Testicular Flashcards by Lourdes Matos

What is the appendix epididymis

A detached efferent duct. It’s seen as a small soft projection off the epididymis.

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What is the appendix testis

Ruminant of the mullerian duct. A small ovoid structure near head of epididymis.

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What is the tunica albuginea and tunica vaginalis

Albuginea: fibrous capsule that surrounds the testicle

Vaginalis:
the inner/visceral layer. It covers the testicle and epididymis.
The outer/parietal layer lines the walls of the scrotal chamber. A small amount of fluid is commonly seen in this space.

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Hydrocele

Collection of fluid in tunica vaginalis

Fluid collection surrounding the testicle.

Congenital/acquired

MC fluid collection in scrotum
MC in newborns

Idiopathic, trauma, infection, infarct, torsion, neoplasm

Fluid collection, enhancement, wall thick, scrotal pearls, septations with old hemorrhage/infection

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Varicocele

Dilated tortuous veins of the pampiniform plexus located posterior to the testis and assoc with male infertility.

Caused by incompetent valves of the internal spermatic vein

MC on left, distend when valsalva or abd compression

Pamp plexus > 2 mm

Infertility, warm temp scrotum, tubular serpiginous veins, > 2 mm, inc with valsalva in upright position.

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Difference between epididymal cyst and spermatocele

Both result from dilatation of the epididymal tubules

Epi cyst are composed of clear fluid.

Spermatoceles are filled with thick milky fluid containing spermatozoa

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2 MC causes of acute scrotal pain

Torsion, epididymalorchitis

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Torsion of spermatic cord

Enlg hetero and hypo when compared to contralateral testis

Enlg epididymis, skin thickening, reactive hydrocele

Prescience of blood flow does not exclude partial torsion
At least 540 degrees of torsion is necessary to completely occlude testicular blood flow.

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Acute epididymitis

Enlg Epi, dec echoes, hetero, hydrocele, skin thickening

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Cryptorchidism / undescended testicle

At or below inguinal canal

May cause infertility or cancer

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2 complications of undescended testicle

Infertility and inc risk of cancer even on the normal testicle with an orchiopexy

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Orchiopexy

Surgery to move undescended testicle into scrotum

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Hematocele

Blood collection in tunica vaginalis

Trauma

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Pyocele

Pus collection in tunica vaginalis

Infection
Echogenic debri

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Endocrine

Testosterone (sex hormones)

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Exocrine

Spermatogenesis

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Spermatic cord

Arteries veins nerves lymphatics vas deferens

Vas deferens connects epididymis to seminal vesicles.

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Blood supply

Testicular artery, cremasteric artery, deferential arteries

Pampiniform plexus-> spermatic vein -> ivc on rt and left renal vein to ivc on left.

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Sperm travels

Epididymis
Vas deferens
Seminal vesicles
Ejaculatory Duct
Urethra

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Epididymis

Stores sperm

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Layers

Tunica vaginalis: double sac covering testis, prevents abdomen contents from herniating into sac

Tunica albuginea: fibrous capsule covering testis

Mediastinum: invagination of tunica albuginea. Echogenic line

Appendix testis: fibrous band sup to testis

Testis & epididymis meas

Testis 3-5 cm L, 2-4 W, 3 AP

Scrotal wall 2-8 mm

Epi head 6-15 mm, body 2-4, tail 2-5 mm

Epididymis

Head / Globus Major
Body / Corpus
Tail / Globus Minor

Patients with vasectomy, inc size of epi & may see cyst

Congenital Anomalies

Testicular Ectopia

Anorchia: rare, only 1 testis, vasc problem in utero

Polyorchidism: very rare

Rupture

Torn capsule, rare, assoc with trauma, early dx & tx critical Irreg capsule, Hematocele, intratesticular hematoma/infarct, wall thick, absent/dec flow, liquefaction after 3 days

Torsion

Twisting of testis. "Bell clapper" deformity. Young males Resting Severe sudden pain, when at rest, n/v, radiating pain, may mimic epididymitis. 5-6 hrs can save. Absent Doppler, inc size, hypo/hetero, skin thickening, hydrocele, necrosis/hemorrhage/infarct Chronic: small hypo testis, large epi

Epididymitis

Inflammation of epi. Bacterial, trauma, idiopathic Focal or diffuse (head body tail) Can lead to epididymalorchitis and abscess Fever, pain urine, tense tender epi/scrotum, Palp hard cord Skin thickening, hydrocele Acute: enlg epi, hypo, hypervascular Chronic: hyper, ca+

Spermatocele

Retention cyst of sperm containing tubules MC in epi head Cystic mass, displace testis ant, septations, indistinguishable from Epididymal cyst Spermatocele more common than epididymal cyst & is milky fluid

Scrotal hernia

Inguinal hernias descended into scrotum. Assoc with patency of vaginalis and heavy lifting. Extratesticular mass, bowel, peristalsis unless bowel stuck. abd pain, blood in stool, constipation

Granulomatous Disease

TB spread, unilateral, initially involves epi but can spread to testis. Acute: focal hypo mass Chronic: blending of epi and testis. Ca+

Scrotal Calcifications

Benign | Assoc with inflammation, tb, vasc ca+, cryptorchidism, klinefelters, sterility, tumors

Microlithiasis

Benign Assoc with infertility, Cryptorchidism, neoplasm Tiny Echogenic foci, don't shadow, well disseminated

Tunica Albuginea Cyst

Rare, 2-5 mm | Cyst ant/lat to testis

Epididymal Cyst

Dilated epi tubules | Less common than spermatocele. Clear fluid.

Testicular cyst

Benign | More common in upper pole

Epidermoid cyst

Benign, germ cell origin Well defined, Echogenic cyst walls/halo, cystic/hypo, homo, ca+

Adenomatoid Tumor

Benign Extratesticular Usually in epi, asymptomatic, uni, left. More common than Leiomyoma Hypo/hyper, well described, assoc hydrocele

Leiomyoma

Benign Extratesticular tumor | Less common than adenomatoid tumors

Extratesticular malignant neoplasms

Fibrosarcoma Liposarcoma Rhabdomyosarcoma (peds) Solid, I'll defined, hetero, complex with necrosis

Intratesticular tumors

Most are malignant. | Leydig cell tumor is MC benign but can turn malignant.

Benign intratesticular tumors

``` Leydig cell tumor: MC, malignant potential Sertoli Tumors Dermoid cyst Cystadenomas Adenomatoid tumors ```

Leydig Cell Tumor / interstitial cell tumor

MC non germ cell, benign. Malignant potential. Endocrine imbalance, impotence (erectile dysfunction), Gynecomastia (inc Breast tissue), dec libido

Testicular cancer

Young, painless mass, unilateral enlargement. 10% with acute pain Focal mass, hypo, mixed echoes, hetero, inc vascularity

Malignant tumors

``` Seminoma Embryonal cancer Choriocarcinoma Teratoma Teratocarcinoma Mets ```

Seminoma

MC testicular cancer 30% hx of cryptorchidism Encapsulated 25% with mets

Embryonal Cell Carcinoma

Second MC Aggressive Cystic necrosis

Choriocarcinoma

Inc HCG Mixed echo Highly malignant Least common

Teratoma

Infants & children Malignant or benign Ca+

Mixed tumors

Teratocarcinoma MC Has teratoma/embryonal cells Aggressive Complex mass

Mets to testis

Rare Prostate and kidneys MC Multiple bilateral hypo

Lymphoma & Leukemia

Infiltration to testis