Scrotal Patho Flashcards
Why can scrotal traumas be difficult to scan?
scrotum is often painful and swollen
What causes scrotal trauma?
- MVA
- athletic injury
- direct blow
- straddle injury
Goal for sonographer:
see if rupture of scrotum has occurred.
How much of the testes can be saved if surgery on ruptured testicle performed within 72 hours?
90%
What percent of ruptured testicles can be saved if surgery is performed after 72 hours?
45%
Son findings of scrotal rupture
- focal alteration of the testicular parenchymal pattern
- interruption of the tunica albuginea
- irregular scrotal contour
- scrotal wall thickening
- hematocele
What is a scrotal hematocele?
blood located between the visceral and parietal layers of the tunica vaginalis
What can scrotal hematocele result from?
bleeding of the pampiniform plexus or other extra testicular structure
Son appearance of acute scrotal hematocele:
echogenic with numerous, highly visible echoes that can be seen to float or move in real time
Son appearance of older scrotal hematocele:
low level echoes with fluid-fluid levels or septations
Son findings of scrotal hematoma:
- may be large, causing displacement of testis
- homogenous areas in scrotum
- become more complex with time, developing cystic components
- avascular
- may involve testis or epididymus or they can be contained in scrotal wall
What is epididymo-orchitis?
infection of the epididymus and testis
What does epididymo-orchitis result from?
- spread of lower UTI via spermatic cord**
- mumps
- syphillis
- viruses
- trauma
- chemical causes
What is the most common cause of acute scrotal pain in adults?
epididymo-orchitis
What’s the term for only infection of the epididymus?
epididymitis..spreads to testis in about 20-40% of cases
Orchitis is almost always secondary to _______
epidymitis
Clinical symptoms of epididymo-orchitis
- scrotal pain that increases over 1 or 2 days
- fever
- urethral discharge
Son findings of epididymo-orchitis
- enlarged hypoechoic epididymus
- focal hyperechoic areas may be seen if hemorrhage has occured
- increased blood flow
- enlarged testis
- may be focal or diffuse (affected areas appearing hypoechoic compared to the surrounding tissue
- scrotal wall thickening
- hydroceles
- pyelocele possible
U/S exam for epididymo-orchitis must include:
- image showing both testes so the size and echogenicity can be compared
- image with color box opened wide to show portions of both testes so that the flow between sides can be compared
Describe scrotal hydroceles:
- fluid formation between the visceral and parietal layers of tunica vaginalis
- found along anterolateral aspect of testis
- may be anechoic or contain low level echoes
- complex hydroceles can be associated with severe epididymitis and orchitis (may contain thick septations and echoes)
Describe pyelocele of the scrotum
- occurs when puss fills the space between layers of the tunica vaginalis
- contains internal septations, debris and loculations
Why does torsion occur?
- result of abnormal mobility of the testis within the scrotum
- the testis and epididymis twist within the scrotum, cutting off the vascular supply within the spermatic cord
- blood flow is compromised to the testis, epididymis and the intrascrotal portions of the spermatic cord
Describe flow issues with torsion
- venous flow affected first with occluded veins, causing swelling of the scrotal structures on the affected side
- if torsion continues, the arterial flow is obstructed and testicular ischemia follows
T/F: Torsion is not a surgical emergency?
False, it is
What is the salvage rate if torsion surgery is performed 5-6 hours after onset of pain?
-80-100%
What is the salvage rate for torsion if surgery is performed 6-12 hours after pain onset?
70%
After 12 hours of pain onset, what is the salvage rate for torsion?
20%
What is the most common cause for scrotal pain in adolescents?
torsion, peak age is 14
Clinical symptoms of torsion:
- sudden onset of scrotal pain
- swelling of affected side
- nausea
- vomiting
Son findings of torsion before 4 hours:
may appear normal
Son findings of torsion after 4-6 hours
- testis may become swollen and hypoechoic
- affected side will be avascular
- epididymal head may appear enlarged and may have a decreased echogenicity or heterogeneous texture
- scrotal skin thickening
- reactive hydrocele
Son doppler findings of torsion
- makes diagnostic images of torsion duh
- an absence of perfusion in the symptomatic side with normal perfusion demonstrated in the asymptomatic side is considered diagnostic of torsion
- doppler parameters must be adjusted for optimal detection of a slow flow rate
Describe scrotal cysts:
- benign fluid collections located within the extra testicular structures
- most are extratesticular and are found in the tunica albuginea or epididymus
What are spermatoceles?
- cystic dilatations of the efferent ductules of the epididymis
- always located in the epididymal head
What do spermatocele cysts contain?
proteinaceuos fluid and spermatozoa
What may be seen more often following a vasectomy?
spermatoceles
Son findings of spermatoceles
-may be simple cysts
-may be mulilocular cystic collections
-may contain internal echoes
-
What are epididymal cysts?
- small, clear cysts containing serous fluid
- found anywhere in the epididymis
- asymptomatic and benign but may be palpable
Son findings of epididymal cysts:
- simple fluid filled structures
- thin walls
- posterior enhancement
T/F: U/S cannot reliably differentiate between epididymal cysts and spermatoceles?
True
What is a varicocele?
-abnormal dilatation of the veins of the pampinoform plexus (in spermatic cord)
What are varicoceles caused by?
incompetent venous valves within the spermatic vein
Where are varicoceles more common?
- on the left due to the left spermatic vein emptying into the left renal vein at a steep angle which may inhibit blood flow
- -left renal vein may also become compressed between aorta and the SMA
T/F: Varicoceles are associated with male infertiity?
True, but treatment can increase sperm count up to 53%
Son findings of varicoceles:
- numerous tortuous tubes of varying sizes within the spermatic cord near the epididymal head
- tubes may contain echoes that move
- measure more than 2 mm in diameter
- increase in diameter with valsalva
How does one scan for varicoceles?
- pt. in upright position will enhance the visibility of the varicoceles because the veins become distended
- color and spectral doppler should be used to demonstrate the presence of venous flow and to demonstrate retrograde filling with valsalva
What is scrotal hernia?
bowel, omentum or other structures herniate into the scrotum
Son findings of scrotal hernia?
- peristalsis of bowel seen with real time imaging in the scrotum
- may require cineloop for physician
What is tubular ectasia or the rete testis?
-a benign condition associated with the presence of a spermatocele, epididumal or testicular cyst or other epididymal obstruction on the same side
Where are the rete testis?
at the hilum of the testis where the mediastinum resides
Tubular ectasia is more common over what age?
45
Son findings of tubular ectasia of the rete testis:
- the normal rete testis may not be clearly seen with U/S imaging
- appears as prominent hypoechoic channels near the echogenic mediastinum testis
- avascular nature
Testicular cysts are more common after what age?
40 years
Testicular cysts are associated with
spermatoceles
What are testicular cysts located near?
mediastinum, may be single or multiple in various sizes
T/F: Testicular cysts are incidental findings and require no follow up?
True
Son findings of testicular cysts:
- anechoic
- post. enhancement
- smooth walls
Describe microlithiasis:
- uncommon
- tiny calcifications within testes
- smaller than 3 mm
- usually bilateral
- associated with malignancy
Another name for microlithiasis
scrotal pearls
Son findings of microlithiasis
- multiple bright, nonshadowing foci scattered throughout testis
- may be numerous or few
- not abnormal unless more than 5 seen in one image
What is the most common malignancy in men between ages of 15 and 35?
testicular cancer
Who is more likely to get testicular cancer?
white men
Undescended testicles are how much more likely to develop cancer?
2.5-8 X’s
Clinical findings of testicular cancer:
- painless bump
- testicular enlargement
- mild discomfort
Primary goal of U/S for testicular cancer
determine the mass location and differentiate between cystic and solid composition
Extratesticular masses are usually ____ while intratesticular masses are more likely to be_____.
benign, malignant
Testicular tumors are classified into:
- germ cell
- non germ cell (usually benign)
Germ cell tumors are associated with:
elevated HcG and AFP
Approx. ____ % of testicular tumors are germ cell tumors and are highly malignant
95%
Types of malignant testicular tumors:
- seminomas (most common)
- mixed embryonal cell tumors
- teratocarcinomas
Son findings of seminomas:
- homogenous
- hypoechoic mass
- smooth borders
Son findings of embryonal cell carcinoma:
- heterogenous
- not well circumscribed
Teratomas are ____ in children but _____ in adults
benign, malignant
Son findings of teratomas
- heterogenous with well defined borders
- may contain dense foci with shadowing
What is cryptorchidism?
undescended testicle that cannot be brought into the scrotum with external manipulation
What causes cryptorchidism?
during fetal growth the testis fail to descend into the scrotum from the retroperitoneum by the kidneys
Where may undescended testis be found?
-abdomen, inguinal canal (most common), other ectopic area
What may cryptochidism result in?
- infertility
- malignancy
- torsion
Describe normal prostate?
- chestnut/oval shaped glandular structure
- retroperitoneal
- surrouded by fibrous capsule
- glandular and fibromuscular tissue
- surrounds prox. urethra
Where is the cephalic end (base) of the prostate?
adhered to the base of urinary bladder
What are the 3 lumenal structures that traverse te prostate?
Rt. and Lt. ejaculatory ducts and urethra
What is the verumontanum?
where the ejaculatory ducts and urethra join (looks like Eiffel tower) in trans.
Where is the verumontanum located?
- inferior to bladder
- b/w rectum (posterior) and pubis (anterior)
- seminal vesicles and vas deferens rest cephalad against base of prostate
- seminal ves. post. to bladder, ant. to rectal wall
***Where are seminal vesicles and vas deferens related to the prostate?
rest cephalad against base of prostate
What attaches the prostate to the symphasis pubis?
prostatic ligaments
Seminal vesicles resemble what?
bows, paired
**How are prostate zones determined?
based on function of tissue within zones
***What are the two types of prostate tissue?
- fibromuscular
- glandular
Describe fibromuscular prostate tissue?
mainly smooth muscle, anterior portion of prostate
How much of prostate is made up of glandular tissue?
2/3, but <1 zones
What are the 4 prostate zones?
- peripheral
- central
- transition
- periurethral
Peripheral zone is what percent of glandular tissue?
70%
What portions of the gland are peripheral zone?
posterior, lateral, apical
What zone is most often involve with cancer and prostatis?
Peripheral zone
The central zone makes up what percent of prostate glandular tissue?
-25%
What percent of the prostate zones does the transition zone make up?
5%
What is a site for BPH (benign prostatic hypertrophy)
transition zone
Periurethral zone: is what % of gland?
1% of gland
T/F: U/S is currently used as a screening for prostate?
False
***Patient complaints that are indications for prostate testing?
- hematospermia
- pain on ejaculation
- dysuria
- perineal pain
**What is the most common finding of prostate test?
prostatitis
***What is benign prostatic hypertrophy?
enlarge prostate
***What are symptoms of benign prostatic hypertrophy?
- frequency
- nocturia
- dribbling
- difficulty starting a stream
***What is the sonographic appearance of BPH?
- enlargement of the central gland, more rounded
- may have nodularity-fibro glandular changes
***What is the most common cancer in American men?
Prostate cancer
***What is the second most common male killer cancer?
Prostate cancer
***How may a patient present with prostate cancer?
- bladder outlet obstruction
- abnormal DRE
- bone pain
- weakness
- weight loss
- anemia
- azotemia
***3 tests that suggest a need for biopsy:
- DRE
- PSA
- endorectal
***Son appearance of prostate cancer:
- hypoechoic nodule in peripheral zone
- calcifications are not usually present
- increased PSA
