ABII Scrotum/Penis
Benign Testicular Masses
TUBULAR ECTASIA OF THE RETE TESTIS •Rete testis is located at hilum of testis where mediastinum resides. • •Tubular ectasia of rete testis uncommon, benign condition. •Associated with presence of a spermatocele, epididymal, or testicular cyst or other epididymal obstruction on same side as dilated tubules
Additional arterial vascularity
Testicular: •Major blood supply •Branch off aorta Cremasteric •Branch of inferior epigastric artery (branch of EIA) •Supplies cremasteric muscle and peritesticular tissue Deferential •Branch of vesicular artery (branch of IIA) •Supplies epididymis and vas deferens Pudendal •Supplies scrotal wall
Blood Flow in the Penis
In resting, flaccid state there is very little flow into the cavernosa. Arterioles are constricted. During erection, vasodilation of the arterioles occurs causing increased inflow. At the same time, penile veins are compressed preventing outflow. With a full erection, flow resistance in the corpora cavernosa should increase. So..... Normal erectile function requires sufficient arterial inflow and decreased venous outflow. An insufficient veno-occlusive mechanism resulting in a cavernosal "venous leak" is thought to be a major cause of impotence. Other causes include: arterial insufficiency, hormonal imbalance, and psychogenesis and neurogenic dysfunction.
APPENDIX TESTIS-
remnant of Mullerian duct, near head of epididymis
Anatomy of the Scrotum
•*Tunica vaginalis lines inner walls of scrotum, covering each testis and epididymis. •Extension of peritoneum into the scrotum Consists of two layers: parietal and visceral -Parietal layer is inner lining of scrotal wall -Visceral layer surrounds testis and epididymis -Hydrocele forms between 2 layers (small amount of fluid is normal*) •VAS DEFERENS IS CONTINUATION OF DUCTUS EPIDIDYMIS •SEMINAL VESICLES join the vas deferens (ductus deferens) to form the ejaculatory duct which enters the base of the prostate. •Blood supply: internal spermatic arteries branch off of the aorta just below the renal arteries. Right testicular vein goes into the IVC, left test. vein goes into left renal vein. -Pampiniform plexus •Vas deferens, testicular arteries, venous pampiniform plexus, lymphatics, autonomic nerves, and fiber of cremaster form spermatic cord •Cord extends from scrotum through inguinal canal and internal inguinal rings to pelvis. •Cord suspends testis in scrotum.
VARICOCELE*
•ABNORMAL DILATION OF VEINS OF PAMPINIFORM PLEXUS WITHIN SPERMATIC CORD •PRIMARY: INCOMPETENT VENOUS VALVES IN INTERNAL SPERMATIC VEIN; MORE COMMON ON LEFT •SECONDARY: INCREASED PRESSURE ON SPERMATIC VEIN FROM HYDRONEPHROSIS, MASS, OR CIRRHOSIS; Abdominal malignancy invading left renal vein •RELATED TO INFERTILITY •STANDING OR VALSALVA OR ABDOMINAL COMPRESSION •Varicoceles measure > 2 mm in diameter.
EXTRATESTICULAR MASSES
•ASYMPTOMATIC •MAY BE PALPABLE •EPIDIDYMAL CYSTS •SPERMATOCELE: MAY BE MULTILOCULAR •TUNICA ALBUGINEA CYST
Choriocarcinoma
•Ages 20-30, rare •↑ hCG •Gynecomastia •Hyperthyroidism •Heterogeneous •Extensive hemorrhagic central necrosis •Metastasis common to lung, brain •Worst prognosis
Peyronie's Disease
•Aquired, unknown etiology •Assoc w/diabetes •Middle- aged men •Painful deformity, shortening of penis, less rigidity, painful erection, curved/bent penis •Erectile dysfunction •Formation of fibrous plaques in tunica albuginea of penis causing scar tissue buildup
CONGENITAL ANOMALIES
•CRYPTORCHIDISM - UNDESCENDED TESTICLE •During fetal growth, testes first appear in retroperitoneum near kidneys. Testes should descend into scrotum from inguinal canal shortly before birth or early in neonatal period. •80% FOUND IN INGUINAL CANAL; PALPABLE •SOME CAN BE MANIPULATED INTO PLACE •MORE COMMON IN PREMATURE BABIES (<37 wks) •MAY BE BILATERAL (10-25%) •True Hermaphroditism - both ovarian and testicular tissue; testes homogeneous, ovaries hetero w/follicles •Cyclic hematuria - cyclic bleeding in males due to the urethra being lined with endometrial tissue •Transverse Testicular Ectopia - both testes in same hemiscrotum, may be smaller with GU anomalies •ORCHIOPEXY: SURGERY TO MOVE TESTICLE TO SCROTUM •IF NO SURGERY DONE: •↑ INFERTILITY •↑ TESTICULAR CA. (CA. CAN'T BE PALPATED) •↑ TORSION *Infertility results from pathologic changes that develop in both the undescended and contralateral normal testis after 1 year of age. *Risk of malignancy is increased in both the undescended testis after orchiopexy, and the normally descended testis. •ANORCHIA - RARE; MONORCHIDISM; MORE COMMON ON LEFT; MAY BE CAUSED BY TORSION IN UTERO; MAY BE BIL. • •POLYORCHIDISM - RARE; DUPLICATION IN SCROTUM, INGUINAL CANAL, OR RETROPERITONEUM; 75% ON LEFT •Increased incidence: Malignancy, cryptorchidism, inguinal hernia, torsion with polyorchidism •Small with efferent spermatic system completely absent.
Nutcracker Syndrome*
•Compression of LRV between SMA and aorta •Evidenced by markedly dilated LRV as compared to RRV •Associated symptoms •Left-sided hematuria •Abdominal pain •Varicocele formation (infertility)
Benign Testicular Masses
•Cysts more common in men over 40 years of age. •Associated with extratesticular spermatoceles •Located near mediastinum •Single or multiple and of variable size
ANATOMY
•Each testicle covered with dense, white, fibrous tissue called the *tunica albuginea which is covered by the tunica vaginalis. •The *tunica albuginea extends to the posterior wall to form the mediastinum testes which forms support for the ducts and vessels entering & exiting the testicle. •Echogenic linear stripe that runs craniocaudal
Embryonal Cell Carcinoma
•Embryonal cell carcinoma is heterogeneous and less well circumscribed. It may contain areas of increased echogenicity resulting from calcification, hemorrhage, or fibrosis •Seen in men ages 25-35 •Painful •Aggressive, invasive •↑ AFP, hCG •Yolk sac tumor= 80% of childhood testicular masses •Embryonal cell in children •Under 2 years, rare in adults •Undescended testes
GERM CELL/NON GERM CELL
•GERM CELL TUMORS •95% OF TESTICULAR CANCER •ELEVATED HCG & AFP •TYPES: SEMINOMA, EMBRYONAL CELL CA., TERATOCARCINOMAS, CHORIOCARCINOMA •Most common type of germ cell tumor is seminoma, followed by mixed embryonal cell tumors and teratocarcinomas. •NON-GERM CELL TUMORS •USUALLY BENIGN •If benign, then typically small •Sertoli-Leydig, Leydig •Precocious puberty •Gynecomastia •Adenomatoid •Juvenile Granulosa Cell tumor •Stromal tissue •< 6 months of age •Ambiguous genitalia •May have ↑ AFP/hCG •Cystic components •Orchiectomy •Seminomas tend to be homogeneous, hypoechoic masses with a smooth border, no calcs •Embryonal cell tumors more aggressive than seminomas. •Choriocarcinoma has a varied sonographic appearance because of mixed cell types. •ULTRASOUND ALMOST 100% SENSITIVE FOR DETECTION •CANNOT DISTINGUISH BENIGN FROM MALIGNANT •DOPPLER IS NOT EFFECTIVE IN DX OF MALIGNANCY •METS TO TESTICLE IS RARE; USUALLY FROM PROSTATE OR KIDNEYS
Appendix testis torsion
•Generally seen in presence of hydrocele •Can torse •"Blue Dot sign" •Differentiate from epididymis
EPIDIDYMO-ORCHITIS
•INFLAMMATION OF EPID. AND TESTIS •USUALLY FROM UTI SPREAD FROM SPERMATIC CORD→EPID.→TESTIS •MOST COMMON CAUSE OF SCROTAL PAIN IN ADULTS •*EPIDIDYMITIS: ENLARGED, HYPOECHOIC, HYPEREMIC (hyper vascularity), INHOMOGENEOUS, REACTIVE HYDROCELE, SKIN THICKENING* •PAINFUL* •SCROTAL WALL-THICKENING •HYDROCELE/PYOCELE Pyocele occurs when pus fills space between layers of tunica vaginalis
TORSION
•MOST COMMON CAUSE OF ACUTE SCROTAL PAIN IN ADOLESCENTS •BELL CLAPPER ANOMALY IS MOST OFTEN THE CAUSE (NORMALLY TESTIS IS ATTACHED TO POSTERIOR SCROTAL WALL) •60% HAVE BILATERAL ANOMALY •UNDESCENDED 10 TIMES MORE LIKELY •VENOUS FLOW AFFECTED FIRST •ARTERIAL FLOW→ISCHEMIA IF NOT CORRECTED •5-6 HRS. - 80 TO 100% OF TESTE SALVAGED •6-12 HRS. - 70% •AFTER 12 HRS - 20% •1-6 hours: enlargement, inhomogeneous, hypoechoic •Extratesticular findings: enlarged epididymis, skin thickening, reactive hydrocele •Presence of intratesticular flow does not exclude a partial torsion •At least 560 degrees of torsion is necessary to completely occlude testicular blood flow •PEAK INCIDENCE IS 14, BUT CAN OCCUR AT ANY AGE •SYMPTOMS: •SUDDEN ONSET OF SCROTAL PAIN •SWELLING •NAUSEA & VOMITING •US: DEPENDS ON TIME FRAME * IN THE EARLY STAGES, THE TESTIS CAN APPEAR NORMAL •4-6 HRS - SWELLING AND HYPOECHOIC •AFTER 24 HRS - HETEROGENEOUS •DOPPLER (DIFFERENTIATES FROM ORCHITIS) -POWER (MORE SENSITIVE TO LOW FLOW) OR COLOR DOPPLER -NORMAL PERFUSION SURROUNDING AFFECTED TESTICLE •SPONTANEOUS DETORSION MAY OCCUR
MALIGNANT MASSES
•MOST COMMON MALIGNANCY IN MEN AGES 15-35; 20-34 AVG. AGE •ONE OF THE MOST CURABLE; WHITE MEN MORE COMMON •Undescended testes are 2.5 to 8 times more likely to develop cancer. •SYMPTOMS: •PAINLESS LUMP •TESTICULAR ENLARGEMENT •VAGUE DISCOMFORT •EXTRATESTICULAR USUALLY BENIGN •INTRATESTICULAR USUALLY MALIGNANT
Metastasis
•Metastasis to testicle is rare, normally occurring later in life. •Primary tumor may originate from prostate or kidneys; less common sites include lung, pancreas, bladder, colon, thyroid, or melanoma. •Metastasis to testicle is bilateral, with multiple lesions found. •*If a solid intratesticular mass is found, evaluate periaortic region for lymphadenopathy •LYMPHOMA - 1% to 7% of all testicular tumors; most common bilateral secondary testicular neoplasm affecting men > 60 years •LEUKEMIA - CHILDREN; 8% HAVE TESTICULAR METS. •APPEAR SIMILAR ON US.
Teratocarcinoma
•Most common mixed germ cell tumor •Mix of embryonal cell ca and teratoma •Second most common germ cell tumor after seminoma •Aggressive, large •Heterogeneous, calcs
TRAUMA
•PAINFUL AND SWOLLEN •DETERMINE IF RUPTURE HAS OCCURRED (SURGICAL EMERGENCY) •WITHIN 72 HRS., 90% SAVED •AFTER 72 HRS., 45% SAVED •US: FOCAL ALTERATION OF PARENCHYMA, INTERRUPTION OF TUNICA ALBUGINEA, IRREGULAR CONTOUR, WALL THICKENING, HEMATOCELE (BLOOD IN SCROTAL SAC) •Causes: MVA, ATHLETIC, DIRECT TRAUMA, STRADDLE INJURY •HEMATOCELES VARY WITH AGE -ECHOGENIC→LOW-LEVEL ECHOES -Presence of hematocele does not confirm rupture. •HEMATOMAS -HETEROGENEOUS→COMPLEX -AVASCULAR -Hematomas may involve testis or epididymis, or they can be contained within scrotal wall. •COLOR DOPPLER - BLOOD FLOW DISRUPTION •TRAUMA MAY CAUSE TORSION: NO COLOR FLOW
TESTICULAR US. PROTOCOL
•Sag. midline rt. testicle with and w/o measurement. •Sag. lateral and medial •Trans. midline with and w/o measurement •Trans. superior and inferior •Sag. and trans. epididymis •Repeat for left •Compare echogenicity with split screen •Evaluate for torsion with Doppler color and/or spectral analysis •Valsalva
EPIDIDYMAL CYSTS, SPERMATOCELES, AND TUNICA ALBUGINEA CYSTS
•Spermatoceles are cystic dilatations of efferent ductules of epididymis. -Always located in epididymal head - Contain proteinaceous fluid and spermatozoa - May be seen more often following vasectomy •Epididymal cysts are small, clear cysts containing serous fluid located within the epididymis. •Epididymal cysts, spermatoceles, and tunica albuginea cysts are generally asymptomatic but may be palpable
Patient Positioning and Scanning Protocol
•Supine position •Penis positioned on abdomen and covered with towel. •Patient asked to place legs close together to provide support for scrotum. •Rolled towel placed between thighs can support scrotum. •Apply generous amount of warmed gel to scrotum. •High-frequency probes (10 to 14 MHz) •Bilateral exam, with asymptomatic side used as comparison for symptomatic side. •Each testis scanned from superior to inferior.
ANATOMY
•TESTES: •SYMMETRIC, OVAL GLANDS •3-5 X 2-4 X 3 CM •250-400 LOBULES WITH SEMINIFEROUS TUBULES •CONVERGE TO RETE TESTIS IN MEDIASTINUM TESTIS •Sonographically, testes appear as smooth, medium gray structures with fine echo texture. •EPIDIDYMIS: •6-7 CM TUBULAR STRUCTURE BEGINNING SUPERIOR & COURSING POSTERLATERAL •HEAD (LARGEST 6-15 MM), BODY, TAIL •ISOECHOIC OR HYPOECHOIC TO TESTES; COARSER TEXTURE •*Normal variant: appendix testis or epididymis - tissue extensions which may be seen only with a hydrocele. AKA detached efferent duct
Bell-Clapper
•Tunica vaginalis extends up spermatic cord so testes are not attached normally •Able to freely rotate in scrotal sac •60% have bilateral anomaly
Clinical Questions...
•Was this patient referred because of palpable mass, scrotal pain, swollen scrotum, or other reason? •Ask patient to describe symptoms, including history, location, and duration of pain. •Can he feel a mass? If so, ask patient to find lump. Place probe exactly over this location to examine site. •Did patient experience trauma? When did trauma occur? Describe what happened. •Vasectomy procedure? When?
Rete testis
•drains into head of epididymis through efferent ductules.