Session 4 - Group Work

Question 1

Which structure lies on the posterolateral border of the tests?

Answer 1

Epididymis

Question 2

What do the seminiferous tubules anastomose to form posteriorly?

Answer 2

Rete testis

Question 3

A fluid layer in the cavity of the ——— allows the testis to move
freely in the scrotum.

Answer 3

tunica vaginalis

Question 4

Where is the origin of the testicular arteries?

Answer 4

Aorta, just inferior to the renal vessels

Question 5

The testicular veins arise from the ______________ plexus and drain into the
_____________ on the right and the ____________ on the left.

Answer 5

pampiniform, IVC, left renal vein

Question 6

How may the cremasteric reflex be evoked and what does it demonstrate?

Answer 6

Stroking the superior part medial thigh evokes elevation of the testis on that side. This part of
the thigh is innervated by the ilioinguinal nerve (L1); the genital branch of the genitofemoral
nerve (L1, L2) innervates the cremaster muscle. Hence, a spinal reflex arc is demonstrated.

Question 7

Which smooth muscle layer causes the scrotal skin to wrinkle when exposed to cold temperatures?

Answer 7

Dartos

Question 8

Discriminate between the lymphatic drainage of the scrotum and that of the testes

Answer 8

The scrotal skin (fascia and tunica vaginalis) drains to the superficial inguinal lymph nodes whereas lymphatic drainage of the testis is via the spermatic cord to the para-aortic glands at the transpyloric plane, L1 (hence, upper abdomen must be palpated). Further spread may be to mediastinal and cervical nodes.

Question 9

Explain why spread of malignancy from the testis to the cervical nodes of the neck is not uncommon?

Answer 9

Lymphatic drainage to para-aortic nodes, which anastomose with intra-thoracic and in turn cervical lymph nodes

Question 10

The efferent ductules transmit sperm from the —– to the ——–

Answer 10

Rete testis, head of the epidiymis

Question 11

Describe the course of the vas deferens

Answer 11

Tail of epididymis, inguinal canal, side wall of pelvis close to ischial spine, then travels
medially and joins with ducts from the seminal vesicle to form ejaculatory duct which joins
the prostatic urethra, inferior to the bladder. (Hence, bladder, urethral and prostate infection
may spread to the vas deferens here.) It is typically 45 cm long

Question 12

The spermatic cord commences superiorly at the deep inguinal ring lateral to the
___________________ artery. Passing through the inguinal canal it
terminates at the posterior border of the __________________.

Answer 12

inferior epigastric, testis

Question 13

During vasectomy, the vasa deferentia are sectioned and ligated bilaterally from the
superoanterior scrotal wall. What are the consequences to (a) the sperm and (b) the
composition of the ejaculate (generally) after vasectomy?

Answer 13

(a) Sperm degenerate in the epididymis and proximal ductus deferens, debris is
removed by phagocytosis
(b) The ejaculate is composed of secretions form the prostate, seminal vesicle, and
bulbourethral glands only.

Question 14

From which layers of the anterior abdominal wall are the fascial coverings of the
spermatic cord derived?

Answer 14

The double layer of the tunica vaginalis is surrounded by

• Internal spermatic fascia (from transversalis fascia)
• Cremasteric fascia (from fascial covering of the internal oblique)
• External spermatic fascia (from the external oblique aponeurosis)
These are followed by a layer of superficial fascia lying directly beneath the scrotal skin

Question 15

During descent of the testes, at what fetal month do they usually …

…reach the iliac fossa …………………. month
…travel through the inguinal canal … month
…reach the external ring ……………… month
…enter the scrotum …………………….. month

Answer 15

(3, 7, 8, and 9 months respectively

Question 16

What are the consequences of undescended testis?

Answer 16

infertility and potentially malignancy

Question 17

What are the contents of the spermatic cord?

Answer 17

Ducts: Vas deferens (and its artery)
Vessels: Testicular artery, cremasteric artery, pampiniform plexus of veins
Nerves: Autonomic nerves, genital branch of the genitofemoral nerve

Question 18

The smooth muschel of which structures contract in peristaltic waves during emission?

Answer 18

Prostate
Vas deferens
Seminal vesicles

Question 19

How is the smooth muscle of prostate, vas deferens and seminal vesicles controlled?

Answer 19

Sympathetic - Hypogastric nerve )L1, L2)

Question 20

Seminal vesicles - identifying the substances
they secrete, the functions of such and the percentage volume of secretion the
glands contribute to the semen (seminal fluid)

Answer 20

Seminal vesicles
- Fructose (Used in ATP production)
- Prostaglandins (facilitate sperm motility and smooth muscle contraction in the female tract)
- Clotting factors (particularly semenogelin (proteins which help temporarily to coagulate semen after ejaculation)
Alkalinity - Helps to neutralize the acid in the male urethra and female reproductive tract

• 60% volume

Question 21

Prostate - identify the substances
they secrete, the functions of such and the percentage volume of secretion the
glands contribute to the semen (seminal fluid)

Answer 21

Prostate

• Proteolytic enzymes (PSA) which breakdown clotting proteins frpom the seminal vesicles, re-liquefying semen 10-20 minutes after ejaculatiion
• Citric acid
• Acid phosphotase
• 25% volume

Question 22

Bulbourethral glands - identify the substances
they secrete, the functions of such and the percentage volume of secretion the
glands contribute to the semen (seminal fluid)

Answer 22

Alkaline fluid neutralizes acid of vagina and a mucous that lubricates the end of the penis and urethral lining

Question 23

A prostate can grow to the size of an orange when enlarged but what is its usual
size?

Answer 23

Chestnut or golf ball (3 cm round)

Question 24

Which part of the prostate gland is felt on rectal examination?

Answer 24

Posterior (median groove)

Question 25

Enlargement of which lobe of the prostate causes urethral obstruction?

Answer 25

Median (This may not be detected on rectal examination; the lateral lobes, however, are
readily detected on rectal examination).

Question 26

The arterial supply to the prostate, the inferior vesical artery, is a branch of the
________________________________.

Answer 26

Internal iliac artery

Question 27

Why is it that cancer of the prostate often presents later than benign prostatic
hyperplasia (BPH)?

Answer 27

The cells that enlarge in BPH are close to the urethra, therefore causing a blockage of the
urethra. Cancerous cells are more peripheral and therefore only occlude the urethra at a
later, more advanced stage.

Question 28

How do levels of PSA vary in BPH and carcinoma of the prostate?

Answer 28

BPH PSA normal/ slightly raised, carcinoma PSA markedly raised

Question 29

Explain why carcinomas of the prostate spread readily to the pelvis and vertebrae.
(Hint : consider venous drainage)

Answer 29

Veins from prostatic venous plexus with dorsal vein of penis into internal iliac vein. Some of the veins pass verterbrae and are valveless, hence spread of malignancy

Question 30

List the three parts of the urethra

Answer 30

Prostatic
Membranous
Spongy

Question 31

Which part of the urethra is lead distensible

Answer 31

Membranous, due to the surrounding sphincter urethrae muscle and perineal membrane

Question 32

Name the erectile tissue in the penis

Answer 32

Corpus cavernosa

Corpus spongiosum

Question 33

Describe the arterial supply of the penis

Answer 33

Branches of the internal pudendal artery form

1) Deep arteries
2) Dorsal arteries
3) Arteries of the bulb

1) and 2) supply the crura and corpus cavernosa. 2) and 3) supply the bulb and the corpus spongiosum

Question 34

Which fibrous capsule surrounds the corpora cavernosa?

Answer 34

Tunica albuginea

Question 35

During erection of the penis, venous engorgement occurs through vasodilation of the
coiled (helicine) arterioles to the corpora cavernosa, hence increasing blood flow.
What is the effect of the tunica albuginea and fascial sheaths?

Answer 35

These resist expansion, such that internal pressure rises and occludes venous
drainage. Blood from the cavernous spaces drains into a venous plexus (which
are compressed during erection), then into the deep dorsal vein. This, along with
increased arterial flow, maintains rigidity of the penis for intercourse.

(Venous return is also restricted by contraction of the bulbospongiosus and
ischiocavernsosus muscles.)

Question 36

Whist the corpus spongiosum swells with blood, it does not become rigid. Why not?

Answer 36

Whilst the tunica albuginea does surround the corpus spongiosum it is not as
fibrous or restrictive as that which surrounds the corpora cavernosa. High
pressure in the corpus spongiosum would occlude the urethra and hence prevent
ejaculation of the semen.

Question 37

Predict what may happen, if the neck of the bladder (vesical sphincter) does not
close during ejaculation?

Answer 37

Retrograde ejaculation into the bladder

Question 38

The pudendal nerves carry afferent, sensory information from the glans to the CNS
but which efferent outflow is involved in erection?

Answer 38

Pelvic nerve, parasympathetic (S2 - S4) , via inferior hypogastic plexuses promotes erection
in erectile tissue, through relaxation of smooth muscle in the fibrous trabeculae and
cooled arteries

Emission is sympathetically controlled. Ejaculation occurs via sympathetic outflow (L1 – L2)

Hypogastric, sympathetic, involved mostly in depression of erection, by increasing myogenic
tone in arterial smooth muscle.

Question 39

Identify some common causes of erectile dysfunction.

Answer 39

• psychological problems
• tears in fibrous capsule of corpora cavernosa
• obstruction of blood flow to corpora cavernosa
• pharmacologica

Question 40

Which part of the penis is removed in circumcision?

Answer 40

prepuce (foreskin)

Question 41

Discriminate between the obstetric conjugate and the diagonal conjugate, which are
assessments of the female bony pelvis made during pregnancy prior to labour. (see
pages 7 - 9 Symonds and Symonds).

Answer 41

The OBSTETRIC conjugate is measured from the midpoint (i.e. thickest ) part of the pubis
(posterior surface) to sacral promontory. This is obstetrically the most important AP diameter
(as it is the narrowest AP diameter that the fetus passes through) and is usually about 10cm.
This diameter can only be assessed with imaging therefore clinicians use the DIAGONAL
CONJUGATE measured from inferior border of pubis to sacral promontory as an
assessment tool. This is measured by introducing two fingers into the vagina and palpating
the sacral promontory and noting where on one’s hand the under edge of pubis is. Most
clinicians do this so often that they immediately know by how far in the fingers go whether
this measurement is adequate. It usually needs to be about 11.5 cm.

Question 42

A 22-year old male has a scrotal swelling.

4.40. List the causes of scrotal swelling?

Answer 42

hernia, hydrocoele, epididymal cyst, epididymitis, orchitis, spermatocoele, varicocoele, a
testicular mass and a cyst of the cord. A testicular mass is the most important diagnosis.

Question 43

Why does a lump in the testis of a 22 year old need follow up?

Answer 43

Any lump in the testis must be a suspected tumour. Testicular cancer is the commonest
cancer that affects young men between the ages of 19 to 44 years old. Almost half of all
testicular cancers occur in men under 35 years old

Question 44

In very general terms, how might you discriminate between a hernia and a swelling
associated with the testis?

Answer 44

A hernia can be reduced then feel for normal scrotal contents.

Question 45

Which veins are dilated in a varicocœle? What does it feel like upon palpation?

Answer 45

The veins of the pampiniform plexus become dilated in the standing position. For reasons
that are postulated rather than known; it occurs, almost invariably, on the left side and a
right-sided varicocœle should always suggest malignant obstruction of the right testicular
vein. On palpation it feels like a bag of worms.

Question 46

Predict why is a varicoceole almost always on the left? Why is a right sided
varicocoele potentially worrying? Hint think about the venous drainage.

Answer 46

The left testicular vein empties vertically into the renal vein. much higher than the right
drainage. The varicosities form when the valve system between these two veins fails and
blood falls backwards under the pull of gravity. The right testicular vein drains directly into
the inferior vena cava at an oblique angle, further down. Its valves do not have to support the
same weight of blood as those in the left testicular vein and are therefore much less likely to
fail. A right sided varicocoele is very uncommon and is suggestive of other, potentially more
serious problems such raised IVC pressure - e.g. due to obstruction.

Question 47

What is a hydrocœle? Explain why hydrocœles in young boys often get bigger when 
they cough (or cry)”

Answer 47

A hydrocœles is usually a painless enlargement of the testis caused by accumulation of
watery fluid, in a persistent processus vaginalis (tunica vaginalis) surrounding the testis. It
can grow as large as a grapefruit!

Hydrocœles at this age are usually still connected to the peritoneal cavity by some persisting
patency of the processus. The patency is limited so raised intra-abdominal pressure is
required to send i.p. fluid through into the hydrocœle.

Question 48

Explain why trans-illumination with a small bright torch can distinguish an epididymal
cyst from a spermatocœle.

Answer 48

An epididymal cyst contains clear fluid and transilluminates ‘brilliantly’, while a spermatocœle
contains turbid fluid that inhibits transillumination. Epididymal cysts arise from unconnected
segments of the efferent tubules that sprouted from the mesonephric duct hence the clear
fluid content. Spermatocœles arise similarly, but the segment is marginally connected to the rete testis and contains degenerate products of spermatogenesis. There is no important
clinical difference between them, other than embryological origin.

Question 49

What is a haematoceole of the testis?

Answer 49

An accumulation of the blood in the tunica vaginalis (e.g., traumatic rupture of the testicular
artery). If therefore does not transilluminate.

Question 50

Why is a NMR very good and palpation very poor at assessing lymphatic spread from
a testicular tumour?

Answer 50

Para-aortic nodes only become palpabl when they are massive