribed + encapsulated mass
-Variable echogenicity
171
Another name for testicular microlithiasis (TM)?
Intratubular testicular calcification
172
What is testicular microlithiasis?
Rare calcifications in tube
173
SF of testicular microlithiasis?
-M/c bilateral
-Multiple calcifications (at least 5 foci m/c seen)
-Measure 1-3mm
-Hyperechoic foci w/o shadowing through testis
174
What clinical findings do most pt's with testicular cancer present with?
-Painless unilateral scrotal mass
-Hardness of testis
-Diffuse testicular enlargement
175
Is testicular cancer common?
No, only accounts for 1-2% of all malignant neoplasms in men
176
What does testicular carcinoma mimic, making it hard to diagnose?
Epididymo-orchitis (b/c cancers can cause inflammation)
177
What 2 pathologies can cause orchitis secondary to obstruction of seminiferous tubules?
Seminomas + testicular lymphomas
178
Pt's with which pathology have a 2.5-8x increased risk for developing testicular cancer?
Cryptorchidism (undescended testis)
179
Can u/s distinguish b/w different types of malignancies?
Nope, need a biopsy
180
List the names of the different types of testicular cancer?
-Seminoma
-Embryonal cell carcinoma
-Choriocarcinoma
-Teratoma
-Yolk sac tumor
-Mixed neoplasms
-Metastases to the testis
-Lymphoma
-Leukemia
181
SF of testicular cancer?
Hypoechoic!!!
-If tumor is confined to the tunica albuginea than the testis keeps oval shape
-If tumor invades the testis + epi than it creates an irregular + lumpy contour of the testis
