Scrotum Flashcards
role of sonography in evaluating the scrotum
Differentiate between intratesticular and extratesticular masses, Differentiate between cystic and solid masses, Evaluation of suspected testicular torsion, Evaluation of suspected testicular infection
shape of testis
Symmetric, oval shaped glands residing in the scrotum
size of testis
3 to 5 cm x 2 to 4 cm x 3 cm
Testis is divided into _____ conical lobules containing the seminiferous tubules
> 250 to 400
where is sperm created
seminiferous tubules
seminiferous tubules converge at apex of each lobule and anastomose (join) to form _______
rete testis in mediastinum.
Rete testis drains into ______ through efferent ductules
head of epididymis
sonographic appearance of testis
Smooth, medium gray structures with fine echo texture
Protrusion off the upper pole of the testis, located between the testis and the epididymis
appendix testis
size of epididymis
6 to 7 mm
Shape of epididymis
Tubular structure.
epididymis divided into
head, body, and tail
location of epididymis
Superior to upper pole of testis.
epididymis runs ________ to testis
superiorly posterolaterally
epididymis contains 10 to 15 efferent ductules from rete testis, which converge to form _________
single duct in body and tail, known as ductus epididymis.
ductus epididymis becomes _______
vas deferens and continues in spermatic cord
largest portion of epididymis
head
Smaller than the head of epididymis, Can be difficult to see sonographically. and Follows posterolateral aspect of testis from upper to lower pole
body of epididymis
Slightly larger than the body of epididymis and Positioned posterior to lower pole of testis
tail of epididymis
Small protuberance from head of epididymis
appendix epididymis
sonographic appearance of epididymis
Isoechoic or hypoechoic compared with testis, Echo texture coarser than testis
Dense, fibrous tissue that completely covers the testis
tunica albuginea
Posterior aspect of tunica albuginea reflects into testis to form vertical septum known as ________-
mediastinum testis
Multiple septa, or divisions, (known as the __________) are formed from tunica albuginea at mediastinum
septa testis
septa within testis separate it into _______
lobules
Mediastinum supports _______ coursing within testis
vessels and ducts
sonographic appearance of mediastinum testis
Bright, hyperechoic line coursing craniocaudad within testis
Lines the inner walls of scrotum, covering each testis and epididymis.
tunica vaginalis
tunica vaginalis consists of two layers: _______
parietal (inner lining of scrotal wall) and visceral (surrounds testis & epi)
bare area located where
posteriorly
________is the point where the testicle is against the scrotal wall, preventing torsion
bare area
________ travel through bare area
Blood vessels, lymphatics, nerves, spermatic ducts
where do hydroceles form
Between the layers of the tunica vaginalis.
A continuation of the ductus epididymis
vas deferens
vas deferens dilates where
at terminal portion near seminal vesicles, known as the ampulla
Vas deferens joins the duct of seminal vesicles to form _______, which empties into urethra
the ejaculatory duct
Urethra courses from ______ to ________
bladder to end of penis
In men, urethra transports _______ outside body.
both urine and semen
Extends from scrotum through inguinal canal and internal inguinal rings to pelvis.
spermatic cord
spermatic cord consist of
Vas deferens, testicular arteries, venous pampiniform plexus, lymphatics, autonomic nerves, and fiber of cremaster
function of spermatic cord
suspends the testes in the scrotum
Primary source of blood flow to testis
right and left testicular arteries
testicular arteries arise from
abdominal aorta
testicular arteries descend in the retroperitoneum and enter the ______
spermatic cord
testicular arteries course along posterior surface of testis and pierce ________
tunica albuginea
testicular arteries form or give rise to ________
capsular arteries
centripetal arteries course
from testicular surface toward mediastinum along the septa
centrifugal arteries branch further into ________
arterioles and capillaries
capsular arteries give rise to
centripetal arteries
Before reaching the mediastinum, centripetal arteries curve backward forming _______
recurrent rami (centrifugal arteries)
capsular and centrifugal arteries show a _________ waveform
low resistance
__________ Accompany testicular artery within spermatic cord to supply extratesticular structures
cremasteric and deferential
__________ Have anastomoses with testicular artery and may provide some flow to testis
cremasteric and deferential
venous drainage of testis occurs through
veins of pampiniform plexus
Pampiniform plexus exits from _________ and courses in spermatic cord
mediastinum testis
prep for sonographic evaluation of scrotum
none
transducer to use for evaluation of scrotum
High-frequency (8 to 12 MHz) linear-array
Scrotum is often painful & swollen with ________
scrotal trauma
scrotal trauma is often the result of ______
MVA, Athletic injury, Direct trauma to scrotum, Straddle injury
goal of sonography in evaluating a patient with scrotal trauma
Determine if rupture is present.
_____ of testicular ruptures can be saved if surgery is within 72 hours
90%
________ of testicular ruptures can be saved after 72 hours
45%
complication of scrotal trauma include
Hydrocele and hematocele
sonographic appearance of scrotal trauma/rupture
Focal alteration of testicular parenchymal pattern, Interruption of tunica albuginea, Irregular testicular contour, Scrotal wall thickening, Hematocele
sonographic appearance of hematocele
Varies with age
sonographic appearance of acute hematocele
echogenic with numerous, highly visible echoes that can be seen to float or move in real time
sonographic evaluation of hematocele that ages over time
low-level echoes and develop fluid-fluid levels or septations
Heterogeneous areas within scrotum that may be large and cause displacement of the associated testis, may involve testis or epididymis or contained within scrotal wall
hematoma
color doppler can be useful to distinguish areas of hematoma, especially when involving testis, because color doppler will show _____
no flow
Infection of epididymis and testis.
epididymo-orchitis
MOST COMMON CAUSE OF ACUTE SCROTAL PAIN IN ADULTS
epididymo-orchitis
most common cause of epididymo-orchitis
spread of lower urinary tract infection via spermatic cord
other causes of epididymo-orchitis
Mumps, Syphilis, TB, Viral, and Trauma
clinical findings of epididymo-orhitis
Increasing scrotal pain x 1 to 2 days, Pain may be mild to severe, May have fever & urethral discharge
sonographic findings of epididymo-orchitis
Enlarged, hypoechoic gland
If secondary hemorrhage has occurred, epididymis may contain focal hyperechoic areas.
Hyperemic flow confirmed with color Doppler
Scrotal wall thickening
Hydrocele (anechoic or contain low-level echoes)
Complex hydroceles (containing thick septations and low level echoes) may be associated with severe epididymitis and orchitis.
If infection isolated to epididymis: testicle will appear _______
normal
normal
enlarged testis, heterogeneous and slightly hypoechoic
_____ is result of abnormal mobility of testis within scrotum
torsion
MOST COMMON CAUSE OF ACUTE SCROTAL PAIN IN ADOLESCENTS
torsion
most common cause of torsion
bell clapper deformity
with ________, tunica vaginalis completely surrounds testis, epididymis, distal spermatic cord (instead of having the bare area where they are fixed to the scrotal wall), allowing them to move and rotate freely within scrotum.
bell clapper deformity
salvageability rate of torsion within 5-6 hours
80% to 100%
salvageability rate of torsion within 6-12 hours
70%
salvageability rate of torsion after 12 hours hours
20%
with torsion, _________ twist within scrotum, cutting off vascular supply within spermatic cord.
testis and epididymis
Up to _______ of torsion patients have anatomic anomaly on both sides
60%
Undescended testes are _______ than normal testes to be affected by torsion
10 times more likely
with torsion, _______ flow affected first, causing swelling of scrotal structures on affected side
Venous
If torsion continues, arterial flow obstructed and ________
testicular ischemia (inadequate blood supply) follows
peak incidence age of torsion
14
clinical symptoms of torsion
Sudden onset of scrotal pain with swelling on affected side
Severe pain causes nausea and vomiting in many patients
Frequently reported incidences of previous scrotal pain
sonographic findings of torsion
Vary depending on how much time has passed
Early stages may appear normal
After 4 to 6 hours: swollen, hypoechoic testis
After 24 hours: heterogeneous testicle as result of hemorrhage, infarction, and necrosis
Scrotal skin thickening
Hydrocele
ABSENCE OF COLOR DOPPLER
Decreased color doppler flow may be seen when torsion is intermittent
extratesticular cysts consist of
epididymal cysts, spermatoceles, and tunica albuginea cysts
Most scrotal cysts are _______, found in tunica albuginea or epididymis.
extratesticular
clinical findings of extratesticular cysts
Generally asymptomatic. May be palpable
Cystic dilations of efferent ductules in epididymis:
spermatocele
location of spermatocele
Always in epididymal head
_______ may be seen more often following vasectomy
spermatocele
spermatoceles contain
Proteinaceous fluid and spermatozoa
location of epididymal cyst
Can be found ANYWHERE in the epididymis
epididymal cysts contain
serous fluid
Abnormal dilation of veins of pampiniform plexus (located within spermatic cord).
varicocele
varicocele more common on the
left
varicocele associated with
impaired fertility
_________ Caused by incompetent venous valves within spermatic vein
primary varicocele
_________ Caused by increased pressure on spermatic vein which may be result of renal hydronephrosis, abdominal mass, or liver cirrhosis. Abdominal malignancy invading left renal vein may cause varicocele with non-compressible veins
secondary varicoceles
ANY non-compressible varicocele in a man older than 40 should prompt search for ________
retroperitoneal mass
sonographic findings of varicocele
Tortuous tubes of varying sizes within spermatic cord near epididymal head.
Tubes may contain echoes that move with real-time imaging (blood flow)
Varicoceles measure > 2 mm in diameter.
Tend to increase in diameter in response to Valsalva maneuver
a ________ is when Bowel, omentum, or other structures herniate into scrotum.
scrotal hernia
sonographic findings of scrotal hernia
Peristalsis of the bowel, seen with real-time imaging, in the scrotal sac confirms the diagnosis of a scrotal hernia.
If peristalsis not seen, air-filled loops of bowel may be present showing a dirty acoustic shadow
MOST COMMON CAUSE OF PAINLESS SCROTAL SWELLING
hydrocele
hydroceles contain
serous fluid
hydroceles may be idiopathic (cause unknown), but commonly associated with ________
epididymo-orchitis and torsion
sonographic findings of hydrocele
Fluid filled collection located outside the anterolateral aspect of testis
Anechoic
May contain low-level echoes
Collection of pus.
pyocele
________ Occur with untreated infection or when an abscess ruptures into space between layers of tunica vaginalis
pyoceles
pyoceles are indistinguishable from ______
hematoceles
sonographic findings of pyoceles
Fluid collection containing internal echoes
Thickened septations
Loculations
Collection of blood associated with trauma, surgery, neoplasms, or torsion.
hematocele
sonographic findings of hematocele
Fluid collection containing internal echoes
Thickened septations
Loculations
________ Occur as chronic inflammatory reaction to leakage of sperm.
spermatic granuloma
________ Most frequently seen in patients with history of vasectomy
spermatic granuloma
Most frequently seen in patients with history of vasectomy
spermatic granuloma
Sperm granuloma may be located ________
anywhere within epididymis or vas deferens
spermatic granulomas Can NOT be reliably differentiated from ________
epididymal tumors
sonographic findings of spermatic granuloma
Well defined, solid mass
May be hypoechoic or isoechoic to epididymis
Often heterogeneous
Increased vascularity may be seen
tubular ectasia benign or malignant
benign
__________ is Associated with presence of a spermatocele, epididymal, or testicular cyst or other epididymal obstruction on same side as dilated tubules
tubular ectasia of the rete testis
sonographic findings of tubular ectasia of the rete testis
Tiny tubular structures near mediastinum
Prominent hypoechoic channels near echogenic mediastinum
Avascular (no color Doppler seen)
testicular cysts are more common in men _______
over 40 years old
testicular cysts associated with
extratesticular spermatoceles
testicular cysts located
near mediastinum
sonographic findings of testicular cysts
characteristics of a cyst
Tiny calcifications in the testis
microlithiasis
characteristics of microlithiasis
Smaller < 3 mm.
Usually bilateral condition
Reported to have association with testicular malignancy; exact nature unknown
testicular cancer prognosis
one of most curable forms of cancer
testicular cancer more common in whom
caucasian men
testicular cancer occurs most frequently between ages
20 and 34
extratesticular masses are usually
benign
intratesticular masses are usually
malignant
clinical findings of testicular cancer
Painless lump
Testicular enlargement
Vague discomfort in scrotum
classification of testicular mass is either
germ cell or non germ cell
germ cell tumors are associated with elevated levels of
human chorionic gonadotropin and alphafetoprotein
germ cell tumors account for ______ of all testicular tumors
95%
germ cell tumors are highly
malignant
most common germ cell tumor
seminoma
types of germ cell tumors
Seminoma, Mixed embryonal cell, Teratocarcinoma, Yolk sac, Choriocarcinoma, Teratoma
non germ cell tumors are generally
benign
Most common testicular cancer
Seminoma
sonographic findings of seminoma
Focal, hypoechoic masses, Homogeneous, Smooth border
sonographic findings of embryonal cell tumors
More aggressive than seminoma, Heterogeneous, Less well-circumscribed, Areas of calcification, hemorrhage, fibrosis, Cystic components
sonographic findings of teratoma
Heterogeneous, Well-defined borders, May show dense foci that produce acoustic shadowing
sonographic findings of choriocarcinoma
Varies due to mixed cell types, Appearance is determined by predominant cell type present, Irregular borders
how common are mets to the testicles
rare, usually occurring later in life
Metastasis to testicle is ______, with multiple lesions found.
bilateral
with mets, the primary tumor may originate from
Prostate or kidneys; less common sites include lung, pancreas, bladder, colon, thyroid, or melanoma
sonographic findings of metastasis to the testicles
Solid hypoechoic mass, Hyperechoic, Mixture of both
Most common bilateral secondary testicular neoplasm affecting men > 60 years
malignant lymphoma
Involvement of testicle is 2nd most common secondary testicular neoplasm of __________. Most often found in children
leukemia
cryptorchidism aka
undescended testicle
During fetal growth, testes first appear in ________
retroperitoneum near kidneys
Testes should descend into scrotum from inguinal canal ______
shortly before birth or early in neonatal period
cryptorchidism more common in whom
premature babies
location of undescended testis may be
in abdomen, inguinal canal or other ectopic location
treatment for cryptorchidism
Orchiopexy: testis is pulled down into scrotum and fixed to scrotal wall
sonographic findings of cryptorchidism
Undescended testis: smaller and less echogenic than normal testis
Usually oval with homogeneous texture
Mediastinum rarely seen
with ________ Ectopic testicle cannot be manipulated into correct path of descent.
testicular ectopia
Most common site for ectopic testicle to rest is ________.
superficial inguinal pouch
anorchia more common on
left side
definitive diagnosis of anorchia depends on
surgical diagnosis
causes of anorchia
Intrauterine testicular torsion or other forms of decreased vascular supply to testicle in utero
Testicular Duplication
Polyorchidism
polyorchidism more common on
left side
Increased incidence of ________ with polyorchidism
malignancy, cryptorchidism, inguinal hernia, torsion
