peds- scrotum and testes Flashcards
what transducer do you use for pediatric pelvis us?
- high resolution linear array transducer
- 10-15 MHz (usually 12 MHz)
testes origin and hormone secretion?
- testes have mesenchymal origin
- secrete hormones that affect mesonephric duct (woliffian)
when ducts are exposed to testosterone what occurs?
male sexual differentiation occurs
wolffian duct develops into what? (5)
- rete testis
- efferent ducts
- epididymis
- vas deferens
- seminal vesicles
the prostate is formed separatley from what?
the urogenital sinus
failure for descent of the testes can result in?
- infertility or malignancy
what are the pathways for the testes to desend?
- inguinal canals are pathways for the testes to descend from their intra-abdominal location through the anterior abdominal wall into the scrotum
testes descent takes place at what weeks of gestation? What are they dependent on?
- desent between 25-32 weeks GA
- Dependant on androgen secretion
- during the 1st 3 months after birth most undescended testes decend (does not occur after 1 year)
u/s apperance of newborn testes?
- echogenicity
- shape
- diameter
- whats not seen
- doppler
- homogeneous low to medium level echogenicity
- spherical or oval in shape
- 7-10mm diameter
- epididymis and mesiastinum testes are usually nor seen in neonate
- doppler will show a pulsatile foci or colour with no branching
u/s apperance of testes by puberty?
- echogenicity
- mediastinum
- tunica albuginea
- doppler
- homogeneous medium-level echoes
- echogenic linear structure along vertical axis which represents mesiastinum testis
- tunica albuginea is a thin echogenic line around the testis
- doppler will show branching of vessels
measurement of testes by puberty?
- length, depth, width
3-5cm long
2-3 cm depth and width
congenital abnormalities of testes? (6)
- absence
- ectopic testes
- cryptochordism
- retractile testis
- small testis
- true hermaphroditism
anorchism?
bilateraal testicular absence
monorchism?
- unilateral testicular absence
- usually left sided
polyochism?
- testicular duplication
- usually a small single accessory testicle
5 abnormal locations of testis?
- contralateral scrotum
- peritoneum
- superficial inguinal pouch
- femoral canal
- suprapubically
when do ectopic testes occur?
- when the gubernaculum passes to an abnormal location and the testes follow it
what is transverse testicular ectopia?
both testes are in the same hemisctotum
what is cryptochordism? what is it associated with? where are they typically located?
- incomplete testicular descent into the scrotum
- associated with urological abnormalities
- typically located within the inguinal canal
Cryptochordism clinical presentations?
- no testes palpated in the scrotum
- one testic not palpated
sono features of cryptochordism? (5)
- smaller testis
- located along the path of testicular descent
- higher echogenicity than other testicle
- often indistinguishable from a lymph node
- renal exam should be performed because of association with renal anomalies
retractile testis?
- one that is fully desended but can move freely from its intrascrotal position to the groin
what is retractile testis caused by?
- hyperactive cremasteric reflex
- no increase in infertility
smaller testis causes? (7)
- cryptorchidism
- torsion
- inflammation
- varicocele
- radiation treatment
- trauma
- congenital causes (klinfelter’s syndrome and primary hypopituitarism)
what is true hermaphroditism?
- both ovarian and testicular tissue
- separate or ovotestis
hermaphroditism testicular vs ovarian tissue on u/s?
testicular portion: homogeneous
ovarian portion: heterogeneous with small follicles
hermaphroditism clinically? pre vs. post puberty
prepubertally- ambigious genitialia
postpubertally:
boys- gynecomastia, cyclic hematuria, cryptorchidism
girls- amenorrhea
true hermaphroditism
Acute Scrotal Pain and Swelling- causes of pediatric pain or swelling? (6)
- torsion
- epididymitis with or without orchitis
- torsion of appendages
- trauma
- acute hydrocele
- incarcerated hernia
what is testicular torsion?
- testis and spermatic cord twist one or more times, obstructing flow
- generally unilateral
- highest in infancy and adolescence
what are the 2 types of torsion?
- extravaginal
2. intravaginal (more common)
extravaginal torsion?
- neonates/ in utero
- spermatic cord poorly fixed in ingunial canal
- all scrotal contents are strangulated
intravaginal torsion?
- more in adolescents
- tunica vaginalis completely surrounds testis and inserts high on spermatic cord
- testis rotates freely on its vascular pedicle
what is bell-and-clapper deformity?
- predisposing factor for torsion
extravaginal torsion clinical features?
- swollen and red scrotum
- firm painless enlarges testicle
in utero- salvage of testis is unlikely
after birth- immediate surgery
intravaginal torsion clinical features?
- sudden onset of scrotal or low abdominal pain
- history or similar self-limited episodes
- N & V
- severely tender scrotum, swollen, hyperemia
intravaginal torsion treatment?
- what is the surgery called?
- there is a 100% salvage rate within ___hrs of pain onset
- immediate surgury (orchidopexy)
- 100% salvage reate within 6hrs of pain onset
extravaginal torsion sono features? recent vs. chronic
recent: heterogeneously enlarged with hypo and hyperechoic areas
chronic: normal size or enlarged, peripheral Ca2+
- scrotal thickening
- hydrocele
- no doppler signals
intravaginal torsion- sono features?
- early stage
- 4-6 hrs
- after 24 hrs
early: normal
4-6 hrs: hypoechoic from edema
after 24hrs: heterogeneous from hemorrhage and infaction
intravaginal torsion- sono features? (5)
- tetsicle of often TRV
- reactive hydrocele
- skin thickening
- enlarged, twisted spermatic cord
- hyprechoic epididymis
Colour flow Doppler in torsion- what you need to demonstrate?
- absent blood flow in affected testis
- normal flow in contralateral testis
- spontaneous detorsion causes normal or increased flow
extravaginal torsion
- Atrophy of the right testicle in a 2 month old neonate possibly caused by a an old testicular torsion
intravaginal torsion
- Acute testicular torsion
- 13yo
- enlarged left epididymis
- swollen hypoechoic testicle
- absence of flow
Acute epididymitis/epididymo-orchitis is more common in?
- pubertal boys
what is Acute epididymitis/epididymo-orchitis?
- inflammation of epididymis and testis
what cause Acute epididymitis/epididymo-orchitis?
- pyogenic, viral, or myocotic infection
- in adolescence often secondary to STD’s
clinical signs of Acute epididymitis/epididymo-orchitis?
- simular to torsion except:
- most gradual onset pain
- fever
- pyuria
treatment of Acute epididymitis/epididymo-orchitis?
antibiotics
what is mumps orchitis?
- seen in prepubertal boys infected with mumps
Acute epididymitis/epididymo-orchitis on u/s?
- foal or diffuse enlargement epididymis with coarse echoes
- focal orchitis shows hypoechoic areas
- doppler- hyperemic
- reactive hydrocele
- skin thickening
acute epididymitis
acute epididymo-orchitis
what is the Most common cause of acute scrotal pain in prepubertal boys?
torsion of the appendages
Torsion of the Appendages is typically seen in what age group?
6-12 years
Blue-dot sign?
- what is it associated with?
small, firm, round, mobile, tender paratesticular mass with bluish discolouration visible through skin
- associated with torsion of the appendages
Torsion of the Appendages on u/s?
- solid, ovoid mass with variable sized hypoechoic centre and hyperechoic rim
- adjacent to superior aspects of the testis or epididymis
torsion of the appendages
Testicular Trauma results in?
- hematoma or rupture
Testicular hematoma ?
- avascular masses with varying echogenicity
testicular rupture?
- surgical emergency
- assess for disruption of tunica albuginea, which is normally a smooth echogenic line
- hematocele present
testicular rupture
Sonography plays an important role in the evaluation of scrotal masses by? (3)
- confirming the presence of a lesion
- determining its orgion
- characterizing its contents
most intratesticular masses are? most extratesticular masses are?
most intratesticular masses are malignant
most extratesticular masses are benign
what % of testicular tumors are malignant?
80%
Two peak incidences of testicular neoplasms?
- children <2.5 years
- late asolescent
Children with cryptorchidism are most likely to develop?
30-50 times more likely to develop a testicular neoplasm
Intratesticular Scrotal Masses presentation?
- palpable mass in scrotum
2 non-primary testicular neoplasms?
- lymphoma
- leukemia
2 categories of primary testicular neoplasms?
- germ cell tumors
- non-germ cell tumors (stromal)
testicular neoplasms- germ cell tumors? (6)
- seminoma
- yolk sac tumor
- embryonal carcinoma
- choriocarcarcinoma
- teratocarcinoma
- teratoma (benign)
testicular neoplasms- non-germ cell tumors (stromal)? (2)
- leydig cell tumor
- sertoli cell tumor
u/s apperance of Most testicular tumors?
Hypoechoic Solid Well-defined Areas of hemorrhage or necrosis Calcifications Hydrocele Hypervascular if large
Germ Cell Tumors: Seminoma?
- most common in adult, rare in children
- 15-35 yr olds
- malignant
Germ Cell Tumors: Seminoma associated with?
cryptochordism
Germ Cell Tumors: Seminoma on u/s?
- hypoechoic masses
- heterogenous
- distorts testis if large
- vascular
seminoma
Yolk Sac Tumor AKA?
endodermal sinus tumor
Yolk Sac Tumor most common in?
prepubertal children
- primarily in 1-2 year olds
- highly malignant
clinical presentaiton of Yolk Sac Tumor?
- painless scrotal mass
- increased AFP
Embryonal carcinoma?
- usually in adolescence
- rare
- highly malignant
Choriocarcinoma?
- highly malignant- worst prognosis
- rare
- increased B-hCG
Teratoma?
- benign
- affects children <4yrs
Teratoma on u/s?
- complex mass
- hypoechoic area (serous fluid)
- hyperechoic areas (fat and calcification)
Stromal Tumors: Leydig and Sertoli characteristics?
- benign
- slow-growing
- usually hormone secreting
- small, well circumscribes
- hypoechoic
Leydig?
- 3-6 years old
- testosterone secreting
- precocious virilization
Sertoli?
- 1 year old
- most hormone inactive
- some secreting
- gynecomastia
Extratesticular Causes of Scrotal Masses (5)?
Hydrocele Hematocele Scrotal hernia/Inguinal hernia Varicoceles Spermatoceles/Epidydimal cysts
Extratesticular Causes of Scrotal Masses (5)?
Hydrocele Hematocele Scrotal hernia/Inguinal hernia Varicoceles Spermatoceles/Epidydimal cysts
what is Hydrocele?
- an abnormal collection of serous fluid in the scrotal sac
causes of Hydrocele?
- trapped peritoneal fluid- absorbs within 18 months of life
- communicating hydrocele- if processes vaginalis fails to close
sono apperance of Hydrocele?
- anachoic
- well-demarcated
- area with increased TT
Acquired hydrocele?
Older children
Reactive hydrocele might be caused by infection, torsion, trauma or tumor
SONO – fluid with septations & echoes
hydrocele
Hematocele?
blood in tunica vaginalis
Hematocele causes?
- surgury or trauma
- might be bleeding disorders or malignant tumor
sono features of Hematocele?
- fluid collection with debris
- septations
varicocele?
- dilated veins of pamphiform plexus
- mostly on left side
varicocele sono features?
- small
- serpentine
- anechoic structures
- flow on doppler
inguinal hernia?
- patent processus vaginalis
- scrotal mass
- more often on right side
ingunial hernia- sono?
- bowel loops with air or fluid in scrotum
- normal testes
- herniated amentum
- no peristaltis in incarcerated hernia
Testicular Microlithiasis?
see in healthy patients and in patients with? (3)
- asymptomatic
- seen in healthy patients and in patients with:
- downs syndrome
- cryptorchidism
- klinefelters syndrome
Testicular Microlithiasis on u/s?
- calcified debris in seminiferous tubules
- 1-3mm hyperechoic
- non shadowing foci
Testicular Microlithiasis associated with?
- diseases that have increased risk of malignancy
Spermatocele occur in?
- epididymis head
- consist of fluid (sprem and sediment)
Epididymal cysts?
Contain no spermatazoa, in epi head, body and tail, anechoic
Can present as a mass
Epididymal cysts?
Contain no spermatazoa, in epi head, body and tail, anechoic
Can present as a mass
ingunial hernia
