Scrotum Flashcards
1
Q
Externally, _________ divides into two compartments
A
The Raphe
2
Q
Internally what merges centrally to form the internal scrotal septum?
A
Dartos tunica
3
Q
Internally (scrotal), _________ merges centrally to form internal scrotal septum
A
Dartos Tunica
4
Q
What is the thickness of scrotal wall?
A
2-8 mm
5
Q
What is the scrotum lined by?
A
Tunica vaginalis
6
Q
How many layers of tunica vaginalis? What are they?
A
Two layers
1. Parietal
2. Visceral
7
Q
How much fluid is between each layer o the tunica vaginalis?
A
1-2 ml of fluid between layers normal
8
Q
What is a pouch of loose skin and fascia?
A
Scrotum
9
Q
What does the scrotum contain? 4
A
- Testicles
- Epididymis
- Vas deferents
- Spermatic cord
10
Q
What does the testicles produce?
A
Sperm and testosterone
11
Q
What is the shape of the testicles? What is the dimensions?
A
Oval shape
Length: 3-5cm
Width: 2-4 cm
AP: 3cm
12
Q
Does the testicles decrease in size? Why?
A
They decrease with advance age
13
Q
What is the tunica albuginea? What does it form?
A
- Fibrous layer surrounding testes
- Form the mediastinum posteriorly
14
Q
Invaginations of the tunica albuginea divide the testicles into what?
A
Lobules
15
Q
What does each lobule contain? What are they the site for?
A
- Seminiferous tubule
- Spermatogenesis
16
Q
What is the mediastinum formed by?
A
The converging of the thin septations of the tunica albugenea
17
Q
Where is the mediastinum functions?
A
Forms and supports for testicular vessels and ducts from extending from testes
18
Q
Where is the mediastinum located?
A
Posterior testes
19
Q
Where does the rete testes converge? Where do they join to form?
A
- Converging of seminiferous tubules at the mediastinum
- Join to form efferent ducts
20
Q
What does Rete testes carry?
A
Seminal fluid to the epididymis
21
Q
What is the bare area?
A
Testes tethered to scrotal wall by visceral layer of the tunica vaginalis
22
Q
Where is the point of attachment for the bare are?
A
Posterior
23
Q
What area is not covered by peritoneum and is a small portion of the posterior testis and epididymis?
A
Bare area
24
Q
What is a appendix testes? Does it have a function? Where is it located?
A
- Remnant of the Müllerian duct; no function
- Upper pole of the testes
25
What is the epididymis shaped like?
Comma shaped structure
26
Where is the head and the body of the epididymis located?
Head: superior
Body: Posterolateral
27
What does the tail of the epididymus empties into?
Vas Deferens
28
How long is the epididymus?
6-7 cm length
29
What is the epididymus formed by?
The convergence of the efferent ducts from rete testes
30
What is the dimensions of the epididymus?
Head: 5-12mm
Body: 2-4mm
Tail: 2-5mm
31
What is another name of the head of the epididymus?
Globus major
32
What is the function of the epididymus? 3
1. Conveys sperm to SV (SV are reservoirs for seminal fluid)
2. Stores small quantities of sperm
3. Maturation of sperm
33
What is the appendix epididymis a remnant of? What is it typically seen with?
1. Remnant of mesonephric (wolffian) duct
2. Typically seen with hydrocele
34
What does the spermatic cord connect?
Testes to pelvis/abdomen
35
What does the spermatic cord do?
Suspends testes in scrotum
36
Where does the spermatic cord travel through?
The inguinal canal
37
What does the spermatic cord contain? 5
1. Vas deferens
2. Arteries
3. Pampiniform plexus
4. Lymphatic
5. Nerves
*Ln pav*
38
What is the arterial supply for the scrotum? 3
1. Testicular arteries
2. Deferential arteries
3. Cremasteric arteries
39
Where does the testicular arteries originate and what doe they supply? 2
1. Aorta, anterior origin
2. Supply the testicles
40
Where is the origin of the deferential arteries? What do they supply?
1. Inferior vesical artery
2. Supply epididymus and vas deferens
41
Where is the origin of the cremasteric arteries? And what do they supply?
1. Inferior epigastric artery
2. Supply peri testicular tissue
42
Where does venous drainage happens in the scrotum? Where does each side drain into?
1. Via pampiniform plexus
2. Empties into testicular veins
3. Right drains into the IVC
4. Left drains into the LRV
43
Will we use doppler for scrotal ultrasound?
Yes,
1. Testicular artery- low resistance
2. Cremasteric and deferential - high resistance
44
What is the patient prep for a scrotal ultrasound?
1. Patient in supine position
2. Scrotum supported with towels
3. Penis covered with towel
4. Comfortable room temp, warm gel
45
When palpable masses what must we do? 3
1. Request the patient localize the palpable mass
2. Once localized, request permission to touch the patient and palpate the mass (individual site policies may require a chaperone)
3. If consent given, palpate the region of interest
46
What is the transducer we will use for scrotal ultrasound?
12MHz transducer or higher
47
How do we document the scrotum? What do we assess? 4
Two planes and assess
1. Epididymis
2. Blood flow in testicles
3. Scrotal wall thickness
4. Transverse of both testes together
48
What do we look for during a sagittal scrotal ultrasound?
1. Lateral, mid, medial
2. Epi head/ superior testicle
49
What do we look for during a transverse image of a scrotum?
1. Superior
2. Mid
3. Inferior
50
Why would we look for scrotum on ultrasound? 8
1. Palpable masses
2. Pain
3. Enlarged scrotum
4. Cystic vs solid
5. Torsion
6. Undescended testes
7. Trauma
8. Post orchiectomy
*Pet put pc*
51
What is the normal sonographic appearance of testes? 2 (echo textures)
1. Homogenous
2. Medium levels of echoes (similar to the thyroid)
52
What is the sonographic appearance of the mediastinum for each plane? (sag + trans)
1. Sagittal: hyperechoic line from superior to inferior
2. Transverse: Hyperechoic region medially (3 RT/ 9LT)
53
What is the sonographic appearance of the rete testis? Are they easy to identify
1. Decreased echogenicity at mediastinum or tiny cystic areas
2. Difficult to identify normally
54
What is the sonographic appearance of the epididymis? 2
1. Isoechoic or slightly hyperechoic to the testicle
2. Slightly coarser
55
For scrotal pathology how close to ______% sensitivity in detecting intrascrotal masses
100%
56
For Scrotal pathology, extratesticular masses are what?
Benign
57
For intratesticualr masses scrotal pathology is what?
Malignant
58
What is cryptorchidism? Where is it common?
1. Undescended testicle
2. Higher incidence in premature infants
59
What is the most common Genital urinary abnormality in children?
Cryptorchidism
60
Cryptorchidism typically causes the testes to be affected unilaterally or bilaterally?
Unilateral
61
Majority or cryptorchidism is located where?
80% located in inguinal canal and palpable
62
What is gubernaculum?
The structure that guides and anchors the testis during descent into the scrotal sac
63
What three factors can interrupt the descent of testes?
1. Deficiency of gonadotropin normal stimulation
2. Adhesions or anatomical maldevelopment
3. Idiopathic
64
What are some complications of Undescended testes? 2
1. Infertility
2. 48x risk of testicular cancer
65
What is the treatment of Undescended testes? 2 (adults and children)
1. Orchiopexy (children)
2. Orchiectomy (adults)
66
What is does Undescended testes look like sonographically? 5
1. Oval or elongated mass (most likely in the inguinal canal)
2. Smaller, less echogenic than normal
3. Homogenous
4. Mediastinum difficulty to identify
5. **Large lymph node >>> Mistaken for testicle**
67
What are some testicular congenital anomalies? 3
1. Polyorchidism
2. Anorchia
3. Testicular ectopia
68
What is polyorchidism?
Testicular duplication
69
What is anorchia? Where is it more common?
Absence, more common on left
70
What is testicular ectopia?
Testicular tissue located anywhere along path of descent
71
What is it hydrocele? Where do we usually see it?
1. Collection of fluid between the tunica vaginalis layers (>2mm)
2. Anterolateral scrotum
72
Is hydrocele congenital or acquired?
Both
73
What is the most common cause of painless scrotal swelling?
Hydrocele
74
What is the most common congenital scrotal pathology? When does it normally resolve itself? 2
1. Patent processes vaginalis
2. Usually resolves by 18 months
75
What are acquired scrotal pathology causes? 3
1. Idiopathic (most common)
2. Infection, infarction, neoplasm
3. **Trauma** (25%)
76
Large hydrocele rarely associated with what?
Neoplasms
77
Small hydrocele are seen in ______ of patients with what?
1. 60%
2. Testicular tumours
78
Is a hydrocele malignant or benign?
Benign Pathology
79
What is a hematocele? What does it look like? 4
1. Blood in the scrotal sac
2. Thick scortal wall
3. Anechoic > variable
4. Septations, debris
80
What is a pyocele?
Pus in the scrotal sac
81
What does pyocele look like sonographically? 4
1. Echogenic
2. Septations/ loculation
3. Thick scrotal wall
4. Focal mural calcifications
82
What is a varicocele?
Dilated veins in the pampiniform plexus (>2mm)
83
How does varicoceles happen? Typically on which side?
1. Obstructed venous return
2. Typically occur on the left side
84
What is the primary cause of varicocele? Who is affected? Can we correct it?? Why does it happen?
1. Idiopathic
2. 15-25 years of age
3. Correctable infertility
4. Incompetent valves in spermatic vein
85
What are some secondary causes of varicocele? What should we look for? What is it called sometimes?
1. Pressure on spermatic veins
2. Look for mass
3. “Nutcracker” syndrome
86
What should doing the valsalva do to a varicocele when the patient standing? 2
1. Should increase the size of the veins
2. Primary will return to normal in supine
87
Does the patient position change the appearance of secondary varicoceles?
Does not!
88
How do we demonstrate change in varicocele?
Valsalva
89
What does the varicocele look like sonographically? 3
1. Multiple anechoic structures >2mm
2. At superior pole/ epididymis head
3. Color flow
90
What are hernias? What might they contain 2
1. Inguinal hernias that descend into the scrotum, usually containing omentum or bowel
2. May contain mesentery, fat or bowel
91
What activity is hernias associated with?
Heavy lifting
92
What is trauma to the scrotum?
Direct or straddle injury to the scrotum
93
What are effects of traumas to scrotums? 3
1. Hematoma
2. Hematocele
3. Ruptured testicles
94
Is a ruptured testicles a surgical emergency?
Yes
95
What is the most common cause of a ruptured testicles?
Blunt trauma most common
96
What is torn normally in a ruptured testicle?
Tunica albuginea
97
For ruptured testes ____% of testicles are salvaged with surgery within ___ hours of surgery. Otherwise what will happen?
1. 90%
2. 72 hours
3. Loss of function/ atrophy will occur
98
What is the area that is blacked out?
Median raphe
99
What is this an image of?
The bare area of the testicle
100
What is this an image of?
Accessory Testicle
101
What is this an image of?
Accessory Epididymis
102
What is this an image of?
The testicle in saggital
103
What is this an image of?
Scrotum in transverse
104
Label the image?
E: Epididymis
T: Testicle
105
Label the image?
T: Testicle
E: Epididymis
106
Label the images?
Undescended testes in
Left: 3 year old
Right: Adult
107
What does the H mean?
Hydrocele
108
What does the H mean?
Hydrocele
109
What does the images demonstrate?
Hematocele
110
What does this image demonstrate?
Pyocele
111
What does these images demonstrate?
Varicocele
112
What do these images represent?
Hernias
113
What does these images represent?
Hernias
114
What do these images demonstrate?
Acute Torsion
115
What does these images demonstrate?
Chronic torsion
116
What does these images demonstrate?
Epididymitis
117
What does this image demonstrate?
Epididymitis
118
What does these Images demonstrate? What do we note? 4
Trauma done to the testicles. Notice the:
1. Focal area of altered echogenicity
2. Irregular contour
3. Hematocele
4. Assess flow
119
What is torsion? What are some effects of torsion?
1. Spermatic cord twists
2. Blood supply cut off to testicle
120
Which population is usually afflicted with torsion?
Males <25 Years old
121
If torsion happens what needs to be done?
Surgery within 6 hours
122
If surgery is done within 6 hours in a torsion situation, how much is salvageable?
80-100%
123
What happens to a testicle in torsion after 12 hours?
Complete infarction
124
What are stages of torsion?
1. Acute
2. Subacute
3. Chronic
125
When does acute torsion happen?
within 24 hours
126
When does subacute torsion occur?
1 to 10 days
127
When does chronic torsion happen?
after 10 days
128
What are two types of torsion?
1. Intravaginal
2. Extravaginal
129
When is intravaginal torsion common?
During puberty
130
What is intravaginal torsion?
1. Anomalous suspension of testicle by long stalk of spermatic cord
2. Testis rotates freely within the tunica vaginalis
131
What increases the incidence of intravaginal torsion?
Orchiopexy
132
What is intravaginal torsion also referred to?
Bell clapper deformity
133
Label the images
A: Intravaginal torsion
B: Extravaginal torsion
134
Which population is usually afflicted with extravaginal torsion?
Newborns
135
What is extravaginal torsion?
1. Poor/ absent attachment of testis to scrotal wall
2. Both tunica vaginalis and spermatic cord under torsion as a unit
136
What are some things we see during acute torsion? 5
1. Enlarged testicle/ epididymis
2. Testicle more hypoechoic
3. Scrotal skin thickening
4. Reactive hydrocele
5. Absent arterial flow
*Stear*
137
What does these images demonstrate?
Acute Torsion
138
What is usually seen for the sub acute phase of torsion? 3
1. Testicle enlarged
2. Epididymis
3. Heterogenous
139
What does these images represent?
Sub acute phase
140
What is seen during the chronic stage of torsion? 3
1. Atrophied testicle
2. Heterogeneous
3. Epididymis remains enlarged
141
What does these images demonstrate?
Chronic stage torsion
142
What are some signs and symptoms of torsion? 3
1. Sudden onset extreme pain
2. N and V
3. Symptoms may mimic epididymitis but diminish after 1 to 2 days
143
Where does infection typically originate for the scrotal region? 3
1. Bladder
2. **Urethra**
3. Prostate
144
What is the most common cause of acute scrotal pain?
Epididymitis
145
Epididymitis is what?
An infection/ inflammation of the epididymis
146
What can epididymitis cause?
Infertility
147
What are some symptoms of epididymitis? 4
1. Fever
2. Pain
3. Dysuria
4. Discharge
148
What are some signs of epididymitis? 7
1. Enlarged epididymis
2. Hypoechoic/ heterogenous epididymis
3. Scrotal thickening
4. Possible reactive hydrocele
5. Increased blood flow
6. Possible abscess
7. **IF CHRONIC**: Possible calcification
*his pep*
149
What does this image demonstrate?
epididymitis
150
What is Orchitis?
Inflammation of the testis
151
How common is orchitis? And who is the common population?
1. Very common secondary to epididymitis
2. Most common cause in men <35: chlamydia
152
What are three types of orchitis?
1. Focal
2. Diffuse
3. Chronic
153
What is focal orchitis? 2
1. Hypo, mass like
2. Hyper vascular
154
What does diffuse orchitis look like sonographically?
Overall decrease in echogenicity and enlargement of the testis
155
What does chronic orchitis look like sonographically? 2
1. Hypoechoic, heterogenous
2. Reactive hydrocele
156
What is this an image of?
Focal Orchitis
**It is hypervascular**
157
What is a abscess? 2
1. Complication of epididymo-Orchitis
2. Pyocele or fistula to skin
158
The abscess can rupture through what?
The tunica vaginalis
159
What are scrotal pearls? What is their etiology? Is it mobile?
1. Calcifcations on tunica or within scrotal sac
2. Unknown etiology
3. Mobile
160
What is a spermatocele? 2
1. Retention cyst
2. Dilated epididymal tubules filled with nonviable sperm
161
Are spermatoceles painful?
No
162
How many spermatoceles can one have?
Single/ multiple
163
Who is usually affected by spermatoceles?
Middle aged men
164
What anatomical area is usually affected by spermatocele?
Epididymal head
165
Is spermatoceles palpable?
Yes
166
How does one develop Spermatoceles?
Epididymitis or trauma
167
What does these images demonstrate?
Spermatoceles. Note the:
1. Well defined
2. Anechoic
3. Enhancement
4. Simple, loculated, +/- Echogenic debris
5. 0.2- 9cm
168
Are true cysts asymptomatic or symptomatic? What are they filled with? Where are they found? 3
1. Asymptomatic
2. Serous fluid
3. Epididymis, tunica albuginea, testicle
169
What does these images represent?
True cysts
170
What kindof tumor is Non-germ cell (gonodal stromal), (benign or malignant) How much of testicular tumors does it represent?
1. Majority Benign
2. represents <5% of testicular tumors
171
Who is usually afflicted with Non- Germ Cell (Gonodal stromal)?
20-50 years of age
172
What are two types of non-germ cell (Gonodal stromal)?
1. Leydig cell
2. Sertoli cell
173
What may leydig cell cause?
Gynecomastia
174
What might sertoli cells cause?
Possible gynecomastia and feminization
175
What does this image demonstrate? Why?
Non- germ cell Gonodal stromal
176
Is a adenomatoid tumor benign or malignant? How fast does it grow? Is it symptomatic or asymptomatic? How big is it? Where is it seen? 5
1. Benign
2. Slow growing
3. Asymptomatic
4. Small
5. typically seen in the epididymis
*bass*
177
What is the most common extravesicular tumor?
Adenomatoid tumor
178
What are these images of? How well is it defined? What is the echogenicity? Is this mass solid? Unilateral or bilateral?
Adenomatoid tumors. *note the*
1. Well defined
2. Variable echogenicity
3. Solid masses
4. Unilateral
5. Typically left side
*us wet*
179
What is microlithiasis?
Calcifications within seminiferous tubules
180
What are the benign and malignant ranges for microlithiasis?
1. Benign = <5
2. Malignancy= >5
181
What are some malignant pathologies? 8 (signs+risk factors)
1. Painless scrotal enlargement, hardness of testicles
2. Unilateral, hypoechoic
3. 15-34 years of age
4. originate from germ cells
5. Divides into seminomas and non seminomatous tumors
6. Increased vascularity
7. Normal scrotal wall and epididymis
8. 10% have reactive hydrocele
*duo pin*
182
What is the most common germ cell tumor?
Seminoma
183
What age demographic usually affected by seminoma?
30-40 years of age
184
What is seminoma usually correlated with? 3
1. Undescended testes
2. Normal AFP
3. **Beta HCG may be elevated**
185
Which germ cell tumor is the least aggressive and has the best prognosis?
Seminoma
186
Non-seminomatous germ cell tumors are less or more aggressive then visceral metastases? Who do they affect?
1. More aggressive > visceral metastases
2. Younger patients
187
What does NSGCT stand for?
Non- seminomatous germ cell tumor
188
What is the 2nd most common germ cell tumor?
Embryonal cell tumor
189
Which ages are most affected by Embryonal cell tumors?
Men aged 25-35 years
190
What is the most aggressive type of germ cell tumor?
Embryonal cell tumor
191
What enzymes are correlated with Embryonal cell tumors?
AFP may or may not be elevated
192
What is a yolk sac tumor? Where is it most common
1. Infantile form of embryonal cell tumors
2. Most common GST in infants <2years
193
What is a difference between embryonal cell and yolk sac tumor?
AFP is always elevated for yolk sac, Embryonal cells may or may not be elevated
194
What does this image represent?
Embryonal cell tumors. *Note the*
1. Hypoechoic
2. Mixed echogenicity
3. Poorly defined capsule
195
What is a choriocarcinoma? What is the incidence rate for pulmonary involvement? Who is affected? Is it common?
1. Highly malignant and aggressive tumor
2. High incidence of pulmonary involvement
3. Men aged 20-30 years are affected
4. Uncommon
196
What are some symptoms of choriocarcinoma?
Gynecomastia/ scrotal pain
197
What is HCG look like for choriocarcinoma?
Serum Beta HCG is always elevated
198
What does this image demonstrate?
Choriocarcinoma
199
How frequent is teratoma? How does it affect children and adults?
1. Lowly frequent
2. In children typically benign
3. In adults typically malignant
200
What do we see for teratoma in terms of hormones? what does it suggest?
1. AFP and BHCG may be elevated
2. Suggestive of malignancy
201
What does this image demonstrate? Why?
Teratoma *note the*
1. Cystic/ Solid components
2. Posterior shadowing or enhancement
3. Well defined boarders
202
What is the most common mixed germ cell tumor?
Teratocarcinoma
203
What is the most aggressive, largest heterogenous tumor?
Teratocarcinoma
204
What is the echogenicity of a mixed germ cell tumor? 2
1. Cystic areas
2. Echogenic foci
205
What does this image demonstrate?
Mix cell tumor
206
What is a burned-out tumor?
Echogenic or calcified scar in the testicle that represents regression of a primary testicular tumor (The primary tumor outgrows its blood supply and regresses)
207
What does patients with burned out tumors present with? 3
1. Mets
2. Unknown primary
3. Testicles that are normal on physical exam
208
What is the most common metastatic tumor of the testes?
Lymphoma
209
When is metastatic tumors more prevalent in men?
>50 years
210
What is the most common type of lymphoma?
Non-hodgkin's
211
What is the most common presentation of Lymphoma? 2
1. Painless testicular mass
2. Diffuse enlargement
212
What does this image demonstrate?
Lymphoma. *Note the*
1. Hypoechoic, homogenous
2. Diffuse or focal mass
3. Hyper vascular
213
What is the second most common secondary testicular neoplasm?
Leukemia
214
What is the most common cause of non-lymphomatous metastatic tumor? (Where does it spread from?)
Prostate and lung
215
What are some possible routes of metastatic spread? 4
1. Retrograde venous
2. Hematogenous
3. Retrograde lymphatic
4. Direct tumor invasion
*hi lv*
216
What kind of changes occur in post vasectomy patients? How many are affected?
45% of patients experience epididymal changes
217
Besides epididymal changes what else presents in post vasectomy patients? 5
1. Epididymal enlargement
2. Heterogenous appearance
3. Cyst/ spermatoceles
4. Sperm granuloma
5. Tubular ectasia
*chest*
218
What is tubular ectasia?
Various sized cystic lesions that affect the epididymis and rete testis
219
Should there be colour flow in tubular ectasia?
No
220
Tubular ectasia are bilateral or unilateral? Is it symptomatic or asymptomatic? What is it associated with?
1. Bilateral/ asymmetrical
2. Spermatocele
221
Is there colour flow with tubular ectasia?
No
222
What is tubular ectasia usually mistaken for?
Neoplasm
223
What does this image demonstrate?
Tubular ectasia
224
For a post orchiectomy patient what should we assess for? 4
1. Hematomas
2. Abscesses
3. Recurrent neoplasms
4. Prosthesis
*harp*
