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Abd / SS 3 > Module 1: Scrotum > Flashcards

Module 1: Scrotum Flashcards

1
Q

what is the scrotum

A
  • a pouch of loose skin and fascia continuous with the abdomen
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2
Q

externally what structure divides the scrotum into 2 compartments

A
  • the raphe/ meidan raphe
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3
Q

internally what structure divides the scrotum into two compartments and forms the internal scrotal septum

A

the dartos tunica

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4
Q

what is the normal thickness of the scrotal wall

A

2-8mm

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5
Q

what structure lines the inside of the scrotal sac

A
  • the tunica vaginalis
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6
Q

what are the two layers of the tunica vaginalis and what are they in contact with

A
  • parietal (scrotal walls)

- visceral (testicles)

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7
Q

how much fluid should be between the layers of the tunica vaginalis

A

1-2ml

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8
Q

what 4 structures are within the scrotal sac

A
  • tesitcles
  • epididymus
  • vas deferens
  • spermatic cord
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9
Q

what are the testicles and what do they produce

A
  • paired reproductive organs

- sperm, testosterone

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10
Q

what shape and normal dimensions are the testicles

A
  • oval
  • LENGTH = 3-5cm
  • WIDTH = 2-4cm
  • AP = 3cm
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11
Q

do the testicles increase or decrease in size with age

A

decrease

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12
Q

what is the fibrous layer surrounding each testicle called

A

tunica albuginea

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13
Q

what structure does the tunica albuginea form

A
  • mediastinum posteriorly
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14
Q

how are the lobules created

A
  • the tunica aluginea invaginates (folds into itself) to create the lobules
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15
Q

what is contained within each lobule and what process is performed

A
  • seminiferous tubules

- spermatogenesis

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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
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17
Q

what forms the rete testes

A
  • convergence of the seminiferous tubules at the mediastinum
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18
Q

what are the efferent ducts

A
  • the rete testes are renamed efferent ducts after they exit the mediastinum
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19
Q

what is the role of the efferent ducts

A
  • carry seminal fluid to the epididymis
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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
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21
Q

what is an appendix testis

A
  • remnant of MULLERIAN DUCT with no function

- upper pole of testicle

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22
Q

what is the epididymis

A
  • comma shaped structure superior and posterolateral to testes
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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

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24
Q

what is the epidydmis formed by

A
  • convergence of the efferent ducts from rete teste
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25
Q

what is another name fro the head of the epidymis

A

globus major

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26
Q

what are the three parts of the epididymis

A

head, body , tail

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27
Q

what is the normal AP of the epi head

A

10-12mm

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28
Q

what is the normal AP of the epi body

A

2-4mm

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29
Q

what is the normal AP of the epi tail

A

2-5mm

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30
Q

what is the function of the epididymis

A
  • conveys sperm to the seminal vesicles

- storage and maturation of sperm

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31
Q

what is an appendix epididymis

A

remnant of the MESONEPHRIC (WOLLFIAN) DUCT

- different origin than appendix testes

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32
Q

what are the seminal vesicles

A
  • reservoirs for seminal fluid
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33
Q

what is the structure that connects the testes to the pelvis and abdomen and suspends testes in scrotum

A
  • spermatic cord
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34
Q

where does the the spermatic cord travel

A

within the the inguinal canal

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35
Q

what four structures are contained within the spermatic cord

A
  • vas deferens
  • testicular artery
  • venous pampiniform plexus
  • lymphatic and nerves
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36
Q

what is the venous pampiniform plexus

A
  • network of veins that drain the testes
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37
Q

what are the 3 arteries that supply the testes and scrotum and structures

A
  • testicular arteries
  • deferential arteries
  • cremasteric arteries
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38
Q

what vessel supplies the testicle with blood

A
  • testicular arteries from aorta
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39
Q

what vessel supplies the epididymis and vas deferens with blood

A

deferential arteries from inferior vesicle artery

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40
Q

what vessel supplies the peri testicular tissue with blood

A
  • cremasteric arteries from inferior epigastric artery
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41
Q

how is the blood drained from the testicules

A
  • blood drainage via the pampiniferous plexus to the testicular veins
  • right testicular vein drains directly into IVC
  • left testicular veins drain into the LRV
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42
Q

what is the waveform of the testicular artery

A
  • low resistance
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43
Q

what is the waveform of the cremasteric and deferential arteries

A
  • high resistance = feeding mostly connective tissue and muscle
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44
Q

what are the 8 indications for a scrotal ultrasound exam

A
  • palpable mass
  • pain
  • enlarged scrotum with or without pain
  • cystic vs solid
  • torsion
  • undescended testes
  • trauma
  • post orchiectomy
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45
Q

what is the sonographic appearance of the testes

A
  • homogeneous medium level echoes similar to thyroid
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46
Q

does the echogenicity of the testes increase or decreased with age

A
  • increases
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47
Q

what is the sonographic appearance of the sagittal mediastinum

A
  • hyperechoic line (band) from superior to inferior pole
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48
Q

what is the sonographic appearance fo the transverse mediastinum

A
  • hyperechoic mass at 3 o’clock on the right and 9 o’clock on the left
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49
Q

what is the sonographic appearance of the rete testis

A
  • decreased echogenicity at the mediastinum or tiny cystic structures
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50
Q

what it is the sonographic appearance of the epididymis

A
  • isoechoic or slightly hyperechoic to the testicle

- slightly coarse texture

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51
Q

are extratesticular or intratesticular masses more likely malignant

A
  • extratesticular = benign

- intratesticular = malignant

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52
Q

what are the 3 main categories of pathologies/anomalies of the scrotum

A
  • congenital anomalies
  • benign pathologies
  • malignant pathologies
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53
Q

what are the 4 congenital anomalies of the scrotum

A
  • cryptorchidism (undescended testes)
  • polyorchidism
  • anorchia
  • testicular ectopia
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54
Q

what is cryptorchidism

A
  • failure fo testicles or testis to descend to normal position
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55
Q

what is the most common GU abnormality in children

A
  • cryptorchidism
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56
Q

is cryptorchidism usually unilateral or bilateral

A
  • unilateral
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57
Q

where are the majority of undescended testis located

A
  • inguinal canal and palpable
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58
Q

what is the gubernaculum

A
  • the structure that guides and anchors the testis during descent into the scrotal sac
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59
Q

what are the three causes of cryptorchidism

A
  • deficiency of gonadotropin hormonal stimulation
  • adhesions or anatomic maldevelopment
  • idiopathic
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60
Q

what are two common complications of cryptorchidism

A
  • infertility = increased heat in abdomen affecting spermatogenesis
  • testicular cancer (48X the risk) both testicles
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61
Q

what is the common treatment for cryptorchidism in infants

A
  • orchiopexy
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62
Q

what is the common treatment for cyprtochidism in older children

A
  • orchiectomy
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63
Q

what is the sonographic appearance of cryptorchidism

A
  • oval mass
  • smaller less echogenic
  • homogeneous
  • mediastinum hard to see
  • enlarged inguinal lymph node may be mistaken for undescended testes
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64
Q

what is polyorchidism

A
  • testicular duplication or supernumerary testis
  • rare
  • unilateral
  • located in scrotum
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65
Q

what is anorchia

A
  • absence of testicle
  • rare
  • unilateral and located in scrotum
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66
Q

what is testicular ectopic

A
  • testicular tissue identified anywhere along the path of descent
  • rare
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67
Q

what are the 15 benign scrotal pathologies

A
  • hydrocele
  • hematocele
  • pyocele
  • varicocele
  • hernia
  • trauma
  • torsion
  • infection
  • abscess
  • scrotal pearls
  • spermatocele
  • true cysts
  • non germ cell neoplasm
  • adenomatoid tumor
  • microlithiasis
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68
Q

what is a hydrocele

A
  • collection of fluid between the tunica vaginalis layers
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69
Q

what is the amount of separation between the visceral layers to indicate hydrocele

A

> 2mm

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70
Q

where is the fluid located in the scrotum with a hydrocele

A
  • anterolateral portion
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71
Q

what is the most common cause of painless scrotal swelling

A
  • hydrocele
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72
Q

what are the 2 categories of causes of hydrocele

A
  • congenital

- acquired

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73
Q

what are the congenital causes of hydrocele

A
  • due to patent processus vaginalis

- resolves by 18-24 months

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74
Q

what are the acquired causes of hydrocele

A
  • IDIOPATHIC

- secondary to infarction, inflammation, neoplasm, trauma

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75
Q

are large or smaller neoplasms more commonly found with tumors

A
  • smaller
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76
Q

sonographic appearance of hydroceles

A
  • simple=anechoic
  • increased through transmission
  • may or may not have calcs
  • may or may not have spetations or debris
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77
Q

what is a hematocele

A
  • blood in the scrotal sac
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78
Q

what are the 4 causes of hematocele

A
  • trauma
  • surgery
  • neoplasms
  • torsion
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79
Q

what is the clinical presentation of hematocele

A
  • mimic epididymitis or torsion
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80
Q

sonographic appearance of hematocele

A
  • acutely scrotal wall thickened
  • anechoic collection
  • variable appearance
  • septations, debris in chronic stage
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81
Q

what is a pyocele

A
  • pus in the scrotal sac
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82
Q

what are the causes of pyocele

A
  • abscesses that rupture into the tunica vaginalis potential space
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83
Q

sonographic appearance of pyocele

A
  • echogenic collection s
  • spetations/loculations
  • thick scrotal walls
  • focal mural nodulations
84
Q

what is a varicocele

A
  • abnormally dilated veins of the pampiniform plexus
85
Q

what is the diameter of the vessels when a varicocele is present

A

> 2mm

86
Q

what is the overall cause of varicocele

A

obstructed venous return

87
Q

on what side to varcicoceles often occur

A
  • left
88
Q

what are the two categories of causes of varicocele

A
  • primary

- secondary

89
Q

what are the primary causes of varicocele

A
  • idiopathic

- incompetent valves in the internal spermatic vein

90
Q

what ages are affected by primary varicocele

A
  • 15-25 years
91
Q

what is the most common cause of correctable infertility

A
  • primary varicocele
92
Q

why does varicocele cause infertility

A
  • increased blood flow around the testicles lead to increase heat affecting spermatogenesis
93
Q

what is the cause of secondary infertility

A
  • due to increased pressure on the spermatic vein
94
Q

what area is important to look at when secondary varicocele is considered

A
  • look for a mass compression the LRV

- RCC likes to invade the LRV causing obstruction

95
Q

what syndrome can cause secondary varicocele

A
  • nutcracker syndrome
96
Q

what is nutcracker syndrome

A
  • compression of the left renal vein between the aorta and SMA
97
Q

what maneuver is used to check for varicocele

A
  • valsalva will increase the size of the vein with increased or reversed blood flow
98
Q

how can you distinguish between primary and secondary varicoceles

A
  • primary varicoceles will return to normal in the spin position
  • secondary will real enlarged no matter what patient position
99
Q

sonographic features of varicoceles

A
  • 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
Q

what is a scrotal hernia

A
  • inguinal hernias the descend into the scrotum containing omentum or bowel
101
Q

what are the signs and symptoms of a scrotal hernia

A
  • scrotal enlargement
  • pain
  • blood in stool
102
Q

sonographic appearance of a scrotal hernia

A
  • mass outside testicle
  • echogenic/anechoic mass
  • peristalsis noted if the hernia is not incarcerated
103
Q

what is trauma to the scrotum

A
  • direct injury or straddle injury
104
Q

what can trauma do to the scrotum

A
  • hematoma
  • hematocele
  • ruptured testicle
105
Q

what is a ruptured testicle

A
  • surgical emergency
  • ## tunica albuginea tears
106
Q

what is the most common cause of scrotal trauma

A
  • blunt trauma
107
Q

sonographic appearance of scrotal trauma

A
  • focal areas od altered echogenicity
  • irregular capsule/contour
  • hematocele
  • color doppler to asses flow
108
Q

what is testicular torsion

A
  • spermatic cord twists cutting off blood supply to testicle
109
Q

what are the stages of torsion

A
  • acute = within 24 hours
  • subacute = 24-10 days
  • chronic = after 10 days
110
Q

what are the 2 types of torsion

A
  • intravaginal

- extravaginal

111
Q

what type of torsion is the most common during puberty

A
  • intravaginal
112
Q

what is intravaginal torsion caused by

A
  • 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
Q

in what patients is intravaginal torsion have an increased chance of occurring

A
  • patients with a history of orchiopexy
114
Q

what is extravaginal torsion caused by

A
  • 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
Q

in what type of patients is extravaginal torsion seen more commonly in

A
  • newborns
116
Q

sonographic appearance of torsion in acute stage

A
  • enlarged testicle and epi
  • testicel more hypoechoic
  • scrotal skin thickening
  • possible reactive hydrocele
  • absent arterial flow if complete torsion
117
Q

sonographic appearance of torsion in the subacute stage

A
  • testicel and epi still enlarged but heterogenous
118
Q

sonographic appearance o torsion in the chronic stage

A
  • atrophied heterogeneous testicle

- epi remains enlarged

119
Q

signs and symptoms of torsion

A
  • sudden onset of extreme scrotal pain
  • nausea and vomitting
  • symptoms mimic epididiymitis but diminish after 1-2 days
120
Q

where does infection usually originate

A
  • bladder
  • urethra
  • prostate
  • then spread to epi
121
Q

what is epididymitis

A
  • inflammation/infection of the epi
  • can cause infertility
  • typically unilateral
122
Q

what is the most common cause of acute scrotal pain and tenderness

A
  • epididymitis
123
Q

what are the signs and symptoms of epididymitis

A
  • fever
  • pain and increasing over 1-2days
  • dysuria
  • discharge
124
Q

sonographic appearance of epididymitis

A
  • thick enlarged epi
  • hypoechoic and heterogeneous
  • scrotal thickening
  • reactive hydrocele
  • increased blood flow
  • abscess collection
  • chronic infection calc possible
125
Q

what is orchitis

A
  • inflammation of the testis (focal or diffuse)

- typically secondary to epididymitis

126
Q

what is the most common cause of orchitis in men under 35

A
  • chlamydia
127
Q

sonographic appearance of focal orchitis

A
  • hypoechoic area adjacent to enlarged epi
  • mass like (looks like neoplasm)
  • hypervascular
128
Q

sonographic appearance of diffuse orchitis

A
  • decreased echogenicity of entire testicle

- enlarged

129
Q

sonographic appearance of chronic orchitis

A
  • hypoechoci and heterogeneous appearance

- reactive hydrocele

130
Q

what is a common complication fro untreated epididymo-orchitis

A
  • abscess
131
Q

what are the signs and symptoms of an abscess

A
  • pain
  • fever
  • and swollen scrotum
132
Q

what can result from an abscess

A
  • can rupture through tunica vaginalis results in a pyocele or fistula to the skin
133
Q

what three things is abscess associated with

A
  • diabetes
  • mumps
  • influenza
134
Q

what is the sonographic appearance of an abscess

A
  • sonolucent or complex mass

- increased blood flow in periphery

135
Q

what is a scrotal pearl

A
  • calcifications floating in the tunica or within the scrotal sac
  • mobile
136
Q

what is a spermatocele

A
  • retention cyst (dilated epi tubule) filled with non viable sperm
137
Q

what does a spermatocele result from

A
  • epididymitis or traumas
138
Q

where are spermatoceles typically located and are they single or multiple

A
  • epi head and can displace
    testicle
  • both
139
Q

are spermatoceles painless or painful lumps

A
  • painless
140
Q

ultrasound appearance of spermatocele

A
  • well defined anechoic was with acoustic enhancement
  • simple lobulated septated
  • echogenic debris
  • 0.2-9cm
141
Q

what is a true cyst

A
  • filled with serous fluid
142
Q

where are true cysts located

A
  • epi (uncommon)
  • tunica albuginea (rare)
  • testicles
143
Q

are true symptoms symptomatic or asymptomatic

A
  • asymptomatic
144
Q

can epi cyst and spermatocele be differentiated on ultrasound

A
  • no
145
Q

are the majority of non germ cell tumors malignant or benign

A
  • benign
146
Q

what are the two non germ cell tumors

A
  • leydig cell tumors

- Sertoli cell tumors

147
Q

what can leydig cell tumors cause

A
  • gynecomastia
148
Q

what can Sertoli cell tumors cause

A
  • gynecomastia

- feminization

149
Q

what is the ultrasound appearance of non germ cell tumors

A
  • small
  • well defined
  • hypoechoic
150
Q

what is another term for non germ cell tumors

A
  • gonadal stromal
151
Q

what is the most common extratesticular tumor

A
  • adenomatoid tumor
152
Q

are adenomatoid tumors most often benign or malignant

A
  • benign
153
Q

where are adenomatoid tumors usually found

A
  • in the epi
154
Q

what are the characteristics of adenomatoid tumors

A
  • slow growing

- asymptomatic and small

155
Q

ultrasound appearance of adenomatoid tumor

A
  • well defined
  • variable echogenicity
  • solid
  • unilateral
  • usually on the left
156
Q

what is microlithiasis

A

calcifications in the seminiferous tubules

157
Q

what is isolated microlithiasis

A
  • 5 or fewer calcifications per transducer field in the testicle
158
Q

is isolated microlithiasis worrisome

A
  • no
  • associated with benign condition
  • inflammatory, granulomatous, or vascular
159
Q

what is associated with having more than 5 calcifications per transducer field

A
  • malignant neoplasms
160
Q

sonographic appearance of microlithiasis

A
  • tiny echogenic speckled areas without posterior shadowing
161
Q

what are the 2 categories malignant scrotal pathologies

A
  • seminoma

- non-seminomatous germ cell tumors

162
Q

do malignant pathologies present painful or painless

A
  • most likely scrotal enlargement or hardness of testicle
163
Q

where do most malignant pathologies originate from

A
  • germ cells
164
Q

is the scrotal wall and epididymis normal with malignant pathologies

A

yes

165
Q

what is the most common germ cell tumor

A

seminoma

166
Q

what condition is a seminoma associated with

A
  • undescended testis
167
Q

what is the prognosis of a seminoma

A
  • least aggressive

- best prognosis

168
Q

what lab values are changed with a seminoma

A
  • serum alpha fetoprotein normal

- beta HCG may elevated

169
Q

sonographic appearance of seminoma

A
  • solid homogenous hypoechoic mass
  • scattered hyperechoic area
  • pseudocapsule
170
Q

what type of patient non seminomatous germ cell tumors affect

A
  • younger patients
171
Q

what is the prognosis of a non seminomatous germ cell tumor

A
  • more aggressive

- can develop visceral metastases

172
Q

what are the 5 types of non seminomatous germ cell tumor

A
  • embryonal cell carcinoma
  • choriocarcinoma
  • teratoma
  • yolk sac tumor
  • mixed germ cell tumors
173
Q

what is the second most common embryonal cell carcinoma

A

embryonal cell tumor

174
Q

what age group is affected with embryonal cell carcinoma

A
  • 25-35 years of age
175
Q

what is the prognosis of embryonal cell carcinoma

A
  • frequently occur with other tumors
  • most agressive
  • metastases and invasion into the tunica albuginea
176
Q

what lab values are affected with an embryonal cell tumor

A
  • alphafetoprotein may o may not be elevated
177
Q

what is a yolk sac tumor

A
  • infantile form of embryonal cell carcinoma

- most common GST in infants under 2 years

178
Q

what lab values are affected with a yolk sac tumor

A
  • alpha fetoprotein is always elevated
179
Q

sonographic appearance of embryonal cell carcinoma

A
  • hypoechoic
  • areas of increased echogenicity echogneicty and cystic areas
  • poorly defined
180
Q

is choriocarcinoma common or uncommon

A
  • uncommon
181
Q

what is the prognosis of choriocarcinoma

A
  • highly malignant and aggressive

- poor prognosis

182
Q

what other organ system is affected with a choriocarcinoma

A
  • pulmonary involvement
183
Q

what lab value is usually affected with a choriocarcinoma

A
  • serum bHCG always elevated
184
Q

what do patients with choriocarcinoma usually present with

A
  • gynecomastia

- scrotal pain

185
Q

sonographic appearance of choriocarcinoma

A
  • small mass with mixed echogenic pattern

- irregular borders

186
Q

what is the nature of teratomas in children and adults respectively

A
  • benign

- malignant

187
Q

what lab values are altered with teratomas

A
  • serum alpha fetoprotein elevated

- bHCG elevated

188
Q

sonographic appearance of teratoma

A
  • cystic and solid components
  • posterior shadowing and enhancement
  • defined borders
189
Q

what is the most common type of mixed germ cell tumor

A
  • teratocarcinoma
190
Q

what is a teratocarcinoma

A
  • contains both teratoma nd embryonal carcinoma cells
191
Q

what is the nature of teratocarcinomas

A
  • agressive

- largest of all testicular tumors

192
Q

sonographic appearance of teratocarcinomas

A
  • heterogenous mass with cystic areas

- echogenic foci

193
Q

what is a burned out tumor and what is its significance

A
  • 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
Q

what isa the most common metastatic tumor of testes

A
  • lymphoma
195
Q

what age group is metastatic lymphoma to the testes most common in

A

> 50 years

196
Q

what type of metastatic lymphoma to the testes is most common

A
  • non Hodgkins
197
Q

what is the most common presentation of patients with metastatic lymphoma to the testes

A
  • painless testicular mass

- diffuse enlargement

198
Q

what is the most common sonographic appearance of metastatic lymphoma to the testes

A
  • hypoechoic
  • homogeneous
  • diffuse or focal
  • hyper vascular
199
Q

what is the second most common secondary testicular neoplasm

A
  • leukaemia
200
Q

what are the 2 most common non lymphomatous types of metastases to the testicle

A
  • prostate

- lung

201
Q

what are the 4 possible routes of metastatic spread to the testes

A
  • retrograde venous
  • hematogenous
  • retrograde lymphatic
  • direct tumor invasion
202
Q

what are the 5 epididymal changes that can occur post vasectomy

A
  • epididymal enlargement
  • heterogeneous
  • cyst/spermatoceles
  • sperm granulomas
  • tubular ectasia
203
Q

which areas of the testicle can be affected by tubular ectasia

A
  • epididymis and rete testis
204
Q

sonographic appearance of tubular ectasia

A
  • variable cystic size lesions seen in the region of mediastinum and epididymis
  • NO COLOR FLOW
  • frequently bilateral and asymmetrical
205
Q

what is tubular ectasia usually associated with

A
  • spermatocele
206
Q

what 4 things do we asses the scrotal sac post orchiectomy

A
  • hematomas
  • abscesses
  • recurrent neoplasms
  • prosthesis

Abd / SS 3 (6 decks)

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