Module 1: Scrotum Flashcards
1
Q
what is the scrotum
A
- a pouch of loose skin and fascia continuous with the abdomen
2
Q
externally what structure divides the scrotum into 2 compartments
A
- the raphe/ meidan raphe
3
Q
internally what structure divides the scrotum into two compartments and forms the internal scrotal septum
A
the dartos tunica
4
Q
what is the normal thickness of the scrotal wall
A
2-8mm
5
Q
what structure lines the inside of the scrotal sac
A
- the tunica vaginalis
6
Q
what are the two layers of the tunica vaginalis and what are they in contact with
A
- parietal (scrotal walls)
- visceral (testicles)
7
Q
how much fluid should be between the layers of the tunica vaginalis
A
1-2ml
8
Q
what 4 structures are within the scrotal sac
A
- tesitcles
- epididymus
- vas deferens
- spermatic cord
9
Q
what are the testicles and what do they produce
A
- paired reproductive organs
- sperm, testosterone
10
Q
what shape and normal dimensions are the testicles
A
- oval
- LENGTH = 3-5cm
- WIDTH = 2-4cm
- AP = 3cm
11
Q
do the testicles increase or decrease in size with age
A
decrease
12
Q
what is the fibrous layer surrounding each testicle called
A
tunica albuginea
13
Q
what structure does the tunica albuginea form
A
- mediastinum posteriorly
14
Q
how are the lobules created
A
- the tunica aluginea invaginates (folds into itself) to create the lobules
15
Q
what is contained within each lobule and what process is performed
A
- seminiferous tubules
- spermatogenesis
16
Q
what is the mediastinum and what is its role
A
- convergence of thin septations of the tunica albuginea in the posterior testes
- forms support for testicular vessels and ducts extending from testes
17
Q
what forms the rete testes
A
- convergence of the seminiferous tubules at the mediastinum
18
Q
what are the efferent ducts
A
- the rete testes are renamed efferent ducts after they exit the mediastinum
19
Q
what is the role of the efferent ducts
A
- carry seminal fluid to the epididymis
20
Q
what is the bare area of the testicles
A
- area not covered by the peritoneum, where it is tethered to the scrotal wall
21
Q
what is an appendix testis
A
- remnant of MULLERIAN DUCT with no function
- upper pole of testicle
22
Q
what is the epididymis
A
- comma shaped structure superior and posterolateral to testes
23
Q
where is the epididymis located in relation to the testes
A
head - superior to testes
body - posterolateral
tail - empties into the vas deferens
24
Q
what is the epidydmis formed by
A
- convergence of the efferent ducts from rete teste
25
what is another name fro the head of the epidymis
globus major
26
what are the three parts of the epididymis
head, body , tail
27
what is the normal AP of the epi head
10-12mm
28
what is the normal AP of the epi body
2-4mm
29
what is the normal AP of the epi tail
2-5mm
30
what is the function of the epididymis
- conveys sperm to the seminal vesicles
| - storage and maturation of sperm
31
what is an appendix epididymis
remnant of the MESONEPHRIC (WOLLFIAN) DUCT
| - different origin than appendix testes
32
what are the seminal vesicles
- reservoirs for seminal fluid
33
what is the structure that connects the testes to the pelvis and abdomen and suspends testes in scrotum
- spermatic cord
34
where does the the spermatic cord travel
within the the inguinal canal
35
what four structures are contained within the spermatic cord
- vas deferens
- testicular artery
- venous pampiniform plexus
- lymphatic and nerves
36
what is the venous pampiniform plexus
- network of veins that drain the testes
37
what are the 3 arteries that supply the testes and scrotum and structures
- testicular arteries
- deferential arteries
- cremasteric arteries
38
what vessel supplies the testicle with blood
- testicular arteries from aorta
39
what vessel supplies the epididymis and vas deferens with blood
deferential arteries from inferior vesicle artery
40
what vessel supplies the peri testicular tissue with blood
- cremasteric arteries from inferior epigastric artery
41
how is the blood drained from the testicules
- blood drainage via the pampiniferous plexus to the testicular veins
- right testicular vein drains directly into IVC
- left testicular veins drain into the LRV
42
what is the waveform of the testicular artery
- low resistance
43
what is the waveform of the cremasteric and deferential arteries
- high resistance = feeding mostly connective tissue and muscle
44
what are the 8 indications for a scrotal ultrasound exam
- palpable mass
- pain
- enlarged scrotum with or without pain
- cystic vs solid
- torsion
- undescended testes
- trauma
- post orchiectomy
45
what is the sonographic appearance of the testes
- homogeneous medium level echoes similar to thyroid
46
does the echogenicity of the testes increase or decreased with age
- increases
47
what is the sonographic appearance of the sagittal mediastinum
- hyperechoic line (band) from superior to inferior pole
48
what is the sonographic appearance fo the transverse mediastinum
- hyperechoic mass at 3 o'clock on the right and 9 o'clock on the left
49
what is the sonographic appearance of the rete testis
- decreased echogenicity at the mediastinum or tiny cystic structures
50
what it is the sonographic appearance of the epididymis
- isoechoic or slightly hyperechoic to the testicle
| - slightly coarse texture
51
are extratesticular or intratesticular masses more likely malignant
- extratesticular = benign
| - intratesticular = malignant
52
what are the 3 main categories of pathologies/anomalies of the scrotum
- congenital anomalies
- benign pathologies
- malignant pathologies
53
what are the 4 congenital anomalies of the scrotum
- cryptorchidism (undescended testes)
- polyorchidism
- anorchia
- testicular ectopia
54
what is cryptorchidism
- failure fo testicles or testis to descend to normal position
55
what is the most common GU abnormality in children
- cryptorchidism
56
is cryptorchidism usually unilateral or bilateral
- unilateral
57
where are the majority of undescended testis located
- inguinal canal and palpable
58
what is the gubernaculum
- the structure that guides and anchors the testis during descent into the scrotal sac
59
what are the three causes of cryptorchidism
- deficiency of gonadotropin hormonal stimulation
- adhesions or anatomic maldevelopment
- idiopathic
60
what are two common complications of cryptorchidism
- infertility = increased heat in abdomen affecting spermatogenesis
- testicular cancer (48X the risk) both testicles
61
what is the common treatment for cryptorchidism in infants
- orchiopexy
62
what is the common treatment for cyprtochidism in older children
- orchiectomy
63
what is the sonographic appearance of cryptorchidism
- oval mass
- smaller less echogenic
- homogeneous
- mediastinum hard to see
- enlarged inguinal lymph node may be mistaken for undescended testes
64
what is polyorchidism
- testicular duplication or supernumerary testis
- rare
- unilateral
- located in scrotum
65
what is anorchia
- absence of testicle
- rare
- unilateral and located in scrotum
66
what is testicular ectopic
- testicular tissue identified anywhere along the path of descent
- rare
67
what are the 15 benign scrotal pathologies
- hydrocele
- hematocele
- pyocele
- varicocele
- hernia
- trauma
- torsion
- infection
- abscess
- scrotal pearls
- spermatocele
- true cysts
- non germ cell neoplasm
- adenomatoid tumor
- microlithiasis
68
what is a hydrocele
- collection of fluid between the tunica vaginalis layers
69
what is the amount of separation between the visceral layers to indicate hydrocele
>2mm
70
where is the fluid located in the scrotum with a hydrocele
- anterolateral portion
71
what is the most common cause of painless scrotal swelling
- hydrocele
72
what are the 2 categories of causes of hydrocele
- congenital
| - acquired
73
what are the congenital causes of hydrocele
- due to patent processus vaginalis
| - resolves by 18-24 months
74
what are the acquired causes of hydrocele
- IDIOPATHIC
| - secondary to infarction, inflammation, neoplasm, trauma
75
are large or smaller neoplasms more commonly found with tumors
- smaller
76
sonographic appearance of hydroceles
- simple=anechoic
- increased through transmission
- may or may not have calcs
- may or may not have spetations or debris
77
what is a hematocele
- blood in the scrotal sac
78
what are the 4 causes of hematocele
- trauma
- surgery
- neoplasms
- torsion
79
what is the clinical presentation of hematocele
- mimic epididymitis or torsion
80
sonographic appearance of hematocele
- acutely scrotal wall thickened
- anechoic collection
- variable appearance
- septations, debris in chronic stage
81
what is a pyocele
- pus in the scrotal sac
82
what are the causes of pyocele
- abscesses that rupture into the tunica vaginalis potential space
83
sonographic appearance of pyocele
- echogenic collection s
- spetations/loculations
- thick scrotal walls
- focal mural nodulations
84
what is a varicocele
- abnormally dilated veins of the pampiniform plexus
85
what is the diameter of the vessels when a varicocele is present
>2mm
86
what is the overall cause of varicocele
obstructed venous return
87
on what side to varcicoceles often occur
- left
88
what are the two categories of causes of varicocele
- primary
| - secondary
89
what are the primary causes of varicocele
- idiopathic
| - incompetent valves in the internal spermatic vein
90
what ages are affected by primary varicocele
- 15-25 years
91
what is the most common cause of correctable infertility
- primary varicocele
92
why does varicocele cause infertility
- increased blood flow around the testicles lead to increase heat affecting spermatogenesis
93
what is the cause of secondary infertility
- due to increased pressure on the spermatic vein
94
what area is important to look at when secondary varicocele is considered
- look for a mass compression the LRV
| - RCC likes to invade the LRV causing obstruction
95
what syndrome can cause secondary varicocele
- nutcracker syndrome
96
what is nutcracker syndrome
- compression of the left renal vein between the aorta and SMA
97
what maneuver is used to check for varicocele
- valsalva will increase the size of the vein with increased or reversed blood flow
98
how can you distinguish between primary and secondary varicoceles
- primary varicoceles will return to normal in the spin position
- secondary will real enlarged no matter what patient position
99
sonographic features of varicoceles
- extratesticular fluid or numerous anechoic structures >2mm in diameter
- located proximal to the superior pole of the testicle and epididymal head
- valsalva maneuver to demonstrate change
- color flow imaging
100
what is a scrotal hernia
- inguinal hernias the descend into the scrotum containing omentum or bowel
101
what are the signs and symptoms of a scrotal hernia
- scrotal enlargement
- pain
- blood in stool
102
sonographic appearance of a scrotal hernia
- mass outside testicle
- echogenic/anechoic mass
- peristalsis noted if the hernia is not incarcerated
103
what is trauma to the scrotum
- direct injury or straddle injury
104
what can trauma do to the scrotum
- hematoma
- hematocele
- ruptured testicle
105
what is a ruptured testicle
- surgical emergency
- tunica albuginea tears
-
106
what is the most common cause of scrotal trauma
- blunt trauma
107
sonographic appearance of scrotal trauma
- focal areas od altered echogenicity
- irregular capsule/contour
- hematocele
- color doppler to asses flow
108
what is testicular torsion
- spermatic cord twists cutting off blood supply to testicle
109
what are the stages of torsion
- acute = within 24 hours
- subacute = 24-10 days
- chronic = after 10 days
110
what are the 2 types of torsion
- intravaginal
| - extravaginal
111
what type of torsion is the most common during puberty
- intravaginal
112
what is intravaginal torsion caused by
- caused by anomalous suspension of the testicle by a long stalk of spermatic cord
- testis are able to rotate freely within the tunica vaginalis
113
in what patients is intravaginal torsion have an increased chance of occurring
- patients with a history of orchiopexy
114
what is extravaginal torsion caused by
- due to poor or absent attachment of the testis to the scrotal wall
- both tunica vaginalis and spermatic cord undergo torsion as a unit
115
in what type of patients is extravaginal torsion seen more commonly in
- newborns
116
sonographic appearance of torsion in acute stage
- enlarged testicle and epi
- testicel more hypoechoic
- scrotal skin thickening
- possible reactive hydrocele
- absent arterial flow if complete torsion
117
sonographic appearance of torsion in the subacute stage
- testicel and epi still enlarged but heterogenous
118
sonographic appearance o torsion in the chronic stage
- atrophied heterogeneous testicle
| - epi remains enlarged
119
signs and symptoms of torsion
- sudden onset of extreme scrotal pain
- nausea and vomitting
- symptoms mimic epididiymitis but diminish after 1-2 days
120
where does infection usually originate
- bladder
- urethra
- prostate
- then spread to epi
121
what is epididymitis
- inflammation/infection of the epi
- can cause infertility
- typically unilateral
122
what is the most common cause of acute scrotal pain and tenderness
- epididymitis
123
what are the signs and symptoms of epididymitis
- fever
- pain and increasing over 1-2days
- dysuria
- discharge
124
sonographic appearance of epididymitis
- thick enlarged epi
- hypoechoic and heterogeneous
- scrotal thickening
- reactive hydrocele
- increased blood flow
- abscess collection
- chronic infection calc possible
125
what is orchitis
- inflammation of the testis (focal or diffuse)
| - typically secondary to epididymitis
126
what is the most common cause of orchitis in men under 35
- chlamydia
127
sonographic appearance of focal orchitis
- hypoechoic area adjacent to enlarged epi
- mass like (looks like neoplasm)
- hypervascular
128
sonographic appearance of diffuse orchitis
- decreased echogenicity of entire testicle
| - enlarged
129
sonographic appearance of chronic orchitis
- hypoechoci and heterogeneous appearance
| - reactive hydrocele
130
what is a common complication fro untreated epididymo-orchitis
- abscess
131
what are the signs and symptoms of an abscess
- pain
- fever
- and swollen scrotum
132
what can result from an abscess
- can rupture through tunica vaginalis results in a pyocele or fistula to the skin
133
what three things is abscess associated with
- diabetes
- mumps
- influenza
134
what is the sonographic appearance of an abscess
- sonolucent or complex mass
| - increased blood flow in periphery
135
what is a scrotal pearl
- calcifications floating in the tunica or within the scrotal sac
- mobile
136
what is a spermatocele
- retention cyst (dilated epi tubule) filled with non viable sperm
137
what does a spermatocele result from
- epididymitis or traumas
138
where are spermatoceles typically located and are they single or multiple
- epi head and can displace
testicle
- both
139
are spermatoceles painless or painful lumps
- painless
140
ultrasound appearance of spermatocele
- well defined anechoic was with acoustic enhancement
- simple lobulated septated
- echogenic debris
- 0.2-9cm
141
what is a true cyst
- filled with serous fluid
142
where are true cysts located
- epi (uncommon)
- tunica albuginea (rare)
- testicles
143
are true symptoms symptomatic or asymptomatic
- asymptomatic
144
can epi cyst and spermatocele be differentiated on ultrasound
- no
145
are the majority of non germ cell tumors malignant or benign
- benign
146
what are the two non germ cell tumors
- leydig cell tumors
| - Sertoli cell tumors
147
what can leydig cell tumors cause
- gynecomastia
148
what can Sertoli cell tumors cause
- gynecomastia
| - feminization
149
what is the ultrasound appearance of non germ cell tumors
- small
- well defined
- hypoechoic
150
what is another term for non germ cell tumors
- gonadal stromal
151
what is the most common extratesticular tumor
- adenomatoid tumor
152
are adenomatoid tumors most often benign or malignant
- benign
153
where are adenomatoid tumors usually found
- in the epi
154
what are the characteristics of adenomatoid tumors
- slow growing
| - asymptomatic and small
155
ultrasound appearance of adenomatoid tumor
- well defined
- variable echogenicity
- solid
- unilateral
- usually on the left
156
what is microlithiasis
calcifications in the seminiferous tubules
157
what is isolated microlithiasis
- 5 or fewer calcifications per transducer field in the testicle
158
is isolated microlithiasis worrisome
- no
- associated with benign condition
- inflammatory, granulomatous, or vascular
159
what is associated with having more than 5 calcifications per transducer field
- malignant neoplasms
160
sonographic appearance of microlithiasis
- tiny echogenic speckled areas without posterior shadowing
161
what are the 2 categories malignant scrotal pathologies
- seminoma
| - non-seminomatous germ cell tumors
162
do malignant pathologies present painful or painless
- most likely scrotal enlargement or hardness of testicle
163
where do most malignant pathologies originate from
- germ cells
164
is the scrotal wall and epididymis normal with malignant pathologies
yes
165
what is the most common germ cell tumor
seminoma
166
what condition is a seminoma associated with
- undescended testis
167
what is the prognosis of a seminoma
- least aggressive
| - best prognosis
168
what lab values are changed with a seminoma
- serum alpha fetoprotein normal
| - beta HCG may elevated
169
sonographic appearance of seminoma
- solid homogenous hypoechoic mass
- scattered hyperechoic area
- pseudocapsule
170
what type of patient non seminomatous germ cell tumors affect
- younger patients
171
what is the prognosis of a non seminomatous germ cell tumor
- more aggressive
| - can develop visceral metastases
172
what are the 5 types of non seminomatous germ cell tumor
- embryonal cell carcinoma
- choriocarcinoma
- teratoma
- yolk sac tumor
- mixed germ cell tumors
173
what is the second most common embryonal cell carcinoma
embryonal cell tumor
174
what age group is affected with embryonal cell carcinoma
- 25-35 years of age
175
what is the prognosis of embryonal cell carcinoma
- frequently occur with other tumors
- most agressive
- metastases and invasion into the tunica albuginea
176
what lab values are affected with an embryonal cell tumor
- alphafetoprotein may o may not be elevated
177
what is a yolk sac tumor
- infantile form of embryonal cell carcinoma
| - most common GST in infants under 2 years
178
what lab values are affected with a yolk sac tumor
- alpha fetoprotein is always elevated
179
sonographic appearance of embryonal cell carcinoma
- hypoechoic
- areas of increased echogenicity echogneicty and cystic areas
- poorly defined
180
is choriocarcinoma common or uncommon
- uncommon
181
what is the prognosis of choriocarcinoma
- highly malignant and aggressive
| - poor prognosis
182
what other organ system is affected with a choriocarcinoma
- pulmonary involvement
183
what lab value is usually affected with a choriocarcinoma
- serum bHCG always elevated
184
what do patients with choriocarcinoma usually present with
- gynecomastia
| - scrotal pain
185
sonographic appearance of choriocarcinoma
- small mass with mixed echogenic pattern
| - irregular borders
186
what is the nature of teratomas in children and adults respectively
- benign
| - malignant
187
what lab values are altered with teratomas
- serum alpha fetoprotein elevated
| - bHCG elevated
188
sonographic appearance of teratoma
- cystic and solid components
- posterior shadowing and enhancement
- defined borders
189
what is the most common type of mixed germ cell tumor
- teratocarcinoma
190
what is a teratocarcinoma
- contains both teratoma nd embryonal carcinoma cells
191
what is the nature of teratocarcinomas
- agressive
| - largest of all testicular tumors
192
sonographic appearance of teratocarcinomas
- heterogenous mass with cystic areas
| - echogenic foci
193
what is a burned out tumor and what is its significance
- echogenic calcific scar in testicle that represents regression of a primary testicular tumor (grows to large and cuts off its blood supply)
- patient presents with mets but unknown primary and normal clinical testicular exam
194
what isa the most common metastatic tumor of testes
- lymphoma
195
what age group is metastatic lymphoma to the testes most common in
>50 years
196
what type of metastatic lymphoma to the testes is most common
- non Hodgkins
197
what is the most common presentation of patients with metastatic lymphoma to the testes
- painless testicular mass
| - diffuse enlargement
198
what is the most common sonographic appearance of metastatic lymphoma to the testes
- hypoechoic
- homogeneous
- diffuse or focal
- hyper vascular
199
what is the second most common secondary testicular neoplasm
- leukaemia
200
what are the 2 most common non lymphomatous types of metastases to the testicle
- prostate
| - lung
201
what are the 4 possible routes of metastatic spread to the testes
- retrograde venous
- hematogenous
- retrograde lymphatic
- direct tumor invasion
202
what are the 5 epididymal changes that can occur post vasectomy
- epididymal enlargement
- heterogeneous
- cyst/spermatoceles
- sperm granulomas
- tubular ectasia
203
which areas of the testicle can be affected by tubular ectasia
- epididymis and rete testis
204
sonographic appearance of tubular ectasia
- variable cystic size lesions seen in the region of mediastinum and epididymis
- NO COLOR FLOW
- frequently bilateral and asymmetrical
205
what is tubular ectasia usually associated with
- spermatocele
206
what 4 things do we asses the scrotal sac post orchiectomy
- hematomas
- abscesses
- recurrent neoplasms
- prosthesis
