Testes & Scrotum Flashcards
Acute Orchitis
- usually occurs in Pt’s w epididymitis
- primary orchitis rate; mumps/HIV
- US findings:
• swollen striated testis compared w contralat* side
• possible omplex hydrocele
• hyperaemia on colour Doppler comp* w contralat* side
Acute epididymitis
- thickening & enlargemy of the epididymis
- originates in the tail & spreads towards the head
- coarse, heterogeneous appearance
- inc* vascularity on colour Doppler
Acute epididymis-orchitis
- enlarged heterogeneous epididymis
- enlarged heterogeneous testis
- epididymal & testicular hypervascularity on colour Doppler
- possible reactive hydro eke or pyocele
- poss* scrotal wall thickening
Cellulitis
- scrotum red & swollen w hyperaemia, which can extend into both groins, but tested & epididymis unaffected
- poss* fluid in scrotal cavity (may be complex)
- look for associated abscess
- clinically significant & can progress to nec* fasc* esp* in diabetic & immunosuppressed Pts
Fournier gangrene (nec* fasc*)
- nec* fasc* of perineum & scrotum (usually makes 50-70yo)
- can feel gas in scrotal wall (crepitus like)
- thickened scrotal wall
- echogenic gas foci in scrotum - look for ‘dirty shadowing’ from air
- testis & epididymis spared - so appear sonographically within normal limits (as arterial supply from aorta)
- scrotal fluid
- begins as cellulitis that causes an endarteritis w thrombosis followed by nec* infection that spreads thru fascial planes
- high morbidity & mortality rate!! Urg surgical resection of devitalised tissue
Acute testicular torsion: types
Intra-vaginal:
- almost freq* type
- adolescent boys or older
- due to Bell-clapper deformity (testis sits more horizontally) where tunica vaginal is completely surrounds testis
- axis of rotation within the tunica vaginalis
Extra-vaginal:
- less frequent
- pre-pubertal/neonatal
- due to tunica vaginalis having abnormally long attach* to testis & rotation is external to tunica vaginalis - hence it’s also torted
- twisting occurs at level of superficial inguinal ring
- poor or absent attachment of testis to scrotal wall at posterolateral aspect
Long mesorchium often assoc* w cryptochidism
Testicular torsion symptoms
Symptoms:
- sudden pin (not relieved by elevating the scrotum), followed by nausea, vomiting & poss* low-grade fever
- swollen hemi-scrotum
- cremasteric reflex usually absent
- transverse location of testis instead of vertical position (bell-clapper type)
Salvage rates:
- with 6 hrs - 100%
- 6-12 hrs - 70%
- 12-24 hrs - 20%
Testicular torsion: sonographically
Less than 6hrs:
- mildly enlarged testis
- normal or decreased echogenicity of testis
- enlarged epididymis
- scrotal skin thickening
- reactive hydrocele
Complete torsion:
- absence of vascularity in colour Doppler
Partial torsion:
- decreased flow, but elevated RI
Whirlpool or Knot sign:
- can often visualise the twisted spermatic cord: knotted looking & colour Doppler will show whirlpool of vessels/flow
Use Power Doppler if struggling to visual on colour
Partial torsion
- less than 360 twist of spermatic cord
- can happen multiple times & spontaneously partially resolve
- some residual perfusion but pain remains!
Sonographically:
- decreased flow, but elevated RI (>0.75)
- ‘to & fro’ flow seen
- altered lie of testis
- may see redundant tortuous spermatic cord in medial part of scrotal sac
- mildly oedematous epididymis - can be confused w epididymitis
Testicular torsion >24hrs
- enlarged testis, epididymis & spermatic cord
- varied echogenicity & heterogeneous echotexture
- poss* multi focal hyper echogenicity due to necrosis, haemorrhage & infarction
- absent intra-testicular flow
- increased peri-testicular flow
Torsion if testicular appendage
Clinical signs:
- firm nodule usually on upper testis
- bluish discolouration ‘blue dot sign’
- cremasteric reflex still elicited
- common in boys 7-14yrs
Sonographically:
- appendix testis >5mm
- peri-appendiceal blood flow
- reactive hydrocele
- skin thickening
Thrombosis of pampiniform plexus
- rare!!
- vein walls are thickened
- may see thrombus within
- may be partially or completely occlusive
- need to be sure U separately identify the ductus deferens (
Henoch-Schonlein purpura
- systemic vasculitis
- usually affects skin, kidneys, GIT & joints
- more commonly encountered in paeds
- episodes of acute scrotal symptoms with pain & enlargement can be encountered in up to 15% of pts
Sonographically:
- scrotal skin thickening
- enlargement of epididymis w hypervascularity
- hydrocele
- unilateral involvement may be observed
- testes are normal shape, vol* & vascularity
Blunt scrotal trauma
- usually affects R testis more
- req* 50kg direct force to cause testicular rupture
- severity ranges from small lac w minimal extravasating to complete parenchymal disruption
- testicular rupture is rare but a serious injury - usually results in rupture of the tunica albuginea & extrusion if seminiferous tubules
Testicular trauma sonography
Intra-testicular haematomas w tunica albuginea intact
- hypoechoic regions within testis
- absence of internal vascularity of haematoma on colour Doppler
- can be seen to get smaller over time (unlike tumours)
- check that tunica albuginea remains intact
- check vascularity if remaining testis
Testicular fracture
- refers to a break or discontinuity in normal testicular parenchyma
- occurs without extrusion if testicular parenchyma
- may be associated w intact or disrupted tunica albuginea
- frac* line can be seen thru testicular parenchyma
- look for continuity of tunica albuginea or extrusion if testicular tissue
- assess vascularity/perfusion of testis
Testicular rupture
- testicular frac* w ruptured tunica albuginea
- look for discontinuity of tunica albuginea
- look for herniation/protrusion if testicular parenchyma outside of tunica
- usually associated w scrotal wall haematoma
- necessitates emergent surgery
Scrotal haematoma
- blood within the tunica vaginalis = extratesticular injury
- most common finding post blunt trauma
- varied sonographic appearances; acute May be echogenic or isoechoic w testis
- 12-24 hrs; echogenicity changes as haematoma evolves
- becomes more hypoechoic w time & develop septa & loculations, fluid levels
- chronic haematoceles can become calcified
- large haematomas can apply pressure on vessels, mimicking torsion or partial torsion
- usually conservative management for haematoceles < 3x contralateral tesits & haematomas <5 mm & non-expanding
Scrotal wall haematoma
- commonly assoc* w blunt trauma
- usually resolve spontaneously or w conservative management
- large haematomas may req* surgical evacuation
Sonographically:
- echogenic focal wall thickening
- complex fluid collection in wall
Penetrating scrotal trauma
Sonographic changes tend to be variable
- check for haematocele or testicular rupture
- check for foreign bodies (intra- or extra-testicular)
- intratesticular missle tract - hypoechoic a vascular linear line sonographically
- check for presence of air within scrotum (intra- or extra-testicular) multiple echogenic foci with reverberation artefacts
- colour Doppler req* to determine viability of the testis
Extra testicular masses
- scrotal hernia
- scrotal abscess
- epididymal cysts
- spermatoceles (look like above but contain low lvl echoes)
- sperm granulomas (often post vasectomy change)
- scrotal calcifications (pearls)
- tumours; benign adenomatoid tumour, leipmyoma (benign), rhabdomyosarcoma (mal*) seen as solid, ill-defined heterogeneous mass
Intra-testicular masses
Cysts:
- intra-testicular or tunica albuginea (use colour Doppler for any vascularity)
Benign tumours:
- Leydig cell tumour
- Sertoli cell tumour
- Teratomas (epidermis cysts)
- microlithiasis (> 5 echogenic foci)
Malignant tumours: (feel hard like rock under probe)
- hypoechoic, heterogenous, may contain echogenic foci
- Seminoma
- embryonal cell carcinoma
- teratoma
- yolk sac tumour
- metastases (rare)
- lymphoma (commonly bilateral)
Cryptorchidism (undescended testis)
- most likely in inguinal canal, but can be hard to locate if superior to this
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