Chapter 13: Male Pelvis (Penny)

c. bell clapper deformity

20. The lack of normal fixation of the testis to the posterior scrotal wall is referred to as: a. klinefelter syndrome b. blue dot sign c. bell clapper deformity d. cryptorchidism

3-5 cm in length 2-4 cm width 3 cm thick

Testicle measurements in adults

coronal and sagittal

The prostate is imaged in what 2 planes

inguinal

The spermatic cord enters the scrotum through the opening in the lower anterior abdominal wall known as the ________ canal, that contains structures including vascular supply and venous drainage for the testicles

cryptorchidism

The testicle(s) can become trapped anywhere along the path of descent into the scrotum and never completely descend into the scrotum. This is known as:

False, clinical history is important to differentiate between the 3

True or False. it is easy to differentiate between a hematocele, pyocele, and complex hydrocele.

in upper abdomen near the kidneys

Where do the testicles begin to develop?

anterior abdominal aorta below the renal arteries

Where do the testicular arteries arise from?

pampiniform plexus

Where does venous drainage occur?

central zone

Which zone is: -located on the base of the prostate -second largest prostatic zone

peripheral zone

Which zone is: -located posterior later, apical gland -largest prostatic zone -most common site for malignancy

cryptorchidism

___________ is associated with infertility and can increase the risk for malignancy in the involved testis

epididymis

a coiled structure that is attached to the testicle and the posterior scrotal wall that is responsible for storing the sperm it is responsible for storing sperm. it also transports sperm into the ductus(vas) deferens.

varicocele

a dilated group of veins within the scrotum

hydrocele

a fluid collection within the scrotum between both layers of the tunica vaginalis, often displaces the testicles posteriorly

prostate-specific antigen, PSA

a protein produced by the prostate gland that is indicative of disease or may be normal and still be found in the presence of cancer

ductus (vas) deferens or deferent duct

a tube that connects the epididymis to the seminal vesicles

appendix testis appendix epididymis appendix vas

appendages of the testis

benign prostatic hypertrophy

benign enlargement of the prostate gland.

LLD position with knees flexed toward chest

during transrectal examinations the patient should be in the ___________ position during trans-rectal imaging of the prostate

human chorionic gonadotropin, hCG

elevated lab value that is found in malignant intratesticular tumors 60% of the time

Alpha-fetoprotein, AFP

elevated lab value that is most often associated with embryonal cell carcinoma, yolk sac tumors, and adult teratomas (malignant tumors)

scrotal pearl

extratesticular calculi.

hydrocele

fluid collection within the scrotum most often found between the 2 layers of the tunica vaginalis

semen

fluid that contains secretions from the testicles, seminal vesicles, and prostate gland

vasectomy

form of male contraception in which the vas deferens is surgically interrupted to prohibit the flow of sperm from the testicles

bulbourethral gland or cowper gland

gland that secretes pre-ejaculate fluid that lubricates the penile urethra prior to ejaculation

syncytiotrophoblastic

hCG is produced by these masses because they contain _____ cells that are found in the developing placenta.

sagittal- echogenic, linear structure transverse- triangular structure

how does the mediastinum testis appear in sagittal and transverse planes?

prostate cancer

in the form of adenocarcinoma, the most common cancer in men

epididymitis

inflammation of all or part of the epididymis; most common cause of testicular pain in adults

epididymoorchitis

inflammation of the epididymis and testis

orchitis

inflammation of the testis or testicles

leydig cell tumor sertoli cell tumor

sex cord stromal tumors of the testicles

seminal vesicles

small glands located superior to the prostate gland and located posterior to the base of the bladder, which secrete an alkaline based fluid

solid, hypoechoic intratesticular mass

sono finding of seminoma

peri-urethral glandular zone

Which zone is: -embedded in the muscle of the proximal urethra -smallest prostatic zone

transitional zone

Which zone is: -located on both sides of the proximal urethra -site for benign prostatic hyperplasia -second most common site of malignancies

2-8mm

scrotal wall thickness ranges between

ejaculatory duct

seminal vesicles and vans deferens combine to create the

"bell-clapper" deformity

TT is often associated with the

b. seminoma

1. What is the most common malignancy of the testicle? a. embryonal cell carcinoma b. seminoma c. choriocarcinoma d. spermatocele

d. >2 mm

19. Dilated veins of a varicocele will measure: a. >8 mm b. >4 mm c. <2 mm d. >2 mm

d. torsion of the testicular appendage

10. The blue dot sign is indicative of: a. testicular torsion b. epididymitis c. orchitis d. torsion of the testicular appendage

c. varicocele

11. A 23-year-old man presents to the ultrasound department with a history of infertility. Which of the following is associated with male infertility? a. spermatocele b. choriocarcinoma c. varicocele d. hydrocele

a. no intratesticular flow

12. All of the following are sonographic findings consistent with torsion of the testicular appendage except: a. no intratesticular flow b. small hyperechoic mass adjacent to the testis c. reactive hydrocele d. scrotal wall thickening

a. varicocele

13. What is the most common correctable cause of male infertility? a. varicocele b. chlamydia c. hydrocele d. testicular torsion

b. hydrocele

14. A simple fluid collection surrounding the testis is referred to as a: a. hematocele b. hydrocele c. varicocele d. spermatocele

d. sperm

15. The exocrine function of the testicles is to produce: a. testosterone b. human chorionic gonadotropin c. AFP d. sperm

c. between the two layers of the tunica vaginalis

16. The most common location of a hydrocele is: a. superior to the testis b. within the scrotal wall c. between the two layers of the tunica vaginalis d. between the tunica vaginalis and tunica albuginea

d. testicular torsion

17. Acute onset of testicular pain at rest is a common clinical finding with: a. testicular carcinoma b. hydrocele c. testicular trauma d. testicular torsion

c. torsion of the testicular appendage

18. A 7-year-old boy presents to the emergency department with acute testicular pain localized to the superior pole of his right testis. What is the most likely diagnosis? a. testicular torsion b. hydrocele c. torsion of the testicular appendage d. yolk sac tumor

c. one or both of the testicles has not descended into the scrotum

25. You have been asked to perform a study to rule out crytorchidism. The term cryptorchidism denotes: a. one or both of the testicles has a malignancy b. the patient lacks the normal fixation of the testis to the posterior scrotal wall c. one or both of the testicles has not descended into the scrotum d. the patient has been kicked in the scrotum

c. seminoma

26. The most common germ cell tumor of the testis is the: a. yolk sac tumor b. embryonal cell carcinoma c. seminoma d. teratoma

b. the left side of the scrotum

27. The most common location of a varicocele is: a. the right side of the scrotum b. the left side of the scrotum c. the inguinal canal d. within the testis

a. peripheral zone

28. The most common location of prostatic cancer is the: a. peripheral zone b. transitional zone c. central zone d. verumontanum

4th week of gestation

When do the testicles begin to develop in the upper abdomen in the fetus?

1. nocturia 2. increased urinary frequency 3. sense of urgency 4. constant feeling of full bladder 5. elevated PSA

Clinical finding of benign prostatic hypertrophy (BPH)

1. persistent or intermittent scrotal swelling 2. may have abdominal pain and blood in stool

Clinical finding of inguinal hernia

1. painless scrotal mass 2. hardening of the testis 3. elevated hCG

Clinical finding of seminoma

1. acute onset of pain (usually during sleep) 2. possible pain w/in the lower abdomen and inguinal region 3. swollen testis/scrotum 4. nausea/vomiting 5. higher positioned, painful testis with horizontal position

Clinical findings of acute testicular torsion

pure seminoma teratoma yolk sac tumor choriocarcinoma burned out germ cell tumor

Germ cell tumors of the testicles

extra-testicular

Normal testicles appear isoechoic and a small amount of ______ fluid is noted around each testicle

Vas Deferens transports sperm to > seminal vesicles- semen created > together they form the ejaculatory duct > semen passes through prostate urethra-more fluid is added from prostate > Cowper gland (bulbourethral gland) - secretes preejaculate to lubricate penile urethra for ejaculation

Process of Ejaculation

30-50; cryptochordism; unilaterally

Seminoma is found in males between _____-_____ age, usually in patients with __________ and is found _________

1. BPH will show enlargement of inner gland 2. can lead to hypo echoic areas within the gland 3. calcifications within the gland 4. diffusely heterogeneous gland 5. cystic changes within the gland

Sono finding of benign prostatic hypertrophy (BPH)

1. simple fluid anterior to the testis 2. scrotal wall thickening 3. chronic hydroceles may have internal debris and septations

Sono findings of hydrocele

testicular

Venous drainage empties into the __________ veins

teratoma

What am i? -Non-seminomatous germ cell tumor -benign with malignant potential -may be palpable -elevated AFP and hCG if malignant -appears as heterogeneous mass with calcifications representing cartilage, bone, and fibrosis; may contain hair and teeth

yolk sac tumors

What am i? -Non-seminomatous germ cell tumor -malignant -may be palpable -elevated AFP -appears as heterogeneous mass with areas of hemorrhage and calcifications

embryonal cell carcinoma

What am i? -Non-seminomatous germ cell tumor -malignant -may be palpable -elevated AFP and hCG -appears as heterogeneous mass with cystic components

choriocarcinoma

What am i? -Non-seminomatous germ cell tumor -malignant -may be palpable -elevated hCG -appears as heterogeneous mass with areas of hemorrhage, necrosis, and calcifications

sexual activity, strenuous exercise, or trauma

What can be associated with TT

28 weeks

When do the testicles descend into the scrotum?

produce testosterone determine male characteristics

What is the endocrine function of the testicles?

produce sperm permits reproduction

What is the exocrine function of the testicles?

sperm fat cellular debris lymphocytes

What makes up a spermatocele?

scrotum

What provides a means of temperature control with the temperature sensitive sperm?

high frequency, linear transducer

What type of transducer is used to perform a scrotal ultrasound?

varicocele

caused by incompetent valves within the pampiniform plexus. the most common cause of correctable male infertility.

calcifications

chronic epididymitis appears as enlarged, hyper echoic, with __________

1. acute testi pain 2. fever 3. dysuria 4. urethral discharge 5. skin wall edema

clinical finding of epididymitis and epidiymoorchitis

1. trauma to the pelvis or scrotum 2. recent pelvic or scrotal surgery 3. low hematocrit

clinical finding of hematocele

1. trauma to the scrotum resulting in acute scrotal pain 2. low hematocrit

clinical finding of scrotal trauma

1. painful, swollen scrotum 2. fever 3. elevated WBC

clinical finding of testicular abscess

unable to palpate testi in scrotum

clinical findings of cryptorchidism

1. palpable extra-testicular mass 2. possible infertility

clinical findings of varicocele

hematocele

collection of blood within the scrotum

spermatocele

common cyst found in the head of the epididymis

pyocele

complex hydrocele that contains pus (pus collection within the scrotum)

klinefelter syndrome

condition in which male has a extra X chromosome; characteristic features include small testicles, infertility, gynecomastia, long legs, abnormally low intelligence

"bell-clapper" deformity

condition in which the patient lacks the normal posterior fixation of the testis and epi. to the scrotal wall and usually occurs bilaterally

cryptorchidism

condition of having undescended testis found in 3-4% of full term birth

testicular torsion

condition that results from the arterial blood supply to the testicle being cut off secondary to the twisting of the testicular axis

epididymal cyst

cyst located anywhere along the length of the epididymis

tunica albuginea cyst

cysts located anywhere within the tunica albuginea surrounding the testis

seminiferous tubules

location of spermatogenesis within the testicles

12-18 years of age

most common age for testicular torsion

torsion of the appendix testis

most common cause of acute scrotal pain in prepubertal boys.

peripheral zone

most common site of prostate cancer

testicular arteries

most of the arterial supply to the testicles is via

germ cell

most of the malignant intra-testicular tumors are _______ in origin

testicular microlithiasis

multiple echogenic foci with no acoustic shadowing. Can be associated with malignancies, infertility, and klinefelter syndrome

rete testis

network of tubules that carry sperm from the seminiferous tubules to the epididymis

lymphoma, leukemia, metastases, and sex cord stromal tumors

non-germ cell tumors include:

10 to 12 mm (1.0-1.2 cm)

normal head of the epididymis measures

testicular abscess

occurs within the testicle and is typically the result of untreated epididymoorchitis

seminoma

one of the most common malignant neoplasm of the testicles that is a germ cell tumor most are unilateral. clinical: painless scrotal mass, hardening of the testis, elevated hCG. sono: solid, hypoechoic intratesticular mass.

tunica vaginalis

paired serous coating of the testis (Double layer of tissue) of parietal and visceral coating

retroperitoneal

prostate is a _______ gland

inguinal hernia

protrusion of bowel or abdominal contents into the inguinal canal

scrotum

sac of cutaneous tissue where the adult testicles are located

80-100% ; 24 hours

salvage rate of patients treated with test. torsion within 6 hours of onset of symptoms is ______% and is not salvageable after ______ hours

1. a group of anehoic, tubular structures located outside of the testis. 2. distended veins that will fill with color with valsalva 3. dilated veins that measure greater than 2mm 4. possibly associated with hydronephrosis, hepatomegaly, or retroperitoneal neoplasm if found on the right (secondary varicocele)

sono findings of varicocele

1. normal intra-testicular flow 2. small, avascular, hypo echoic or hyper echoic mass adjacent to the superior pole of the testis 3. reactive hydrocele 4. scrotal wall thickening

sonographic findings of torsion of testicular appendage

mediastinum testis

structure formed by the tunica albuginea and contains the rete testis

transabdominal or transrectal

2 methods of imaging to view the prostate

a. left sided location

2. Secondary varicoceles are associated with all of the following except: a. left sided location b. right sided location c. hepatomegaly d. renal mass

a. valsalva maneuver

21. Which of the following techniques is useful at providing sonographic evidence of a varicocele? a. valsalva maneuver b. sitting position c. pulsed Doppler d. right lateral decubitus position

a. testosterone

22. The endocrine function of the testicles is to produce: a. testosterone b. human chorionic gonadotropin c. AFP d. sperm

a. hyperemic flow within the testis

23. All of the following are sonographic findings consistent with the diagnosis of testicular torsion except: a. hyperemic flow within the testis b. hypoechoic testis c. reactive hydrocele d. decreased intratesticular flow (as compared with the asymptomatic testis)

d. seminiferous tubules

24. Spermatogenesis occurs within the: a. tunica albuginea b. rete testis c. mediastinum testis d. seminiferous tubules

d. prostate cancer

29. What is the most common cancer found in men? a. testicular cancer b. lung cancer c. liver cancer d. prostate cancer

b. transitional zone

3. The most common location of benign prostatic hypertrophy is the: a. peripheral zone b. transitional zone c. central zone d. verumontanum

d. hypoechoic

30. What is the most common sonographic appearance of a seminoma? a. hyperechoic b. anechoic c. heterogeneous with calcifications d. hypoechoic

c. benign prostatic hypertrophy

4. Enlargement of the prostate in older men is most often caused by: a. prostatitis b. prostate cancer c. benign prostatic hypertrophy d. klinefelter syndrome

c. a simple-appearing cyst, found within the head of epididymis, that may contain debris

5. Which of the following best describes a spermatocele? a. the most common malignant neoplasm of the scrotum b. a benign intratesticular cyst c. a simple-appearing cyst, found within the head of epididymis, that may contain debris d. a dilated group of veins found within the scrotum

a. varicocele

6. A dilated group of veins found within the scrotum is defined as a: a. varicocele b. spermatocele c. seminoma d. hydrocele

b. retroperitoneal mass

7. Primary varicoceles are associated with all of the following except: a. left sided location b. retroperitoneal mass c. infertility d. palpable extratesticular mass

c. spermatocele

8. A common cyst most often seen in the head of the epididymis that contains nonviable sperm is the: a. epididymal cyst b. tunica albuginea cyst c. spermatocele d. seminoma

d. varicocele

9. What scrotal abnormality is caused by incompetent valves are within the pampiniform plexus? a. testicular carcinoma b. testicular microlithiasis c. testicular torsion d. varicocele

1. trans-illuminates light 2. painless scrotal swelling 3. may present with pain when found in the presence of scrotal infection, testicular torsion, trauma, or a tumor

Clinical findings of hydrocele

1. elevated PSA 2. enlarged prostate 3. blood in urine or semen 4. back pain, pelvic pain, hip or thigh pain 5. impotence 6. decrease in amount of ejaculated fluid

Clinical findings of prostate cancer

1. if large enough, may be palpable 2. typically not painful

Clinical findings of spermatocele, epididymal cyst, and tunica albuginea cyst

1. acute testicular pain 2. pain localized to the superior pole of the testis 3. blue dot sign

Clinical findings of torsion of the testicular appendage

1. testicular artery 2. pampiniform plexus 3. lymph nodes 4. nerves 5. cremaster muscle

Components of the sperm cord

1. enlargement of epididymis 2. thick scrotal wall 3. hypo-echoic or heterogeneous testis 4. reactive hydrocele 5. no intra-testicular flow 6. decreased intra-testicular flow (as compared to the asymptomatic testis)

Sono findings of acute testicular torsion

1. round, anechoic mass with acoustic enhancement 2. may contain some layering debris

Sono findings of spermatocele, epididymal cyst, and tunica albuginea cyst

-testis located outside of scrotum. -these testis will appear hypoechoic to normal testis

Sonographic finding of cryptorchidism

1. extremely echogenic 2. extra-testicular mobile structure that produces shadowing

Sonographic finding of scrotal pearl

1. enlargement of the spermatic cord, epididymis, and testis 2. no intra-testicular flow 3. hyperemic flow around the testis 4. heterogeneous testis with areas of necrosis

Sonographic findings of chronic TT

1. benign prostatic hypertrophy (benign enlargement of prostate) 2. prostatic cancer 3. prostatitis (inflammation of prostate) 4. prostatic infarcts

an increase in PSA protein can be indicative of diseases such as:

chlamydia

an STD that can lead to inflammatory disease in males and is the most common cause of epididymitis; found in both sexes

verumontanum

an elevated area within the prostatic urethra at which the ejaculatory ducts meet the urethra

1. enlargement of the entire epididymis (diffuse) 2. enlargement of only part of the epididymis (focal) 3. hyopechoic echo texture of the affected sections of the epididymis 4. hyperemia within the epididymis and/or testis 5. thickened scrotal wall

sono finding of epididymitis and epidiymoorchitis

1. complex fluid collection within the scrotum 2. scrotal wall thickening

sono finding of hematocele

1. heterogeneous mass within the scrotum that moves (peristalsis) 2. mass may contain air and fluid 3. hydrocele may be present

sono finding of inguinal hernia

1. complex fluid collection within scrotum 2. scrotal wall thickening 3. may be seen in conjunction with rupture of a testicular abscess or persistent scrotal infection

sono finding of pyocele

1. possible fracture line 2. indistinct testi margins 3. hematocele

sono finding of scrotal trauma

1. complex intra-testa mass 2. mass that has no flow centrally but increased flow around its margins 3. may have co-existing pyocele

sono finding of testicular abscess

1. varying sonographic appearance 2. hypoechoic mass 3. may be hypervascular

sono findings of prostate cancer

appendix testis

testicular appendage located between the head of the epididymis and the superior pole of the testis

"blue dot" sign

the appearance of a torsed testicular appendage that can be observed as a blue dot just under the skin surface

spermatogenesis

the creation of sperm that occurs within the seminiferous tubules found throughout each testicle

tunica albuginea

the dense connective tissue that is closely applied to each testicle that extends posteriorly and enters each testicle to help form the mediastinum testis

head (superior to upper testi pole) body (posterior to the testicle) tail (inferior to the lower testi pole)

the epididymis is divided into what 3 parts?

LRV

the left testicular vein drains into the ________

seminoma

the most common cancer found in cryptorchidism

cremaster muscle

the muscle that raises the testicles

1. peripheral zone 2. central zone 3. transitional zone 4. peri-urethral glandular zone

the prostate is divided into 4 zones:

inferior, rectum

the prostate is located ______ to the bladder, between the symphasis pubis and _________ with the base located superior and the apex located inferior

13-30%

the prostate secretes alkaline fluid that constitutes _____ of the volume of semen.

IVC

the right testicular vein drains into the _________

median raphe

the structure that divides the scrotum into two parts externally

tunica dartos

the structure that separates the two compartments internally

spermatic cord

the structure that travels through the inguinal cal and contains blood vessels, nerves, lymph nodes, and the cremaster muscle

orchiopexy

the surgery that moves an undescended testis into the scrotum

1. wolffian duct 2. mesonephric duct 3. mullerian duct

the testis appendages are said to be embryologic remnants of what 3 ducts?

1. primary; within the left, palpable 2. secondary; within the right

two types of varicocele

germ cell tumor

type of neoplasm derived from the germ cells of the gonads and may be found outside of the reproductive tract

-isoechoic or slightly more echogenic than the testis -should be checked fro hyperemic flow, enlargement, and/or masses

ultrasound appearance of epididymis