scrotum Flashcards
At __ weeks of gestation female and male embryo appear identical
7-8
•
Testes develop from area near where the ____ develop, and about the same time
•
kidneys
____ month the testes descend through inguinal canal into the scrotum
•
8th – 9th
________ is the condition when 1 or both testes don’t reach the scrotum. Occasionally a testicle may remain undescended and will need to be surgically brought down where it will be sutured into the scrotum.
This procedure is called_______.
Cryptorchidism
ORCHIOPEXY
Between the 3rd and 9th month of pregnancy the testes descend from the____ area (medial to the mesonephros, remember this tissue? It is the second fetal kidney) into the future scrotum. The descend is due to a combination of ______________.
lumbar
growth processes and hormonal influences
The_______ also plays a decisive role in testis descent. When does it develop?
Cranially it has its origin at the testis and inserts in the region of the genital swelling (future scrotum).
At the same time, at the inguinal canal along the lower gubernaculum, an evagination of the peritoneum arises, the vaginal process, on which the testes will slide through the inguinal canal.
gubernaculum testis
IT develops in the 7th week from the lower gubernaculum, after the mesonephros has atrophied.
testicular development at 2 months. label.
- Gubernaculum testis 2. Penis 3. Inguinal canal
- Testis 5. Peritoneal cavity 6. Deferent duct
what is the arrow pointing to?
parietal peritoneal lining. (it pulls the lining down as it descends)
In this diagram, the beginning of the formation of the vaginal process is visible. It enters with the testis into the inguinal canal. Shown in blue is the gubernaculum that becomes increasingly shorter.
Between the____ and ____ month of pregnancy the testes remain near the inguinal canal in order to pass through it. The vaginal process lengthens while the gubernaculum shortens, thereby drawing the testis, the deferent duct and its vessels on both sides downwards
3rd and 7th
In the____ month of pregnancy (but also sometimes only after birth) the testes reach the scrotum. The vaginal process forms now a serous bilaminar structure on the front side of the testis.
9th
serous bilaminar
The parietal layer: lines the scrotal sac The visceral layer: surrounds the testicle
serous memebrane
This type of tissue creates a____ in the scrotum or_____ within the abd. of pleural fluid within the thorax.
scrotum lining – a serous membrane (or serosa) is a smooth membrane consisting of a thin layer of cells which secrete serous fluid.
hydrocele, ascites
process vaginalis
canal created by descent
bare area
no visceral tunica vaginalis (lymphatics, nerves, veins and sperm exit this area)
testes are _____ in fetal life.
retroperitoneal
scrotum
sac of skin continuous w/ the abdomen
•
_____muscles within scrotal wall; controls the contraction of the scrotal skin. The contraction of the skin will drawl the testes closer to the body.
Dartos
causes skin to pucker, regulating temperature. autosomal ( we can’t control it) but can be a problem (caused by nerves, temp) you get a lousy image then on US
the scrotum sac is divided into 2 halves by the ____. ____ divides the scrotum into a rt and lt hemishere
septum
median raphe
what does each hemiscrotum contain?
A testis
An epididymis
A portion of spermatic cord
A vas deferens (ductus deferens) (makes sperm)
what can you see here? why?
Median Raphe
•
Scrotal wall is inflamed but the median raphe is clearly seen separating the two hemiscrotums.
notice the lobules in the testes. what do they contain?
seminiferous tublues (place sperm is made)
what is the testes endocrine function?
what type of cells are found here?
testosterone
Sertoli cells: provide nourishment to the sperm cells
–
Leydig Cells: These cells are in the intestinal space and secrete the male sex hormone testosterone
Cross section of a Seminiferous tubules
what are the testes exocrine functions?
spermatozoa (germ cell) via- Seminiferous tubules
–
spermatogonium cells develop into sperm
–
primitive sperms cells are peripheral
–
immature sperm cells at the lumen
–
once in the lumen sperm travel to the epididymis to mature
what is the tete testes
–
Within the mediastinum still beneath the tunica albuginea
–
Connects seminiferous tubules to epididymis
what does the epididymis do?
what parts does it have?
Store spermatozoa. acts as Transport conduit
Head thickest portion, can be more echogenic than that body
Body is the longest portion
Tail smallest and most inferior
what are teh vas deference aka?
what doe they do?
Ductus Deference
–
The excretory duct of the testis
Continuation of the epididymis
Thin muscular tube which transports sperm from the testis to the prostatic urethra
____ serves as a conduit. contains arteries, veins (network called the pampiniform plexus), nerves, lymph vessels
spermatic cord
the _____ muscle raises and lowers testes from body. It, along with the scrotal wall muscle the dartos help to control the temperature of the testes.
cremaster
what is the out most layer of the testes?
fascia
_____ is a vestigial remnant of the Müllerian duct (paramesonephric duct), present on the upper pole of the testis and attached to the tunica vaginalis. It is present about 90% of the time.
appendix testis
•
This structure is derived from the Wolffian duct (mesonephric duct) as opposed to the appendix testis which is derived from the Müllerian duct remnant.
Appendix testis / appendix epididymis
____ is The hilum of the testis
•
Linear fibrous structure, thicken area of the tunica albuginea (more echogenic fibrous surrounding that holds open the hilum)
•
Each testicle has one
•
Arteries, veins, nerves, lymphatics, and spermatic ducts enter and exit through the hilum
medistinum testes
patient prep
Warm room and warm gel - Prevents dartos and cremaster muscles from contracting
–
Simple instructions
Be relaxed and matter of fact/ nonchalant
Patient will stop listening once you instruct them to remove their clothing from the waist down
–
Give patient privacy
Leave the room
Turn the lights down a little
what’s the difference here?
rt dartos muscle iscontracted, lt not contracted
what do the testes look like on a sonogram?
(similar to thyroid)
medium level echoes
–
homogenous
–
often vessels seen within parenchyma
–
mediastinum is only echogenic area within testes
–
post vasectomy/infection/trauma can alter appearance
•
tubular ectasia
•
calcification
____ is the dilation of the rete testis. Common to see in males the are post vasectomy
tubular ectasia
sonographic appearance of the epididymis
–
Shape: epididymal head can be triangular, crescent, teardrop or round in shape.
–
Echogenicity: usually homogeneous and isoechoic to testicle. Appearance can change after vasectomy. Not uncommon to see cystic structures in the head (head is usually a bit brighter than the rest)
•
Cysts
•
Spermatoceles - little hole happens in epididymis and sperm gets out, the body walls it off and you get little cysts. can’t tell dif b/t this and epididymis cyst you are born with
scanning techniques
Open towel-Covering abdomen
–
Rolled towel-hold penis ventral side up. Pt. can hold this
–
Open towel in a sling- to keep scrotum up and out from between the legs
–
Pt. legs crossed
this will help testes to stay put
–Sheet to cover pt. legs
Some sonographers like to use a rolled up towel placed as a block between the legs to set the testes on. I have found this position inadequate to evaluate the testes thoroughly as the posterior approach is block by the towels.
imaging techniques and Td selection
Linear transducers
8 MHz or higher
Longer foot print is better
Appropriate depth setting
Gain settings
Unaffected side 1st, if appropriate
Do not readjust gain during scan if possible
indications for scrotal eval
Size changes or discrepancy
•Differentiating an intratesticular from an extratesticular palpable mass
•Finding occult neoplasm: known CA elsewhere, suspect testes as primary
•Etiology of acute scrotum: pain, swelling…
•? Varicoceles: dilated pampiniform plexus
•Undescended testes: aka cryptorchidism
•Trauma
•Fertility issues
protocol (long)
(same as renal) Long with measurement
–
Long lateral portion
–
Long medial portion
–
Long head of epididymis with measurement
–
Long body of epididymis with measurement
–
Long tail of the epididymis (typically include with the epididymal body image)
protocol trans
Superior
–
Mid with measurement
–
Inferior
–
Bilateral Transverse
•
Dual screen if needed
–
Epididymal head with measurements
what plane is this?
trans and below
Which images shows the mediastinum? Find the epididymal tail Which images shows the superior part of the testis? Find the median raphe
what plane?
what is this?
Spermatic cord
–
Along inguinal canal
–
Sometimes we need to look at the cord (right over pubic bone)
•
Inguinal hernias
•
Localized pain in this area
what images do you want if the pt has a history of pain/infection?
mass or lump?
History of pain / infection
Testes and all parts of the epididymis must be evaluated
Doppler exam for flow to R/O torsion
–
Mass / Lump
Sonographer must find the mass and determine its origin
Hernias can cause enlarged scrotums
what common findings are there in the epididymis?
spermatoceles and ipdidymal cysts
the below are ____ of a testicular exam
Getting testicle symmetric
Scan through transversely and figure how testicle is laying
Inaccurate measurements
Not in the longest axis
Not symmetric
See the testicles but missing the scrotal pathology
Large spermatocele / epididymal cyst mistaken for hydrocele
Node vs. undescended testicle
(the below is a dirty sperrmatocele, a collection of sperm outside of the epididymis, could be a hemorrhagic hydrocele an abscess.)
pitfalls
Two images have a small air bubble between the transducer and skin can you find them?
what do you see?
this common variant is when One or both testes fail to descend to normal position.
cryptorchidism
this scrotal variant is when there is more than one testicle per hemiscrotum…
polyorchidism
indications for a scrotal exam
–
Pain
–
Enlargement
–
Palpable mass
–
Search for undescended testicle
–
Trauma
–
Male infertility
_____ may be implatned in the case of erctile dysfunction.
erectile implants
which chromosome determines gender?
Y
the testis develop approx the same time and approx the same area as the ____.
kidneys
The term undescended testis is used to describe what phenomena.
when one or both tesis fail to descend
The descend of the testicles into the scrotum is trigger by
a. increased fetal intrabdominal pressure.
b. hormones.
c. the fetus turning into the cephalic position.
d. the scrotum becomes larger.
b
The testes are retroperitoneal, when within the abdomen. Upon there descend through the canal a layer of ______ is pulled through the canal and into to scrotum along with the testes.
The specific term used to describe the pouching of the peritoneum through which the testes travel through is the _____ _____.
pertoneum
processus vaginalis
A =
B =
Another term for scrotal septum is the ____ ____.
Name the AREA within the circle. Note it is not covered by a layer of peritoneum.
tunica vaginalis
tunica albuginea
median raphe
bare area
The condition of an undescended testis is also known as Cryptorchidism. What do you believe the term Crypto means?
hidden or secret
Image A is showing what? Image B is representative of normal.
A patient with this anatomic defect is a risk for what primary testicular problem?
an open processus vaginalis
torsion
What does the term hemiscrotum mean?
Each hemiscrotum contains a testis, epididymis, portion of the spermatic cord and vas deferens. What is the vas deferens?
1/2 of the scrotum
the conduit duct for sperm betwee the tail of the ipididymis and the urethra
- What divides the Rt. hemiscrotum from the Lt. hemiscrotum?
- The testes are both and endocrine and an exocrine gland. True / False
median raphe
true
- Testosterone is produced from the exocrine portion of the testes. True / False
- Spematozoa are produced from the exocrine or endocrine portion of the gland?
false
exocrine
- What are the functions of the epididymis?
- Name the parts of the epididymis.
a.
b.
c.
storage of sperm and transport conduit
head (globu major), body and tail (globus minor)
- The most proximal portion of the epididymis is the _____.
- The testes are divided into lobes by septula. Each lobe contains tubules from which spermatozoa are produced. Name these tubules.
head
seminiferous tubules
- Within the seminiferous tubules are spermatogonium from which sperm cells are derived and two other types of cells. Name these cells.
- Testosterone is produce by which if these cells?
sertoli cells, leydig cells
leydig cells
- A =
- What is the dotted circle is surrounding?
- What is the green circle is surrounding?
retes testis
globus major
body of the eipdidymis
- What portion of the testis is the large arrow pointing to?
- What is the small arrow pointing to?
- What is the most distal portion of the epididymis?
inferior
vas deferens
globus minor
Starting with the seminiferous tubules and ending with the urethra name the path of flow for sperm. Include the retes tesis.
seminiferous tubules, retes testis, eipdidymal head, body, tial, vas deferens, urethra (prostatic portion)
Name the muscle which controls the position of the testes from the body.
- The spermatic cord contains all of the following EXCEPT.
a. arteries / veins / lymphatic vessels
b. vas deferens
c. cremaster muscle
d. head, body and tail of the epididymis
cmuscle
d
- The area of the testicle in which arteries, veins, nerves, lymphatic vessels and spermatic ducts enter and leave the testis is called the _______ testis.
mediastinum testis
Name the muscle within the scrotal wall which when contracted pulls the scrotal skin closer to the testes.
When this happens during an US, what does it do to the image?
dartos muscles
degrades the image, creates shadowing from the currugated folds of scrotal skin
Dilation of the retes testis is not uncommon after this procedure.
What is the name of this condition when seen with US?
vasectomy
tubular ectasia (ectasia = dilation)
What is the shape of the normal testicle?
What are the normal dimensions of the adult testicle?
Define spermatocele.
Name the plexus of veins found within the spermatic cord which drain the testicles of blood.
oval
length 3x5cm aP 2-4cm
a cystic structure containing sperm (viable or dead)
pampiniform plexus
Name the TYPE of transducer which yields the BEST images of the testicles.
Which MHz. range would best be suited for a testicular examination.
a. 2-3 MHz.
b. 4-6 MHz.
c. 7-10 MHz.
linear
c
When preparing a patient for a scrotal examination, through instructions with details will insure the patient is properly prepared for the exam. True / False
By using the sling method, where the scrotum is cradled on a towel draped over the patients thighs, the posterior aspect of the scrotum can be examined. True / False
Having a warm room and gel will help prevent the patients’ scrotum from contracting. True / False
F
T
T
During a examination of the scrotum, both testes are routinely examined. When beginning an exam on an acute scrotum it is advisable to set the gain settings using which testicle?
the unaffected side
Which of the following probes is the better choice when doing a scrotal examination? Why?
a. 8 MHz. linear 4cm footprint
b. 8 MHz. linear 6cm foot print
b - lgr footprint willimage greater portion of the testis
The testes can be thoroughly examined from the anterior surface of the scrotum. True / False
Prior to beginning a scrotal examination, how can the penis be placed to be out of the way?
F
lay the penis uon th ept’s abd and lay a rolled towel across it
List the 2-D testicular images taken during a routine scrotal examination. Assume that the entire testis can be seen in the longitudinal views. Don’t list the epididymal images. Hint: there will be an odd number of images.
long mid w/ measure
long medial
long lateral
trans sup, mid inf
tran bilateral
All of the following are potential reasons for a scrotal US examination EXCEPT.
a. infertility
b. palpable mass
c. pain
d. difficulty urinating
One of the most common mistakes new sonographer make when measuring the testes is to foreshorten them. Why do you think this is?
d
failure to find the longest axis; settline fr the best guess
What is the difference between the following?
Testes
Testis
testes - pleural
testis - singular
What plane was this image taken in?
The asterisk is on which testicle?
trans
right
what plane?
long
This image was taken in the transverse plane. At what level was it taken? Why did you choose this answer?
a. superior
b. mid
c. inferior
b - mediastinum testis
what is the arrow pointing to?
epididymal head
wht is the arrow pointing to?
scrotal wall
What is this image showing, why was it taken?
epididymal head, showing measurement
what is the arrow pointing to?
mediastinum
What is causing this image to appear this way.
dartos muscle contraction, skin of scrotum is corregated
what is this condition?
tubular ectasia
which image was taken in long?
a
Why is this image part of the protocol, what is the image used for?
bilateral testes, shows echogenicity comparison
what is the arrow pointing to?
median raphe
What plane is this image taken in?
Name the anatomy the yellow arrow is pointing to?
Name the specific anatomy the green arrow is pointing to?
trans
mediastinum
epididymal body
The following image shows contraction of the cremaster muscle. True / False
false - dartos muscle
This image was taken from a patient with a history of oligospermia (low sperm count). What is displayed within the circle which could account for this history?
varicocele; dilated pampiniform plexus
What specific anatomy is shown in this image?
What plane was this image taken in?
epiddiymal body
long
what is the arrow pointing to?
epdidymal tail
Name the structure from which the testicular arteries arise.
Name the structures into which each of the testicular veins drain into. Be specific.
aorta
rt to ivc, lt to renal vein
Name this anatomic structure.
Which testis would you use to set your gain setting?
Rt. or Lt.
scrotal wall
lt
