pathology Flashcards
goal of the exam
- evaluate size, echogenicity, and structure of each testis.
- determine whether testicular parenchyma appears uniform with an equal echogenicity between sides
- document masses
evaluation of the scrotum
- is epididymis normal? is scrotal skin thickened?
- turn on color Doppler to assess flow. is there an absence of flow in testis or is it hyperemic? how does color Doppler compare between sides?
- check flow in each epididymis
trauma may be result of
- MVA
- athletic injury
- direct blow to scrotum
- straddle injury
ultrasound of scrotal trauma presents challenge due to
edema and pain
if surgery is performed within 72 hours following injury,
up to 90% of testes can be saved but only 45% can be saved after 72 hours
potential complications of trauma
- testicular rupture
- hematocele
- hematoma
- hydrocele
- epididymitis
- orchitis
- torsion
determine if rupture is present
- focal alteration of testicular parenchymal pattern
- interruption of tunica albuginea
- irregular testicular contour
- scrotal wall thickening hematocele
- blood flow disruption across surface of testis indicates rupture
hematocele
blood collected within the layers of the tunica vaginalis
hematocele sonographic appearance
varies with age
acute hematocele sonographically is
echogenic with numerous highly visible echoes that can be seen to float or move in real time
with time hematocele sonographically show
low-level echoes and develop fluid-filled levels or septations
presence of hematocele does not confirm
rupture
hematomas may involve
testis or epididymis or they can be contained within scrotal wall
hematomas appear as
heterogenous areas within scrotum which becomes more complex with time, developing cystic components
hematoma may be
large and cause displacement of the associated testis
epididym-orchitis
infection of both epididymis and testis
epididymitis and/or orchitis may result from
trauma
epididym-orchitis most commonly results from
spread of lower urinary tract infection
color Doppler imaging with epididymo-orchitis can be used to identify associated
increased vascularity
epididym-orchitis most common cause of
acute scrotal pain in adults
sonographic epididymitis appears
enlarged, hypoechoic gland and increase vascularity
sonographic findings of epididymo-orchitis with color Doppler
hyperemic flow confirmed
hyperemic flow with epididymo-orchitis seen in epididymis and testis when both involved but
is restricted to epididymis if testis is normal
orchitis
inflammation in the testis
hydrocele
contain serous fluid within the cavity of the tunica vaginalis
hydrocele most common cause of
painless scrotal swelling, acute or chronic
hydrocele may be
idiopathic but commonly associated with epididymo-orchitis and torsion
hydrocele are much more common than
hematoceles and pyoceles
pyocele is
a collection of pus
pyocele occur with
untreated infection or when an abscess ruptures into space between layers of tunica vaginalis
torsion
testis and epididymis twist within scrotum, cutting off vascular supply within spermatic cord
torsion comprised blood flow to
testis, epididymis, and intrascrotal portion of spermatic cord
torsion first affects
venous flow cause swelling of scrotal structures on affected side
if torsion continues
arterial flow obstructed, and testicular ischemia follows
torsion within 5 to 6 hours of onset pain
80% to 100% of testes can be salvaged
torsion 6-12 hour salvage rate is
70%
torsion after 12 hours only
20% will be saved
clinical symptoms of torsion
- presents with sudden onset of scrotal pain with swelling on affected side
- severe pain causes nausea and vomiting in many patients
torsion can occur at
any age
torsion most common in
adolescents/ young adults, peak age 14
undescended testes are
10 times more likely than normal testes to be affected by torsion
bell clapper deformity occurs when
the gubernaculum ligament absent that tunica vaginalis completely surrounds testis, epididymis, distal spermatic cord, allowing them to move and rotate freely within scrotum
gubernaculum ligament
which helps to hold testis in place
extratesticular masses
- epididymal (head) cysts
- tunica albuginea cysts
- tunica vaginalis cysts
- varicocele
- scrotal hernia
- sperm granuloma
epididymal cysts, tunica albuginea/ vaginalis cysts, and spermatoceles are generally
asymptomatic but often palpable
epididymal (head) cyst
are clear cysts containing serous fluid located within the epididymis
epididymal cyst typically
small but can grow large
epididymal cyst occur most often
in the epididymal head
spermatocele
is a large cyst at the epididymis head
varicocele
abnormal dilation of veins of pampiniform plexus and/ or of peritesticular veins
varicocele most common cause of
male infertility
varicocele most common on
left
varicocele is seen
40% of left testicular and 23% of right
varicocele could be
primary or secondary
primary varicoceles usually caused by
incompetent venous valves within scrotal veins
secondary varicoceles are caused by
increased pressure on testicular vein
varicocele may be result of
renal hydronephrosis, abdominal mass, or liver cirrhosis
varicocele sonographic appearance
- numerous tortuous tubes of varying sizes within spermatic cord near epididymal head or adjacent to testis
- > 2cm A-P
- tubes may contain echoes that move with real-time imaging
- increased flow upon Valsalva maneuver
scrotal hernia occurs when
bowel or omentum herniate into scrotum
scrotal hernia clinical diagnosis usually
sufficient, sonography helpful in cases of equivocal findings
most herniated structure
bowel followed by omentum
peristalsis of bowel seen with
real-time imaging, confirms the diagnosis of a scrotal hernia
inguinal hernia is confined to
the inguinal canal
sperm granulomas occur as
focal chronic inflammatory reactions to extravasation of spermatozoa
sperm granuloma most frequently seen in
patients with history of vasectomy
sperm granuloma may be located
anywhere within epidiymis or vas deferens
benign testicular masses
- tubular ectasia of the rete testis
- cyst
- epidermoid cyst
- microlithiasis
tubular ectasia of the rete testis
dilation of rete testis, uncommon, benign
tubular ectasia of the rete testis associated with
presence of a spermatocele, epididymal or testicular cyst or other epididymal obstruction on same side as the dilated tubules
testicular cyst more common in men
over 40
testicular cyst associated with
extratesticular spermatoceles (epididymal cysts)
testicular cyst located
near mediastinum
testicular cyst can be
single or multiple and of varying size
epidermoid cyst
composed of keratin
epidermoid cyst presentation can be like
that of a malignant tumors
epidermoid cyst sonographic appearance
- variable
- may demonstrate an onion skin or target appearance
- no color flow
microlithiasis
multiple calcifications
microlithiasis measure
< 3mm
microlithiasis are usually
bilateral
microlithiasis reported to have association with
testicular malignancy, exact nature unknown
microlithiasis associated with
- cryptorchidism
- Klinefelter’s syndrome
- infertility
- varicoceles
- testicular atrophy
- male pseudohermaphroditism
extratesticular masses usually
benign
intratesticular masses more likely to be
malignant
testicular masses are categorized as either
germ cell (malignant) or non-germ cell (usually benign)
germ cell tumors elevated
HCG and AFP
germ cells approximately
95% of all testicular tumors are of germ cell type
most common type of germ call tumors is
- seminoma
- followed by mixed embroyonal cell tumors and teratocarcinomas
non-germ cells tumors are generally
benign
non-germ cell tumors sonographically
tumors appear as focal, hypervascular, hypechoic, or heterogenous masses
testicular cancer is
rare (1% of male cancers)
testicular cancers usually occur
in males between the ages of 20-34
testicular cancer is one of the most
curable types of cancer
testicular cancer symptoms
- painless lump
- testicular enlargement
- vague discomfort in scrotum
seminoma is
germ cell tumor
seminoma most common primary
testicular tumor
seminomas tend to be
homogenous, hypoechoic masses with a smooth border
seminoma do not often contain
calcification or cystic components
embryonal cell carcinoma is
more aggressive than seminomas
embryonal cell sonography
- heterogenous
- calcifications present
germ cell tumors
- seminoma
- embryonal cell carcinoma
- leydig cell tumors
- teratocarcinomas
- choriocarcinoma
leydig cells make
testosterone
leydig cell tumors are
rare, making up less then 5% of testis cancer
leydig cell tumors have an
excellent prognosis if surgically resected
teratocarcinomas form of
malignant teratoma occurring especially in the testis
teratocarcinomas made of
different tissues such as hair, muscle or bone
choriocarcinoma
has varied sonographic appearances because of mixed cell types
metastasis to testicle
is rare, normally occurring later in life
with metastasis primary tumor may originate from
prostate or kidneys
with metastasis less common sites
- lung
- pancreas
- bladder
- colon
- thyroid
- melanoma
sonographic findings of metastasis
- solid hypo or hyperechoic mass
- mixture of both
lymphoma most common
bilateral secondary testicular neoplasm affecting men >60 years
leukemia next common
secondary testicular neoplasm, most often found in children
cryptorchidism
undecended testis(es)
cryptorchidism may be located in
- abdomen
- inguinal canal
- other ectopic location
cryptorchidism associated with
infertility and increased risk of cancer
cryptorchidism sonographic findings
- smaller and less echogenic than normal testis
- mediastinum rarely seen
cryptorchidism is
bilateral 10% to 25% of cases
testicular ectopia
very rare condition
ectopic testicle cannot be
manipulated into correct path of descent
testicular ectopia most commonly
in inguinal canal
testicular ectopia other sites include
- perineum
- femoral canal
- suprapubic area
- penis
- diaphragm
- other hemiscrotum
anorchia
rare condition
unilateral anorchia or monorchidism found
in 4% of patients with nonpalpable testis
anorchia most common on
left side
anorchia caused by
intrauterine testicular torsion or other forms of decreased vascular supply to testicle in utero
polyorchidism
very rare disorder
polyorchidism more common on
left side
polyorchidism usually found in
scrotum, has also been found in inguinal canal or retroperitoneum
polyorchidism increased risk of
- malignancy
- cryptorchidism
- inguinal hernia
- torsion
polyorchidism duplicated
testis, usually small, efferent spermatic system completely absent
