Chapter 23 Scrotum Flashcards
1
Q
Where does the tunica vaginalis lines?
A
Tunica Vaginalis lines the inner walls of the scrotum
2
Q
What are the two layers of scrotum? and describe them.
A
Two layers- parietal and visceral
Parietal layer- inner lining of the scrotal wall
Visceral layer- surrounds testis and epididymis
3
Q
What is the posterior bare area?
A
Small posterior bare area- testicle is against the scrotal wall to help prevent torsion-in normal
4
Q
Where are the testes located?
A
Testes are within the scrotum
5
Q
Describe the appearance of testes?
A
Testes are symmetrical
Oval-shaped
6
Q
What are the testes covered with?
A
Covered with a dense, fibrous tissue- tunica albuginea
7
Q
What does the posterior aspect of tunica albuginea form?
A
Posterior aspect of tunica albuginea forms the mediastinum testis
8
Q
What is the size of the testes in adults?
A
Length- 3-5 cm
Width- 2-4 cm
Height- 3 cm
9
Q
How many conical lobules is there and what do they contain?
A
Each testis is divided into 250-400 conical lobules containing the seminiferous tubules
10
Q
How is the rete testis formed?
A
Tubules converge at apex of each lobule and anastomose to form rete testis in mediastinum
11
Q
Where does the rete testis drain into?
A
Rete testis drains into head of epididymis through the efferent ductules
12
Q
Where is the epididymis lie?
A
Lies on the posterolateral aspect of the testis
13
Q
What are the parts of the epididymis?
A
Divided into head, body and tail
14
Q
What is the biggest part of the epididymis?
A
Head-largest and located superior to the upper pole 6-15mm in width
15
Q
define ductus epididymis
A
Contains 10-15 efferent ductules from the rete testis, which converge to form single duct in body and tail—ductus epididymis
Ductus epididymis- becomes vas deferens and continues in the spermatic cord
16
Q
What is vas deferens?
A
Vas deferens- continuation of ductus epididymis
17
Q
Where does the vas deferens dilate?
A
Vas deferens dilates at the terminal portion near the seminal vesicles—this portion is the ampulla of the deferens
18
Q
What does the vas deferens join?
A
Vas deferens joins duct of seminal vesicles to from the ejaculatory duct
19
Q
Where does the ejaculatory duct empty into?
A
Ejaculatory duct empties into the urethra
20
Q
What is the spermatic cord formed by?
A
Spermatic cord is formed by: Vas deferens Testicular arteries Venous pampiniform plexus Lymphatics Autonomic nerves Fiber of the cremaster
21
Q
Where does the testicular artery originate from?
A
Testicular artery originates below the renal arteries directly from the aorta and branches within the testicule
22
Q
Where does the testicular artery enter into?
A
Testicular artery enters the spermatic cord and courses along the posterior surface of each testicle
23
Q
What does the testicular artery then do?
A
Testicular artery then pierces tunica albuginea forming the capsular artery
24
Q
What does the capsular arteries do?
A
The capsular arteries then give rise to centripetal arteries which course towards the mediastinum
25
Before reaching the mediastinum the centripetal artery curves backward forming what?
Before reaching the mediastinum the centripetal artery curves backward forming recurrent rami
26
Where does the venous drainage occur through?
Venous drainage occurs through the vein of the pampiniform plexus
27
Where does the pampiniform plexus exits through?
Pampiniform plexus exits through the mediastinum and courses in the spermatic cord
28
Where does the right testicular vein drain into?
Right testicular vein drains directly into the IVC
29
Where does the left testicular vein drain into?
Left testicular vein drains into the left renal vein which then drains into the IVC
30
What questions to ask for scrotal exam?
Was this patient referred because of palpable mass, scrotal pain, swollen scrotum, or other reason?
Ask patient to describe symptoms, including history, location, and duration of pain.
Can he feel a mass? If so, ask patient to find lump. Place probe exactly over this location to examine site.
Did patient experience trauma? When did trauma occur? Describe what happened.
Vasectomy procedure? When?
31
What are some patient prep?
Highest frequency transducer possible (10 to 14 MHz)
Explain the exam to the patient prior to them getting prepped
Patient supine
Penis positioned on the abdomen and covered with a towel
A second towel can be placed under the scrotum
Generous amount of warm gel is used
32
What is the protocol for scrotal exam?
Both testes should be evaluated in sagittal and transverse
Transverse image with both testicles in the image should be taken for comparison
Transverse
Upper
Mid- with and without measurements also color and Doppler
Lower
Sagittal
Lateral
Mid- with and without measurements
Medial
Epididymis
33
What are sonographer tips?
Explain procedure and preparation to patient; patient will get ready in private.
Image of right and left testicle together for comparison in both gray scale and color Doppler
Perform Valsalva maneuver when varicocele suspected.
Sensitize color Doppler for slow flow when evaluating torsion.
34
What are the two traumas?
Direct Injury-hit or kicked
| Straddle Injury-fall on something
35
What is the most important info to find out with trauma?
Most important to find out whether rupture has occurred, but the patient can also have hematoma or hematocele
36
What is the medical procedure with a ruptured testicle?
Ruptured testicle- surgical emergency if done within 72 hours 90% can be saved, but only 45% after 72 hours
37
Ultrasound findings with trauma
```
Focal alteration of testicular parenchymal pattern
Interruption of tunica albuginea
Irregular testicular contour
Scrotal wall thickening
Hematocele
```
38
Define epididymo-orchitis
Infection of the epididymis and testicle
39
What is the most common cause of acute scrotal pain in adults?
Epididymo-orchitis
40
What is the most common result of epidiymo-orchitis?
Most commonly results as spread of infection from lower urinary tract infection
41
What are the less common causes of epididymo-orchitis
Less common causes- mumps, syphilis, tuberculosis, viruses, trauma, and chemical causes
42
What is the organ primarily involved with infection?
Epididymis is the organ primarily involved with infection- spreads to testis 20% to 40% cases
43
What is second to epididymitis?
Orchitis- almost always secondary to epididymitis
44
What are symptoms of epididymo-orchitis?
Symptoms- scrotal pain > 1-2 days, mild to severe, fever, urethral discharge
45
Ultrasound findings of epididymitis
Ultrasound Findings- Epididymitis
Enlarged and hypoechoic
If hemorrhage occurs epididymis may have hypoechoic areas within
Hyperemic flow- normal epididymis has little flow with color Doppler
Compare both sides
46
Ultrasound findings of orchitis
Ultrasound Findings- Orchitis
Focal or Diffuse
Enlarged
Affected areas may be hypoechoic compared to normal
Diffusely infected- enlarged, hypoechoic and homogenous
Hyperemic flow
47
What can be associated either with orchitis and epididymitis?
Scrotal wall thickening and hydrocele can be associated with either
48
Why does torsion occur?
Torsion of spermatic cord occurs because of abnormal mobility of testis within scrotum
49
What is the most common cause of torsion?
Most common cause- bell clapper deformity
50
testis and epididymis are normally surrounded by what?
Testis and epididymis are normally surrounded by tunica vaginalis, except bare area where they are attached to the posterior scrotal wall
51
Define bell clapper anomaly
Bell clapper anomaly- tunica vaginalis completely surrounds the testis, epididymis, and distal spermatic cord, allowing them to move and rotate freely in the scrotum=tunica vaginalis completely surrounds the testis so no bare area
52
What does torsion results from?
Torsion results from testis and epididymis twist with scrotum, cutting off vascular supply
53
What is more common to be affected by torsion?
Undescended testis are 10 times more likely to be affected by torsion
54
What flow is affected first with torsion?
Venous flow affected first- occluded veins cause swelling of the scrotal structures
55
is torsion continues what else gets obstructed?
If torsion continues the arterial flow is obstructed and ischemia follows
56
What is the most common cause of acute scrotal pain in adolescents?
Torsion- Most common cause of acute scrotal pain in adolescents, but more common in young adults and adolescents
peak incidence age 14
57
What are clinical symptoms of torsion?
Clinical Symptoms:
Sudden onset scrotal pain with swelling of affected side
With severe pain- N & V
Previous episodes of scrotal pain in many cases
58
ultrasound findings of torsion
Ultrasound Findings:
Depends on how much time has passed since torsion occurred
Early stages- normal
> 4-6 hours- swollen and hypoechoic
> 24 hours- heterogeneous as a result of hemorrhage, infarctions, necrosis, and vascular congestion
Color Doppler, power Doppler, and PW Doppler are all crucial
Spontaneous detorsion can occur- color flow may be present but abnormal with an abnormal sonographic appearance
59
What are the ultrasound findings of torsion in early stage?
normal
60
what are the ultrasound findings of torsion >4-6 hours?
> 4-6 hours- swollen and hypoechoic
61
What are the ultrasound findings of torsion >24 hours?
> 24 hours- heterogeneous as a result of hemorrhage, infarctions, necrosis, and vascular congestion
62
What is crucial when examining torsion?
Color Doppler, power Doppler, and PW Doppler are all crucial
63
What can occur spontaneously with torsion?
Spontaneous detorsion can occur- color flow may be present but abnormal with an abnormal sonographic appearance
64
Define spermatocele
Cystic dilation of the efferent ductules of the epididymis
65
Where are spermatoceles located?
Located in the head of the epididymis
66
What do spermatoceles contain?
Contains proteinaceous fluid and sperm
67
When are spermatoceles more likely to be seen?
May be seen more often following vasectomy
68
ultrasound findings of spermatocele
Ultrasound Findings
Simple cyst
Multiloculated and contain echoes
69
What does epididymal cyst contain?
Contain Serous Fluid
70
Where are epididymal cyst located?
Located anywhere within the epididymis
71
Where are small cysts find?
Small cyst are sometimes found between layers of tunica vaginalis or between the tunica vaginalis and tunica albuginea
72
findings of epididymal cyst
Generally asymptomatic, but may have palpable mass
73
ultrasound findings of epididymal cyst
Ultrasound Findings:
Anechoic
Thin walls
Enhancement
74
Define varicocele
Abnormal dilation of veins of pampiniform plexus- located within the spermatic cord
75
What side of the testes is a varicocele more common
left
76
What can varicoceles cause?
infertility
77
What are the primary and secondary causes of varicoceles?
Primary or secondary cause
Primary- incompetent valves within spermatic vein
Secondary- increased pressure on spermatic vein- hydronephrosis, abdominal mass or liver cirrhosis
78
What are possible with varicoceles?
Intratesticular varicoeles are possible- near mediastinum-
79
What are ultrasound findings of varicoceles?
Ultrasound Findings:
Multiple tortuous tubes varying sizes
Varicoceles measure more than 2mm in diameter Typically increase in diameter with Valsalva maneuver
80
What can herniate into the scrotal?
Bowel, omentum, or other structures herniate into the scrotum
81
What are clinical diagnosis typically sufficient with?
scrotal hernia
82
What is the most common herniates structure?
Bowel is the most common herniated structure followed by omentum
83
Ultrasound findings of scrotal hernia
Peristalsis of bowel seen on real-time confirms diagnosis of scrotal hernia
Cine clip is helpful
Peristalsis may not always be visible
Fluid-filled bowel loops- easily recognizable
Air-filled loops and loops containing solid stool- more difficult
Omental hernias echogenic because of omental fat
84
Define hydrocele
Collection of fluid between the visceral and parietal layers of the tunica vaginalis- pyoceles and hematoceles can also develop in this area
85
True or false: it is normal to see a small amount of fluid in this area
true
86
what is the most common cause of painless scrotal swelling?
hydrocele
87
What can hydrocele develop from?
Can develop from an unknown cause, but are commonly seen with epididymo-orchitis and torsion
88
When can hydroceles be seen after?
May also be seen after trauma or with development of a neoplasm
89
define pyocele
Pyocele- contains pus—result of untreated infection or rupture of abscess between layers of tunica vaginalis
90
Define hematocele
Hematocele- collection of blood—associated with trauma, surgery, neoplasms or torsion
91
ultrasound findings of hydrocele
Anterolateral aspect of testis
May be anechoic but most often has low-level echoes
When associated with infections show more echoes and septations
92
When does sperm granuloma occur?
Occur as a chronic inflammatory reaction to extravasation of spermatozoa
93
Most frequent to see sperm granuloma with patients with what?
Most frequently seen in patients with history of vasectomy
94
Where are sperm granulomas located?
Located anywhere within epididymis or vas deferens
95
What does ultrasound determine with sperm granulomas?
We determine if it is intratesticular or extratesticular.
96
What does extratesticular masses have a lower rate of what?
Extratesticular masses have a lower rate of malignancy
97
Ultrasound findings of sperm granulomas
Ultrasound Findings
Well-defined solid mass
Hypoechoic to isoechoic to epididymis
Calcifications are not commonly seen
98
true or false: sperm granulomas are painful
true
99
Define Tubular Ectasia of the Rete Testis
Uncommon and benign
Associated with presence of a spermatocele, epididymal or testicular cyst, or other epididymal obstruction on same side as dilated tubules.
100
Cyst are more common in who?
Common in men older than 40
101
What are cyst associated with?
Association with extratesticular spermatoceles
102
Where are cyst located?
Located near mediastinum
Single or multiple
Do not require treatment
103
Define microlithiasis
Uncommon
Tiny calcifications within testis
Smaller than 3 mm
Typically bilateral
104
what association does microlithiasis have with?
Association with testicular malignancy- annual follow-up is suggested to exclude development of a neoplasm
105
What are microlithiasis associated with?
```
Associated with:
Cryptorchidism
Klinefelter’s syndrome
Infertility
Varicoceles
Testicular atrophy
Male pseudohermaphroditism
```
106
What is most frequently between the ages of 20-34 years old?
Malignant testicular tumors
107
Undescended testes are more likely to what?
Undescended testes are 2.5 to 8 times more likely to develop cancer
108
What are clinical symptoms of malignant testicular tumors?
Most patients have painless lump, testicular enlargement, or vague discomfort
109
What is our primary goal with malignant tumors?
Our primary goal is to determine location and cyst vs solid
110
extratesticular masses verse intratesticular masses
Extratesticular masses are more likely benign and intratesticular masses are more likely malignant
111
What accounts for most testicular tumors?
95% testicular tumors are germ cell and highly malignant
112
What is the most common germ cell tumor?
Most common germ cell tumor- seminoma
113
Define lymphoma
Lymphoma
Makes up 1%-7% of all testicular tumors
Most common bilateral secondary testicular neoplasm
Affects men older than 60 years old
Hypoechoic to multiple focal areas
Lymphoma and Leukemia look similar on ultrasound
114
Define leukemic involvement
Next most common secondary testicular neoplasm
Most often seen in children
Of children with leukemia, 8% have been reported to have testicular involvement
Chronic may appear anechoic but will have increased vascularity with color Doppler
115
Define cryptorchidism
undescended testicle
| Cannot be brought into the scrotum with external manipulation
116
ectopic testicle cannot be what?
Ectopic testicle cannot be manipulated into correct path of descent
117
What is the most common site for testicular ectopia?
rare, most common site is inguinal pouch
118
What are other sites for testicular ectopia?
Other sites- perineum, femoral canal, suprapubic area, penis, diaphragm, other scrotal compartment
119
Define anorchia
Anorchia
rare, more common on the left side
Bilateral .6%-1% patients with a nonpalpable testis
120
What are causes of anorchia?
Causes- intrauterine testicular torsion or another form of decreased vascular supply
121
Define polyorchidism
Polyorchidism (testicular duplication)- very rare, only 80 cases reported
Most common on the left
122
Where can cryptorchidism be located?
May be located in the abdomen, inguinal canal, or other ectopic location
123
Where are 80% of crytorchidism in?
80% are in the inguinal canal and palpable
124
What is the medical procedure to treat undescended testicle?
Orchiopexy- surgical procedure to treat undescended testicle
125
What are risk factors of undescended testicle?
Infertility, development of testicular cancer, and torsion are all risk of an undescended testicle
126
Ultrasound findings of crytorchidism
Ultrasound Findings:
Smaller and less echogenic than normal
Usually oval and homogenous
