Male A & P Flashcards
Normal testis echoetxture
homogeneous medium-level echotexture
Testicle is surrounded by a fibrous capsule called the
tunica albuginea
multiple septations (septula) arise from the tunica albuginea to form the _____________ __________
mediastinum testis
Sonographic appearance of the mediastinum
echogenic linear band extending longitudinally within the testis
The ______ forms wedge-shaped compartments that contain the _________ _________, which converge to form the _____ ______, which connects the semineferous tubule to the _______ ______.
septula
seminiferous tubules
tubuli recti
rete testis
What is the rete testis?
Anastomosing network of delicate tubules located in the hilum of the testicle (mediastinumvtestis) that carries sperm to the epididymis.
The efferent ductules carry seminal fluid from where to where?
rete testis to the epididymis
Parts of the epididymis and anatomical position
head (globus major) adjacent to superior pole of testis, largest part of epi, where efferent ductules converge to form a single convuluted dut (ductus epididymis)
body (post/medial along tetsicle)
tail (globus minor) forms an acute angle and courses cephlad as the vas deferens (ductus deferens)
Epi is parallel to the testicle
Echotexture of the epi?
normally isoechogenic or slightly hyperechoic than the testis
Appendix testis
remnant of Mullerian duct
small ovid structure located beneath the head of the epididymis
Risks assocaited with an appendix testis
torsion of the appendage can occur in boys 7-12 years, resulting in a blue dot sign
appendix epididymis
derived from the Wolffian duct
detached efferent duct
small stalk porojecting off
Dartos
layer of muscle beneath the scrotal skin, diving the scrotum into chambers
The dividion of the two scrotal chamber is called the ______ _______.
scrotal pahie
Tunica vaginalis
saccular extension of the peritoneum into the scrotal chambers
Which layer of the tunica vaginalis covers the testis and epididymis?
The inner or visceral layer, the outer or parietal layer lines the scrotal chamber
Testicular blood flow is supplied by the (3)
deferential arerty
cremasteric (external spermatic) artery
testicular artery
What are the branches of the teticular artery?
divides into the capsular and centripetal (intratesticular) branches
the capsular comes down and encapsulates entire testicle, right under the surface
the centripetal arteries course along the septula converging on the mediastinum testis
What does the spermatic cord consist of?
vas deferens crenasteric, deferential, testicular arteries pampiniform plexus of veins lymphatics nerves
The ______ zone comprises the majority of the prostate.
peripheral zone
the bell-clapper deformity is strongly associated with the development of what abnormality?
testicular torsion
the area where the urethra and the ejaculatory ducts join in the prostate is referred to as the _________.
verumontanum
Corpora amylacea are best defined as:
Macrocalcifications associated with chronic prostatitis
Approximately 70% of prostate malignancies are identified in the:
perioheral zone
Hyperemic flow during a scrotal exam would suggest which of the following conditions?
orchitis
The most common malignancy of the testicle is of what tissue origin?
germ cell
Sonographic evaluation of the scrotum for suspected testicular torsion requires optimization of the color Doppler to determine perfusion. How should the equipment be set in order to optimize the sensitivity to this abnormality?
Low PRF, high gain, and low filter
the testicle want blood flow at all times so not going to resist, low RI, but doesn’t deman a lot so slow flow velocity…..scale down, no wall filters, gain up, multiple focal zones, light pressure, high frquency
Cryptorchidism is defined as:
A congenital anomaly which is identified as an abnormally positioned testis which leads to an increased risk of testicular malignancy
The most common cause for scrotal swelling is:
hydrocele
The location of the rete testis is best described as:
Mediastinum of the testicle
The function of the pampiniform plexus is to:
Provide venous drainage from the testicles and scrotum (RT into IVC and LT in renal vein)
The epididymis receives the majority of its blood supply from what vessel?
deferential artery
The presence of a ________ demonstrates fluid between the tunica vaginalis parietal and visceral layers
hydrocele
The RT and LT hemiscrotum are divided by a fibrous septum called the _____ ______.
median raphe
Encases everything that has to go to and from the pelvi cavity
cremamaster muscle
Where does spermatogenisis occur?
seminiferous tubules
In the case of a hydrocele, is there fluid next to the testis?
No
may see in patients with ascites (peritoneal cavity)
T/F - venous first to go in torsion becasue muscel wall not as thick
T
Most _______ masses are benign, but the majority of ______ lesions are malignant.
extratesticular
intratesticular
Most malignant tetsicular neoplasms are _______ compared to the normal testicular parenchyma.
hypoechoic
Testiclar neoplasms are the most common malignancy in men ____to ______ years of age.
15-35
Most common testicular cancers.
germ cell tumors, either seminoma or nonseminoma
_______ is the most common germ cell type found in both pure seminoma and mixed germ cell testicular masses.
Seminoma
-they are radiosensitive and chemosensitive resulting in the most favorable prognosis of all testicular tumros
Risk factors for seminoma testicular ca (7)
cryptorchidism (undescended testicles) family Hx of test ca infertility Klinefelter syndrome (XXY0 Down Syndrome smoking white race
When an intratesticular mass is found, what area should be evaluated for lymph nodes mets
paraaortic region in the retroperitoneum
Tumor markers for seminoma test tumors
beta-hCG
AFP
LDH
Nonseminomas are masses that are not pure seminomas and consist of other cell types such as (4)
embryonal carcinomas
teratomas
yols sak tumors (endodermal sinus tumors)
chriocarcinomas
-when a mixture of these tumors exists, the tumor is referred to as a mixed tumor
-a tumor with both seminomatous with nonseminomatous elements is considered a nonemninomatous germ cell tumor
Treatment for nonseminomatous germ cell test tumors
radical (inguinal) orchiectomy
What lab is associatied with nonseminomas?
AFP
ascending lymphatic Mets from nonseminoma test tumors occurs in the retroperitoenal nodes and _____ renal hilar lymphadenopathy and _____ retro-caval lymphadenopathy is frequently seen
left
right
Most common testicular tumor in infants and young children.
Yolk sac tumors (endodermal sinus tumor)
What lab value is assocated with Yolk Sac Tumors?
AFP
Rare stromal (non-germ cell) testicular tumor occuring in boys (5-10) and men (30-60)
Leydig Cell Tumors
Leydig cell tumors may be _____ ________ or ______.
pure non-germ
mixed
T/F - Leydig cell tumors are always malignant in children.
F - always benign in children, maligant variations reported in adults
Type of testiuclar tumor that is also found in the ovaries and is typically malignant?
Ovarian Leydig cell tumors
Leydig cell tumors produce ______ resulting precocious puberty and they produce _____ resulting in feminizing symtptoms.
testosterone
estrogen
AFP, beta-hCG, and LDH are normal in ____ _____ ____ ___
pure leydig cell tumors
Elevation of beta-hCG and AFP cab be associated with many conditions but their elevation in conjucion with a _______ mass suggest _______ cancer.
testicular
testicular
Which testicular cancer is suggested if AFP is elevated?
nonseminomatous
If there is the presence of high levels of tumor markers, what is the prognosis?
Increased liklihood of metastatic disease and poor prognosis
What is recommended inorder to determine the histology of a possible testicluar cancer?
inguinal orchiectomy, not Bx, inorder to prevent teh spread of cellular components
What are the 2 types of benign testiular cysts and where are they usually located?
cysts of the tunica albuginea
intratesticular cysts - normally found near the mediastinum testis, probably originate from the rete testis
Epidermoid cysts
benign soild tumor
germ cell origin
well-circumscribed
beneath the tunica albuginea
Sonographic appearance of epidermoid cysts
well-defined solid hypoechoic with echogenic capsule or onion ring patter formed by multiple layers of keratin (cheesey-white) or bow-tie central echogenic pattern
what are absecsses usually a complication of?
epididymo-orchitis (epididymitis, orchitis)
Sonographic appearance of tetsicular abscess?
enlarged testicle containing a predominantly fluid-filled mass with hypoechoic or mixed echogenic areas
where are scrotal calcifications (scrotal pearls) typically located?
may be located within the testicle or between the layers of the tunica albuginea
T/F - Testicular microlithiasis in an asymptomatic healthy man shoudl be considered to confer a definite but minimal risk of testicular germ cell tumor
T
Is testicular infarct a common event?
No, it is uncommon typically with an undetermined cause
How do segmental testicular infarcts typically present?
As a triangular-shaped avascular intratesticular lesion.
but the appearance depends on the age of the infarction.
Initially - focal or diffuse hypoechoic testicle
Progresses - testicle decreases size and devlops areas of increased echogenicity representing fibrosis or calcifications
Fluid that accumulates within the tunica vaginalis, visceral and parietal
hydrocele
Most hydroceles are ______ and are noted in boys ____-____ years.
congenital
1-2
-caused by failed closure of teh processus vaginalisi at the internal ring
chornically acquired or secondary hydroceles usually occur in men older than ____ years.
40 years
Whay are th epossible causes of hydroceles in adults?
idiopathic trauma torsion neoplasms epididymitis orchitis
___-____ echoes from ____ or _____ crystals may be visulaized within the hydrocele.
low-level
fibrin or cholesterol
Similar to a hydrocele but seen when blood fills the scrotal chamber from trauma.
hematocele
Varicocele
dilatation of the pampiniform venous plexus of the testicular veins which drain the testicle
_____ of varicoceles are on the _____ side.
90%
left
-becasue of the length of the left testicular vein, which drains into the left renal vein
What should happen to the varicoceles with standing, valsalva, or abdominal compression?
They should distend
-may produce aching pain after a patient has been standing for extended time or with heavy lifting
Is there as association between varicoceles and infertility?
Yes, but difficult to know for certain if the varicocele is directly to blame
What is the most correctable cause of male infertility?
varicocels
If a patient present with unilateral scrotal pain, what are some the possible Dx (3)
testicular torsion
epididymitis
varicocele thrombosis
What criteria is set for varicoceles.
mutliple >2mm diameter
enlargement with valsalva and increased color Doppler
What kind of hernias involve the scrotum?
indirect inguinal hernia
What cause an indirect scrotal inguinal hernia?
results from bowel protruding through the inguinal canal into the tunica vaginalis of the scrotum
What may be seen sonographically if there is an indirect inguinal scrotal hernia?
presence of peristalsis confirms the Dx
bowel may contain air, producing shadows
small hernias can be visualized by using valsalva
Benign extratesticular tumors usulaly involve the ______.
epididymis
Most common extratesticular tumor?
adenomatoid turmor
What are spermatoceles?
Cystic masses that result from dilatation of the epididymal tubules
Which are more common, spermatoceles or epididymal cysts?
spermatoceles
Difference between spermatoceles and epididymal cysts?
spermatoceles are filled with thick mailk fluid containing spermatoza while epididymal cysts are composed and clear fluid
-both result from prior episodes of epididymitis
Where do spermatoceles usually occur?
at the epididymal head
What is tubular ectasia of the rete testis
a rare cystic dilatation of the mediastinal tubules
What causes tubular ectasis of the rete testis?
Thought to result from partial or complete obliteration of the effernet ducts
Tubular ectasia of the rete testis is a _____ condition that is often ______ and frequently associated with ______. Also it is more common in men over the age of ____.
benign
bilateral
spermatoceles
55
Sonographic appearance of tubular ectasia of the rete testis
cluster of small anechoic structures adjacent to the mediastinum testis.
2 most common causes of acute scrotal pain.
epididymitis* and torsion of the spermatic cord
Possible DDx of acute scrotal pain (6)
testicular torsion trauma epididymitis/orchitis incarcerated hernia torison of the appendix testis varicocele thrombosis
Sonographic findings of epididymitis
enlarged epididymis hypoechoic increased blood flow (hyepremia) reactive hydrocele scrotal wall thickening
Epididymitis may extend into the testicle causing ______.
orchitis
Sonographic findings of orchitis
enlarged hypoechoic tetsicle
hyepremia
decreased arterial resistance (low-reistance waveform)
The testicle is attached to the tunica vaginalis and w/o it or w/ a high attachment, the testicle can rotate freely on the spermatic cord which is known as the _____ ____ ______.
Bell clapper deformity
Testicular torsion leads to ______ and ______ occlusion.
venous
arterial
If testicular ischemia, what happens to the torsed testical in comparison to the contralateral testicle after 6 hrs?
it becomes enlarged and hypoechoic
Who primarily suffers from testicular torsion, what ages?
adolescents and neonates
younger than 30, most 12-18
What is associated with testicular torsion with pain for <6hrs?
fever nausea vomiting hx of trauma or activity absence fo cremasteric reflex high position of testicle horizontal lie of testicle
Torsion varies between 180-540 degrees. Partial vs torsion-detorsion syndrome or intermittent torsion is challenging to diagnose because the changes in the arterial waveforms are subtle. A partial or incomplete may be associated with a RI _______ or ______ waveform.
> .75 or
biphasic (to and fro)
Time between onset of pain and performance of detorsion and the corresponding salvage rate:
<6hrs = 90 to 100% salvage rate 12-24hrs = 20 to 50% >24hrs = 0-10%
What should the sonographer do to optimize for slow blood flow in the testicle to rule out a complete torsion?
decrease PRF
Type of torsion that is exclusive to newborns?
Extravaginal testicular torsion - occuring oustide the vaginalis, when the testis and gubernaculum can rotate freely
Symptoms of extravaginal testicular torsion
scrotal swelling
discoloration
firm mass in scrotum
-these are usually necrotic from brith and must be surgically removed
HIdden testicle or undescended testicle
crytorchidism
When do the testicles usually descend?
before birth but may occur spontaneously in eth first year so orchiplexy is usually reserved for age 2-10 years
Key structure that guides testicular descent out of the abdomin to the scrotum
gubernaculum
Complications assoicated with cryptorchidism
inferitility and cancer (increased risk for malignancy in both undescended testis and the contralateral testis
Most common location of the cryptochid testis
inguinal canal
Anorchia
congenital absence of testis
rare and accounts for 4% of PTs that present with crytorchidism
Polyorchia
congenital duplication of the testes
imaging posterior to a filled bladder may aid in locating an abdominal testicle
describe the anatomical position of the penis for scanning
erect and pointing upward so dorsal side is posterior and touching the belly while the ventral/anterior side is the scanning side
What is directly under the TDx when scanning the anteriro surface of the penis?
corpus spongiosum and urethra
Priaprism
erection that lasts for more than 4hrs and is painful
blood can get trapped in the erection chambers casuing ischemic priaprism
Often no clear cause for priprism but is associated with
sickle0cell disease, 42%
leukemia
malaria
drugs for depression, mental illnesses, erectile dysfunction, marijuana, cocaine
Peyronie’s disease
bent, rather than straight erect penis that result from scar tissue (plaque) that forms inside the penis
-some believe it result from trauma that cause bleeding in the penis
Peyronie’s disease is associated with connective tissue and autoimmune disorders such as:
Dupuytren's disease (trigger finger) plantar fascitis scleroderma systemic lupus erythenatosus Sjogren's sudnrome Behcet's syndrome
Why is ultrasound used to eval for Peyronie’s disease?
used to pinpoint the location of the plauqe buildup on the anterior or posterior aspect
