Scrotal Pathology

Non-germ cell tumors are generally

benign

Most extratesticular masses are ___ , but the majority of intratesticular masses are ____

benign, malignant

Seminomas are both radio-sensitive and chemo- sensitive resulting in the ____ ____ prognosis of all testicular tumors Risk factors include: - Cryptorchidism (undescended testicle) - Family history of testicular cancer - Infertility - Klinefelter Syndrome (XXY) - Down Syndrome - Smoking - White race

most favorable

Cryptorchidism Patients have an increased risk of developing a _____ in both the undescended testis and the contralateral testis

malignancy

Rete testis is located at hilum of testis where ______resides

mediastinum

masses that are not "pure seminomas" and consist of other cell types such as: - Embryonal carcinoma - Teratoma - Choriocarcinoma - Yolk sac tumors (Endodermal sinus tumors) - When a mixture of these tumors exists, the tumor is usually referred to as a mixed tumor. A tumor with both seminomatous and non-seminomatous elements is considerd a ????

non-seminomatous germ cell tumor

Sonographic findings associated with : - Focal alteration of testicular parenchymal pattern - Interruption of tunica albuginea - Irregular testicular contour - Scrotal wall thickening - Hematocele

scrotal rupture (Sono findings)

Most common correctable cause of male infertility

varicocele

Sonographic findings: - Dilated veins - shows numerous tortuous tubes of varying sizes within spermatic cord near epididymal head - Valsalva maneuver or having patient stand will increase venous pressure - Reversal of flow occurs when intra-abdominal pressure increase - measure > 2 mm in diameter - Unilateral scrotal pain may be the result of testicular torsion, epididymitis or ???? thrombosis

varicoceles (Sono findings)

caused by scar tissue, called plaque, that forms inside the penis. It can result in a bent, rather than straight, erect penis

Peyronie's

congenital duplication of the testes

Polyorchia

Enlarged cord with variable echogenicity, hypoechoic to hyperechoic with a ___ or ____ mass appearance, representing venous congestion, hemorrhage and arterial occlusion. Color Doppler reveals no flow or partial flow depending on the duration and degree of torsion

"knot" or "whirlpool"

Non-Seminomas The method of treatment is a radical _____ - Alpha Fetoprotein is associated with non-seminomas - Serum beta-hCG is seen in both seminomas and non- seminomas

(inguinal) orchiectomy

Blood chemistry profile:

- Beta-human chorionic gonadotropin (B-hCG) - Alpha-fetoprotein (AFP) - Lactic Dehydrogenase (LDH)

- Testicular torsion leads to venous and arterial occlusion - With testicular ischemia, the testicle becomes enlarged and hypoechoic compared to the contralateral side - Torsion primarily occurs in adolescents and neonates - It is also observed in males under 30, with most aged ___ to ___

12 through 18

With trauma surgery performed within __ hours following injury, up to 90% of testes can be saved, but only 45% can be saved after 72 hours

72 (- Hydrocele and hematocele are both complications of trauma - Hematoceles contain blood; found in advanced cases of epididymitis or orchitis)

Varicocele - Majority (___%) occur on left side due to venous drainage into left renal vein - Large, right-sided varicocele may be associated with renal or retroperitoneal tumor

90

Elevation of serum ____ is an indicator of nonseminomatous tumor. Elevated serum ??? is NOT found with seminomas

AFP

Most commonly caused from untreated epididymo- orchitis

Abscess (Intratesticular or more commonly extratesticular Clinical findings: - Fever - Scrotal pain - Swelling)

Sonographic findings: - Enlarged testicle - Predominantly fluid filled mass with hypoechoic or mixed echogenic areas - Increase blood flow around periphery of the mass - No blood flow in mass

Abscess (Sono findings)

or congenital absence is rare and accounts for only 4 % of patients who present with cryptorchidism

Anorchia

Elevation of serum ___ and ___ levels can be associated with other conditions. Although their elevation in conjunction with a testicular mass suggests testicular cancer

B-hCG and AFO

___ ____ disruption across surface of testis indicates rupture

Blood flow

- Rare germ cell tumor with worst prognosis; all have elevated levels of beta-hCG - Heterogeneous with extensive hemorrhagic necrosis in the central portion of the tumor - Its appearance is determined by the dominant cell type, but it typically has irregular borders

Choriocarcinoma

___ ____ used to confirm absence of flow in testis with torsion, epididymitis.

Color Doppler (Torsion: no flow epididymitis: increased flow in epi)

- Torsion varies between 180 - 540 degrees - Blood flow within the testicle would exclude the diagnosis of a ____ ______, although the presence of flow does not exclude a partial torsion - Partial torsion, torsion-detorsion syndrome or intermittent torsion is challenging to diagnose as arterial waveform changes are subtle - A partial or incomplete torsion may be associated with a Resistive Index > .75 or a to and for (biphasic) waveform

Complete torsion

hidden testicle and generally refers to an undescended testicle

Cryptorchidism (- Testicles usually descend before birth, although spontaneous descent may occur in the first year - Orchioplexy is the treatment of choice and is usually performed on patients aged 2 - 10 years - Testicular descent to the scrotum involves complex anatomical rearrangements and hormonal regulation - The gubernaculum is the key structure guiding testicular descent out of the abdomen to the scrotum)

- Most aggressive of the primary scrotal malignancies - heterogeneous and less well circumscribed - It may contain areas of increased echogenicity resulting from calcification, hemorrhage, or fibrosis - The AFP and beta-human chorionic gonadotropin (beta-hCG) levels are elevated

Embryonal Cell Carcinoma

also known as keratocysts, are rare benign tumors of germ cell origin. The are well- circumscribed and lie beneath the tunica albuginea - They are the most common type of benign testicular neoplasms - The presentation can be similar to those of malignant germ cell tumors. Patients typically present with a painless and non-tender, testicular mass between 1-3 cm in diameter

Epidermoid Cyst

Sonographic Findings: - Non-vascular, well-marginated intratesticular mass - May demonstrate a characteristic lamellated "onion skin" or "whorled" appearance with alternating hyperechoic and hypoechoic rings formed by multiple layers of keratin - Some lesions may show a target appearance with a halo of hypoechogenicity and a central hyperechoic region

Epidermoid Cyst (Sono Findings)

Most common cause of acute scrotal pain.

Epididymitis (- Clinical findings: - Fever - Pain - Dysuria - May have urethral discharge - Usually caused by sexually transmitted organisms such as Chlamydia and Gonorrhea)

Sonographic findings: - Enlarged, hypoechoic ???? (usually of head) - Scrotal wall thickening - Increased blood flow (Hyperemia) - Reactive hydrocele - Hypoechoic testicle - Infection may extend into the testicle causing orchitis

Epididymitis - Normal epididymis shows little flow with color Doppler. - Affected side shows significantly more flow than asymptomatic epididymis (Sono findings)

- Most commonly results from spread of lower urinary tract infection via spermatic cord - Less common causes include mumps, syphilis, tuberculosis, viruses, trauma, and chemical causes - Usually occurs secondary to epidiymitis - Infection of epididymis and testis

Epididymo-orchitis

Clinical findings of: - Intratesticular more common than extratesticular - Associated with trauma - ???? are usually focal but may also be multiple or diffuse - In extratesticular ????, blood collects beneath the tunica dartos and tunica vaginalis - In intratesticular ????, the blood is contained within the scrotum itself - In both conditions, the scrotum is swollen, painful, and sometimes discolored

Hematomas (Clinical findings)

most common cause of painless scrotal swelling

Hydrocele (- Low-level echoes from fibrin or cholesterol crystals may be visualized with the hydrocele - Chronically acquired or secondary hydroceles usually occur in men older than 40. May be idiopathic or the result of trauma, torsion, neoplasms, epididymitis or orchitis - Pyoceles and hematoceles much less common than hydroceles)

Abnormal accumulation of serous fluid within the tunica vaginalis or between the layers of the tunica vaginalis (visceral and parietal layers) Congenital or idiopathic - Most are congenital and noted in boys ages 1-2 years. They are caused by failed closure of the processus vaginalis at the internal ring - Often due to epididymitis - May be seen with orchitis, spermatic cord torsion and trauma

Hydrocele (clinical findings)

involvement of testicle is next most common secondary testicular neoplasm; most often found in children

Leukemia

- Rare, stromal (non-germ cell) testicular tumor occurring in boys (5-10 yrs) and men (30-60 yrs) - May be pure non-germ cell or mixed - Always benign in children, malignant variants have been reported in adults AFP, beta-Hcg and LDH levels are normal

Leydig Cell Tumors (- Commonly found in males, although have been reported in the ovaries of females. Ovarian Leydig cell tumors are usually malignant - Tumor produces testosterone resulting precocious puberty - Tumors may also secrete estrogen resulting in feminizing symptoms)

1% to 7% of all testicular tumors; most common bilateral secondary testicular neoplasm affecting men > 60 years

Malignant lymphoma

- Microcalcifications < 3 mm - bilateral condition - Reported to have association with testicular malignancy; exact nature unknown. This topic is not well understood - Microlithiasis has been associated with cryptorchidism, Klinefelter's syndrome, infertility, varicoceles, testicular atrophy, and male pseudo- hermaphroditism

Microlithiasis

Chlamydia most common cause, other causes: mumps, viral, idiopathic - Sonographic Findings of Include: - Enlarged hypoechoic testicle - Increased blood flow (hyperemia) - Decreased arterial resistence

Orchitis (Sono findings)

an erection that lasts for more than 4 hours and is usually painful.

Priaprism

severe cases of Epididymo-orchitis result in

Pyocele (- Pyocele occurs when pus fills space between layers of tunica vaginalis - Usually contains internal septations, loculations, debris - Same appearance can occur following trauma or surgery)

occur when bowel, omentum, or other structures herniate into the tunica vaginalis of the scrotum - Clinical diagnosis usually sufficient; sonography helpful in cases of equivocal findings - Bowel most common, followed by omentum - Peristalsis of the bowel, seen with real-time imaging, confirms the diagnosis

Scrotal (Indirect Inguinal) Hernia

Most common germ cell tumor type found in both pure seminoma and mixed germ cell masses. - Common in patients with testicular microlithiasis (TM) - Labs show normal AFP - Well-defined, homogeneous, hypoechoic mass without calcification or tunica invasion. Some present with small cystic areas. Echotexture change with infiltration - Color and power Doppler demonstrates hypervascularity in tumors greater than 1.6 cm

Seminoma

occur as chronic inflammatory reaction to extravasation of spermatozoa - Most frequently seen in patients with history of vasectomy - may be located anywhere within epididymis or vas deferens

Sperm granuloma

Cystic lesion of epididymis containing sperm that result from dilatation of the epididymal tubles - Usually located in epididymal head - May be seen more often following vasectomy - Are filled with thick milky fluid containing sperm - ???? and epididymal cysts are the most common epididymal lesions (????? are more common than epididymal cysts - Edelman reference)

Spermatoceles

- Second most common testicular neoplasm in children. Serum AFP (38%) and beta-hCG levels are sometimes elevated - Composed of all three germ layers - Contain multiple tissue elements such as bone, soft tissue, skin, and cartilidge - Large and markedly inhomogeneous masses; cystic components are common; echogenic foci may or may not shadow, which may represent calcification, cartilage, immature bone, and fibrous tissue

Teratoma

Intratesticular - Benign cysts that are normally located near the mediastinum and probably originate from the rete testis - Cysts more common in men over 40 years of age - Associated with extratesticular spermatoceles - Located near mediastinum and probably originate from the rete testis - Single or multiple and of variable size

Testicular Cysts

Clinical findings - Painless lump - Unilateral enlargement - Testicular cancer is uncommon; accounts for only 1% of cancers in men - Is most common malignancy in men between ages of 15 and 35 - Is one of most curable forms of cancer

Testicular cancer

What are all of these? - Testicular torsion - Trauma - Epididyitis/Orchitis - Incarcerated hernia - Torsion of the appendix testis - Varicocele thrombosis

The differential diagnosis of the acutely painful scrotum includes:

Clinical Presentation: - Sudden onset of severe unilateral scrotal pain with swelling on affected side - Fever, nausea, vomiting, absence of cremasteric reflex, high position of the testicle and horizontal lie of the testicle are all associated with ??? Sonographic findings: - Varied and non-specific - Enlarged testicle and epididymal head with decreased echogenicity - Absent flow on color Doppler - Twisting or looping of arteries in the spermatic cord in inguinal canal

Torsion (Clinical/ sono findings)

- ???? occurs as a result of abnormal mobility of the testis within the scrotum - Normally, the testicle is attached the tunica vaginalis, without this attachment or with a high attachment the testicle can rotate freely on the spermatic cord (bell clapper deformity. - "Bell clapper deformity" is the most common cause

Torsion of the spermatic cord (intravaginal, most common)

_____ may be result of MVA, athletic injury, direct blow to scrotum, or straddle injury

Trauma (- Scrotal trauma presents a challenge because scrotum often painful and swollen - Determine if rupture present)

Dilatation of the efferent ductules - More common in men over 55 years - Often bilateral and associated with epididymal cysts and spermatoceles Sonographic appearance: multiple tiny cystic (anechoic) tubules located within or adjacent to the mediastinum testis. With color Doppler, dilated tubules are avascular and fluid filled

Tubular Ectasia of the Rete Testis

most common testicular tumor in infants and young children. _____ are associated with elevated AFP

Yolk sac tumors (also called endodermal sinus tumor)

Extratesticular tumors usually involve the epididymis - The most common extratesticular tumor is the???? - Most scrotal cysts are extratesticular, found in tunica albuginea or epididymis Extratesticular cysts include: - Spermatoceles - Epididymal Cysts - Tunica Albuginea Cysts

adenomatoid tumor

- Undescended testes are 2.5 to 8 times more likely to develop cancer - Testicular tumors categorized as ____ or ____

germ cell and non- germ cell tumors (Approximately 95% of all testicular tumors are of germ cell type and highly malignant)

Germ cell tumors: associated with elevated level of ___ and ____

human chorionic gonadotropin and alpha-fetoprotein (AFP not elevated in Seminomas)

Potential space exists between visceral and parietal layers of tunica vaginalis This space is where a___ ____ ____ may develop

hydrocele, pyocele, or hematocele

- Primary varicocele usually caused by ____ ___ ____within spermatic vein - Secondary varicoceles are caused by ___ ____ on spermatic vein

incompetent venous valves increased pressure

Varicocele is an enlargement (dilatation) of veins of the ____ ____ (located within spermatic cord) which drain the testicle

pampiniform plexus

Metastasis to the testes is rare, with an incidence of 0.68% - The most common primary tumors to metastasize to the testis are ____ (35%), ___ (19%), malignant ____ (9%), ____ (9%), and _____ (7%) Metastases are more common than germ cell tumors in patients >50 years and are often multiple and bilateral

prostate, lung, melanoma, colon, kidney

Seminoma spreads initially to draining lymph nodes in the _____ - When an intratesticular mass is discovered, the paraortic region should be evaluated for lymph nodes - Further investigations includes evaluation of tumor markers (beta-HCG, AFP, LDH)

retroperitoneum

Both ____ and ____ are thought to occur as a result of dilatation of the epididymal tubules, whether secondary to vasectomy, scrotal surgery, trauma, or epididymitis. - Presents as painless scrotal masses (0.2 to 9 cm) - Epididymal cysts are small, clear cysts containing serous fluid located within the epididymis - may be palpable

spermatoceles and epididymal cysts

Torsion of spermatic cord is ____ emergency. Testicular torsion is a clinical diagnosis; imaging studies are not usually necessary and can waste valuable time

surgical (The time between onset of pain and performance of detorsion, and the corresponding salvage rate: - < 6 hours - 90-100% salvage rate - 12-24 hours - 20-50% salvage rate - >24 hours - 0-10% salvage rate)