Scrotum Flashcards by Grace Phillips

pouch of loose skin and fascia continous with abdomen

scrotum

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divides scrotum into 2 compartments

midline raphe

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forms internal scrotal septum

dartos tunica

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thickness of scrotal wall

2-8 mm

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lining of scrotal sac

tunica vaginalis (visceral, parietal)

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normal amount of fluid between layers

1-2 mL

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paired reproductive organs

testes

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function of testicles

produce sperm and testosterone

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fibrous layer surrounding each testicle

tunica albuginea

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tunica albuginea forms ___ posteriorly

mediastinum

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invagination of tunica albuginea creates

lobules

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number of lobules per testicle

250-400

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lobules contain

seminiferous tubules

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seminiferous tubules are the site of

spermatogenesis

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convergence of thin septations of tunica albuginea

mediastinum

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mediastinum is located

posterior testes

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convergence of ductules at mediastinum

rete teste

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rete teste forms

efferent ducts

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tubules within mediastinum

rete teste

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function of rete teste

carry seminal fluid to epididymis

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area not covered by peritoneum, small portion of posterior testes and epi

bare area

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rete teste is tethered to what by what

scrotal wall, by visceral tunica vaginalis

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mullerian duct remnant

appendix testis

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appendix testis usually located

on UP

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paramesonephric duct

mullerian duct

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mullerian duct

paramesonephric duct

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epi head is located

superior to testicle

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epi body is located

posterolateral to testes

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epi tail is located

inferior to testicle

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epi tail empties into

vas deferens

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length of epididymis

6-7 cm

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epi head aka

globus major

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epi tail aka

globus minor

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epididymis function

conveys sperm to seminal vesicles, storage and maturation of sperm

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remnant of mesonephric duct

appendix epididymis

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mesonephric duct

Wolfian duct

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Wolfian duct

mesonephric duct

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seminal vesicles function

reservoir for seminal fluid

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connects testes to pelvis and adbomen

spermatic cord

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suspends testes in scrotum

spermatic cord

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travels in inguinal canal

spermatic cord

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spermatic cord contains

vas deferens, testicular arteries, venous pampiniform plexus, lymphatics, nerves

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right testicular vein drains into

IVC

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left testicular vein drains into

left renal vein

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waveform of testicular artery

low res

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waveform of cremasteric & deferential arteries

high res

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indications for scrotal exam

palpable mass, swelling, pain, cyst vs solid mass, torsion

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echogenicity of testes

homogeneous, medium level echoes, similar to thyroid

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echogenicity of testes ___ with age

increases

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hyperechoic band from SUP to INF pole in SAG

mediastinum

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hyperechoic mass at 3 o’clock in right testicle, 9 o’clock in left testicle

mediastinum

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decreased echogenicity at mediastinum of tiny cystic structures

rete teste

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isoechoic or slightly hyperechoic to testicle

epididymis

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coarse echotexture

epididymis

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undescended testicle

cryptorchidism

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failure of testicles to descend to normal position

cryptorchidism

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higher incidence of cryptorchidism in

premature infants

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most common GU abn in children

cryptorchidism

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cryptorchidism is usually

unilateral

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structure that guides and anchors testis during descent into scrotal sac

gubernaculum

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causes of cryptorchidism

deficiency of gonadotropin hormonal stimulation in utero, adhesions, anatomic maldevelopments, idiopathic

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complete descent of testis is needed for

full maturation, fertility

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cryptorchidism complications

infertility, testicular cancer

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rate of testicular cancer in pt with cryptorchidism

48 X

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testicular cancer can occur in _____ with cryptorchidism

BOTH testes

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surgical repair of cryptorchidism

orchiopexy

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removal of testicle

orchiectomy

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cryptorchidism fixed under 2 yrs old will remain

fertile

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cryptorchidism fixed after 2 yrs old will be

infertile

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U/S appearance of ectopic testis

smaller, less echogenic, homogeneous, mediastinum difficult to id

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ectopic testis can be mistaken for

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testicular duplication

polyorchidism

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supernumary testis

polyorchidism

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most common form of polyorchidism

unilateral, in scrotum ( 2 testis in 1 sac)

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absence of testicle

anorchia

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anorchia is more common on which side

left side

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testicular ectopia can occur

anywhere along path of descent

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most common cause of painless scrotal swelling

hydrocele

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collection of fluid between tunica vaginalis layers > 2 mm

hydrocele

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hydrocele occur usually

anterolateral potion of scrotum

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congenital cause of hydrocele

patent processus vaginalis

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congenital hydrocele occurs in

young children/babies usually resolves 18-24 months

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most common cause of hydrocele

idiopathic, acquired

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acquired hydrocele

idiopathic

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acquired hydrocele can be due to

infarction, neoplasm, trauma, inflammation,

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large hydrocele is usually associated with

benign findings

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small hydrocele is usually associated with

malignant neoplasms - 60 %

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hydroceles may contain

septations, debris, calcifications - scrotal pearls

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blood in scrotal sac

hematocele

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hematocele can be due to

trauma, sx, neoplasm, torsion

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clinical presentation of hematocele may mimic

epididymitis, torsion

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acute hematocele on U/S

scrotal wall thickening, anechoic thickening

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chronic hematocele on U/S

sepatations, debris

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pus in scrotal sac

pyocele

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cause of pyocele

abscess rupture into tunica vaginalis potential space

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U/S appearance of pyocele

echogenic collections, sepatations/loculations, thick scrotal wall, focal mural calcs

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abnormal dilated veins of pampiniform plexus

varicocele

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Nutcracker syndrome

LRV passes under SMA which compress it, blocking drainage of spermatic vein

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size of varicocele

> 2 mm

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varicocele is due to

obstructed venous return

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varicoceles typically occur on

left side

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varicoceles typically occur on left because

increased length of left testicular vein, crosses over aorta

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primary varicocele

idiopathic

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primary varicocele age group

15-25

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most common cause of correctible infertility

primary varicocele

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primary varicocele due to

incompetent valves in internal spermatic vein

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cause of secondary varicocele

increased pressure on the spermatic vein

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effect of Valsalva on varicocele

increase size of vein, increased or reversed flow

primary varicocele will ___ in supine

return to normal

valsalva will NOT change appearance of

secondary varicocele

varicocele size

> 2 mm

location of varicocele

prox to UP, use colour

inguinal hernia that descends into scrotum

scrotal hernia

scrotal hernia contains

omentum, bowel

scrotal hernia associated with

heavy lifting

S/S of scrotal hernia

enlargement, pain, blood in stool

U/S of scrotal hernia

mass outside testicle, echogenic or anechoic, peristalsis if not incarcerated

scrotal trauma is due to

direct injury, straddle fall

scrotal trauma can cause

hematoma, hematocele, ruptured testicle

ruptured testicle surgical repair

repair tunica, remove testicle

tunica albuginea tear

ruptured testicle

most common cause of ruptured testicle

blunt trauma

90% of testicular tissue can be salvaged within

72 hrs

if ruptured testicle not repaired

loss of function, atrophy

U/S features of ruptured testicle

focal areas of altered echogenicity, irregular capsule/contour, hematocele,

spermatic cord twists, cutting off blood supply to testicle

torsion

weakening in mesenteric attachement from spermatic cord to testicle

torsion

testicular torsion is common in males

< 25 yrs

surgery done < 6 hrs after torsion

80-100 % saved

complete infarct after

12 hrs

acute torsion

within 24 hrs

subacute torsion

24 hrs - 10 days

chronic torsion

> 10 days

two types of torsion

extra-vaginal, intra-vaginal (Bell- Clappers)

extra-vaginal torsion

at level of external inguinal ring

extra-vaginal torsion occurs in

neonates

intra-vaginal torsion

Bell-Clapper’s deformity

intra-vaginal torsion occurs in

adolescents, young adults

more common type of torsion

intra-vaginal

Bell Clapper’s deformity

intra-vaginal torsion

extra-vaginal torsion due to

poor/absent attachment of testis to scrotal wall

in extra-vaginal torsion which things twist?

both tunica vaginalis and spermatic cord twist together

U/S of acute torsion

enlarged testicle + epididymis, hypoechoic, scrotal skin thickening, reactive hydrocele, no flow

U/S of subacute torsion

enlarged but heterogeneous

U/S of chronic torsion

atrophied, heterogeneous, hydrocele

in all stages of torsion, the ____ always remains enlarged

epididymis

torsion S/S may mimic

epididymitis

symptoms of torsion will diminish because

tissue is dead

symptoms of epididymitis will persist because

living tissue ongoing infection

inflammation/infection of epididymis

epididymitis

origin of epididymitis

bladder, urethra, prostate

most common origin of epididymitis

urethra

most common cause of acute scrotal pain and tenderness in adults

epididymitis

epididymitis can cause

infertility

epididymitis is typically

unilateral

painful urination

dysuria

U/S of epididymitis

thick, enlarged epididymitis, hypoechoic, hetergeneous, scrotal thickening, reactive hydrocele, increased flow compared to contralateral side, abscess

if untreated epididymitis can lead to

spread to testicle -> epididymo-orchitis

inflammation of testis

orchitis

orchitis can be

focal or diffuse

most common cause of orchitis in men < 35

chlamydia

orchitis is typically secondary to

epididymitis

orchitis may appear like a

neoplasm

U/S appearance of orchitis

focal= hypo area, enlarged epi, increased blood flow,
diffuse = decreased echogenicity, enlarged testicle, 
chronic = hypo, hetero, +/- hydrocele

common result of untreated epididymo-orchitis

abscess

testicular abscess symptoms

pain, fever, swollen scrotum

testicular abscess rupture

fistula to skin

testicular abscess associated with

diabetes, mumps, influenza

abcess flow will look like

increased flow in periphery

calcifications floating on tunica or within scrotal sac

scrotal pearls

scrotal pearls are

mobile

retention cyst

spermatocele

dilated epididymal tubules

spermatocele

spermatocele is filled with

non-viable sperm

spermatocele can result from

trauma, epidiymitis

spermatocele typically located

at epi head

spermatocele can

displace testicle

spermatoceles are common in

middle aged men

spermatocele S/S

painless scrotal swelling

pt with spermatocele present with

palpable lump

U/S of spermatocele

well-defined, anechoic mass with post enhancement, simple, loculated, septated, echogenic debris

true cysts are

extremely rare

true cysts are

aymptomatic

what 2 things CANNOT be differentiated sonographically

spermatocele and true cyst

true cyst in epi are

uncommon

true cyst in tunica albuginea are

rare

10 % of true cysts are found in

less than 5% of testicular tumours are

non-germ cell neoplasm

occur in men 20-50 yrs

non-germ cell neoplasm

non-germ cell neoplasms include

Sertoli, Leydig cell tumours

S/S of Sertoli, Leydig cell tumours

gynecomastia, feminization

U/S appearance of Sertoli, Leydig cell tumours

hypoechoic area within testicle

most common extratesticular tumour

adenomatoid tumour

neoplams typically in epididymis

adenomatoid tumour

characteristic of adenomatoid tumour

slow-growing, asymptomatic, small

U/S of adenomatoid tumour

well-defined, variable echogenicity, solid, unilateral, usually LEFT side

adenomatoid tumours usually occur on

LEFT side

calcifications in seminiferous tubules

microlithiasis

5 or fewer microcalcs

isolated microlithiasis

isolated microlithiasis is associated with

benign conditions

isolated microlithiasis can be caused by

inflammatory, granulomatous, vascular processes

greater than 5 microcalcs is associated with

malignant neoplasm development

microlithiasis has no

posterior shadowing

presentation of malignant pathologies

painless scrotal enlargement, hardness of testicle

malignant pathologies are usually

unilateral, hypoechoic

most common cause of death of men 15-34 yrs

testicular neoplasm

testicular neoplasms originate from

germ cell

testicular neoplasms are divided into

seminomas, non-seminomatous tumours

__% of testicular neoplasms have

10%, small reactive hydrocele

with malignant neoplasm, scrotal was and epi will be

normal thickness, normal

most common germ cell tumour

seminoma

seminomas occur in which age group

30-40 yrs

seminoma is associated with

undescended testicle (cryptorchidism)

least aggressive, best prognosis

seminoma

seminoma has ___ AFP

normal

seminoma has ___ beta hCG

may be elevated

U/S features of seminoma

solid, homogeneous, hypo, scattered hyper areas, microlithiasis, pseudocapsule

NSGCT

non-seminomatous germ cell tumour (category)

NSGCT affects

younger pts

more aggressive, visceral mets

NSGCT

NSGCT includes

embryonal cell CA, chorioCA, teratoma, yolk sac tumour, mixed germ cell tumour

2nd most common testicular tumour

embryonal cell CA

embryonal cell CA occurs in

25-35 yrs

embryonal cell CA frequently occur in combo with

other tumours

most aggressive tumour

embryonal cell CA

embryonal cell CA has mets/invasion

in tunica albuginea

embryonal cell CA _____ AFP

may or may not be elevated

U/S of embryonal cell CA

hypo mass, hyper areas, cystic areas, poorly defined, irregular

infantile form of embryonal cell CA

yolk sac tumour

AFP ALWAYS elevated in

yolk sac tumour

sreum beta hCG ALWAYS elevated in

choriocarcinoma

highly malignant and aggressive test. tumour

choriocarcinoma

choriocarcinoma occurs in

20-30 yrs

high incidence of pulmonary involvement

choriocarcinoma

poor prognosis

choriocarcinoma

present with gynecomastia, scrotal pain

choriocarcinoma

U/S of choriocarcinoma

small mass, mixed echogen., irregular borders, mixed components

rare scrotal malignancy

teratoma

benign in children, malignant in adults

teratoma

AFP, beta hCG levels in teratoma

may be elevated (esp if malignant)

U/S of teratoma

cystic + solid components, post. shadow + enhancement, defined borders, calcs

most common type is teratocarcinoma

mixed germ cell

teratocarcinoma contains

teratoma + embryonal ca cells

largest of all testicular tumours

teratocarcinoma

heterogeneous mass with cystic areas and echogenic foci

teratocarcinoma

burned out tumour

echogenic/calcified scar in testicle

burned out tumour represents

regression of a primary testicular tumour. tumour outgrows blood supply, regresses

most common mets to teste

lymphoma

lymphoma occurs in men

> 50 yrs

most common type of lymphoma

non-Hodgkins

presentation of testicular lymphoma

painless testicular mass, OR diffuse enlargement of testicle (most common)

sono. appearance of testicular lymphoma

hypo, homogeneous, increased vascularity, diffuse or focal

kidney appearance with lymphoma

diffusely enlarged, hypo

second most common testicular neoplasm

leukemia,

2 most common non-lymphomatous mets to testicle

prostate, lung

4 routes of mets spread to testes

retrograde venous, hematogenous, lymphatic, direct invasion

post vasectomy changes occur in

epididymal changes

post vasectomy epididymal changes

enlargement, heterogeneous, cysts/spermatocele, sperm granulomas, tubular ectasia

tubular ectasia involves

rete testis or epi

tubular ectasia occurs in

mediastinum + epi

tubular ectasia will have ___ flow

NO flow

tubular ectasia often associated with

spermatocele

use colour to differentiate between

tubular ectasia , varicocele

tubular ectasia is frequently

bilateral, asymmetrical

post orchiectomy assessment

scrotal space - hematomas, abcess, recurrent neoplsm, prosthesis

innermost layer surrounding testis

tunica albuginea

has visceral and parietal layers

tunica albuginea

outermost layer surrounding testis

tunica vaginalis

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Scrotum Flashcards

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