Scrotal Pathology Flashcards
What is testicular rupture?
Disruption to the tunica albuginea caused by trauma.
What are the US appearances of testicular trauma?
Focal change to testicle parenchymal pattern (haemorrhage or infarction)
Interruption of tunica albuginea
Irregular testicular contour
Scrotal wall thickening
Disruption of blood flow along testicle surface
What are some complications of testicular trauma?
Hydrocele and haematocele
Epididymitis
Torsion
What is testicular fracture?
Discontinuity of the normal testicular parenchyma (may have disruption of tunica albuginea)
What are the US appearances of a haematocele (two stages)?
Acute - echogenic fluid with highly visible echoes that move
Old - low-level echoes and fluid levels/septations. More complex and develop cystic components.
What do haematoceles develop from?
Bleeding/rupture of the pampiniform plexus or other extratesticular structures
What are the two causes of torsion?
Absence of gubernaculum leads to twisting of the testicular within the tunica vaginalis (bell-clapper deformity) or outside of the tunica vaginalis (perinatal torsion)
What are the S+S of testicular torsion?
Sudden onset of pain which can cause nausea and vomiting
Swelling on affected side
Who are the patients most likely to get torsion?
Adolescents (peak age 14yo)
Undescended testicles
What are the US appearances of very early torsion?
Usually normal grey-scale appearance. No colour flow.
What are the US appearances of torsion of 4-6 hours?
Swollen and hypoechoic testicle. Lobes of testes become well-defined from interstitial and septal oedema. No colour flow.
What are the US appearances of torsion of 24 hours?
Heterogenous testicle from haemorrhage, necrosis, infarction, vascular congestion. No colour flow.
What are other associated findings of torsion?
Testicular knot - twisted spermatic cord immediately superior to testis displays whirlpool sign with CD.
Scrotal skin thickening
Reactive hydrocele
Epididymal head enlargement and decreased echogenicity
What are some of the imaging appearances post spontaneous de-torsion, depending on the length of time since resolution?
Intratesticular flow may be minimal or increased. Extratesticular flow increased.
What pathology produces similar S+S to testicular torsion?
Torsion of the appendix testis or appendix epididymis.
What are the US appearances of testicular or epididymal appendix torsion?
Small, hypoechoic mass between epi head and superior testis.
Increased flow around the mass.
What is epididymo-orchitis?
Infection of epididymis and testes
What causes epididymo-orchitis?
Spread of UTI down spermatic cord.
Viruses, syphilis, tuberculosis, trauma.
What are the signs and symptoms of epididymo-orchitis?
Scrotal pain increasing over 1-2 days
Fever
Urethral discharge
What are the US appearances of epididymitis?
Enlarged, hypoechoic epididymis
Focal hyperechoic areas (haemorrhage)
Hyperaemia
Increased flow velocity and low-resistance waveform
What are the US appearances of orchitis?
Enlarged testis
Focal - affected areas hypoechoic
Diffuse - whole testis hypoechoic
What is the most helpful imaging tool to differentiate between torsion and infection?
Colour Doppler
What are the US appearances of testicular infarction?
Decreased or absent flow
High resistance flow with little to no diastolic flow (reversed end diastolic indicates threatened infarction)
Focal - no flow in affected areas and heterogenous parenchyma
What are spermatoceles?
Dilation of the efferent ducts of the epididymis. Contain spermatozoa.
What are some findings that may suggest a spermatocele over a epididymal cyst?
Spermatocele always in epi head
Contain internal echoes and septa
More common in patients with vasectomy
How do you tell a large tunica albugenia cyst from a hydrocele?
Hydrocele will not distort the testicle.
Where are the three areas you can get benign extratesticular cysts?
Epididymis, tunica albuginea, and between layers of the tunica vaginalis.
What are the two types of causes of varicoceles?
Primary - venous valve incompetence
Secondary - masses, hydronephrosis, cirrhosis, nutcracker syndrome, retroperitoneal mass.
What are the US appearances of a varicocele?
Numerous tortuous tubes within spermatic cord
Measure >2mm diameter
Increase in size with valsalva
Retrograde fill with CD and valsalva
How can we differentiate between a tumour vs. a scrotal abscess?
Clinical symptoms
Interval change
What are the US appearances of an intratesticular haematoma (two stages)?
Acute - isoechoic or heterogenous compared to parenchyma
Chronic - hypoechoic or anechoic
What is a physical sign unique to torsion of the epididymal or testicular appendix?
Blue discolouration of the skin
What other pathologies are hydroceles associated with?
Epididymo-orchitis, torsion
What causes a pyocele?
Untreated infection, abscess rupture into the space
What are some events/pathologies that cause of a haematocele?
Trauma, surgery, neoplasms, torsion
What are the US appearances of a hydrocele?
anechoic (or low-level echoes) excess fluid on the anterolateral side of testicle.
What are the US appearances of a pyocele/haematocele?
internal echoes, thickened septations, loculations.
Air within space indicates abscess (abscess can occur without air)
What is a sperm granuloma and where are they located?
Chronic inflammatory reaction to extravasation of spermatozoa.
Located anywhere in epididymis or vas deferens.
What are the US appearances of sperm granuloma?
Well-defined, heterogenous, solid mass that’s hypo or isoechoic to epi.
Calcs not generally present.
Increased flow when inflammation present.
What is tubular ectasia and where is it located?
Dilation of the rete testes. Located in the rete testes (mediastinum of the testicle).
What causes tubular ectasia?
Anything that may obstruct the movement of sperm from the testes to the epididymis.
What are the US appearances of tubular ectasia?
Prominent hypoechoic channels near the mediastinum.
Avascular.
What other pathology may tubular ectasia mimic? How can you differentiate between the two?
Intratesticular varicocele. Use CD with valsalva - tubular ectasia will not fill with colour.
What is microlithiasis and what US criteria must be seen to make this diagnosis?
Tiny calcs throughout the testicles.
Calcs must be <3mm each and there must be more than ≥5 calcs per image.
What congenital abnormalities/pathologies is microlithiasis associated with?
Cryptorchidism, infertility, varicoceles, testicular atrophy.
What are the US appearances of intratesticular varicocele?
Hypoechoic tubes passing from mediastinum to parenchyma.
What anatomical abnormality increases the likelihood of testicular cancer?
Cryptorchidism.
What are the S+S of testicular cancer?
Painless lump
Testicular enlargement
Vague scrotal discomfort
What are the US appearances of a seminoma?
Hypoechoic
Smooth, well-defined walls
Usually no calcs
What are the US appearances of a teratoma?
Complex (solid + cystic)
Well-defined borders
Dense foci that produce shadowing
What are the US appearances of a embryonal cell carcinoma?
Hypoechoic
Calcs
Irregular borders
May contain cystic areas
What are the US appearances of a choriocarcinoma?
Irregular borders
Complex lesion
Focal necrosis and calcs
What are the US appearances of mets to the testes?
Solid hypoechoic lesion (uncommon but can appear hyperechoic or heterogenous)
What are the US appearances of testicular lymphoma and leukaemia?
Enlarged testes
Diffuse or focal areas of decreased echogenicity
Hypervascularity
What are the US appearances of chronic lymphocytic leukaemia?
Well-circumscribed
Anechoic
Posterior enhancement
What are three different anatomical anomalies that may arise in relation to the testes?
Cryptorchidism
Anorchia
Polyorchidism
What are the complications of cryptorchidism?
Infertility (higher temperatures inhibiting spermatogenesis)
Higher risk of cancer and torsion
