Scrotum

Sono of malignant forms of Leydig and Sertoli:

Larger (>5cm) and have less well-defined borders. - solid testicular mass, echogenicity of mass varies, usually hypoechoic relative to normal parenchyma.

Spermatocele/Epididymal Cysts

Most common epididymal lesions - 20-40% of asymptomatic patients - painless scrotal masses; 0.2-9 cm - both thought to occur as result of dilatation of epididymal tubules, whether secondary to vasectomy, scrotal surgery, trauma or epididymitis - most common location for spermatoceles is HEAD OF EPI - epididymal cysts arise THROUGHOUT EPI

- Focal EPI-it; isolated orchitis

_____ occurs in approx. 25% of cases; _____ =occurs in 10%

Testicular Torsion

- 20% of scrotal disease in postpubertal males - most commonly during adolescence, between 12-18 yrs; peak incidence @14 yrs

Mixed Germ Cell Tumors:

- 40-60% of all germ cell tumors - Teratocarcinoma is most common mixed GCT - contains both teratoma and embryonal carcinoma cells. - Aggressive and largest of all testicular tumors - Sono: heterogeneous mass with echogenic foci and cystic areas secondary to hemorrhage and calcifications

Testicular lymphoma

- 5% of all testicular neoplasms - most common bilateral testicular tumor - occurs in less than 1% of pts who have lymphoma - occurs in older pts - most common testicular neoplasm in men OVER 60 YRS old - aggressive; infiltrates the epididymis and spermatic cord in 50% of cases

Epididymitis

- 75-80% of all acute inflammatory processes in scrotum - ages 20-30 yrs most often effected - adolescents and young men: secondary to STOrganisms like chlamydia/gonorrhoeae - prepubertal boys and men over 35: E Coli and Proteus mirabilis

Yolk Sac Tumor

- Account for 80% of childhood testicular tumors (most occur before 2 yrs of age) - exclusively produce AFP in more than 90% of cases. - Pure yolk sac tumors are rare in adults - presence of any yolk sac tumor element in an adult mixed cell tumor indicates poor prognosis

Metastases:

- More common than GCT in pts >50 yrs - often multiple and bilateral - primary tumors TO testis: prostate (35%) lung (19%) malignant melanoma (9%) colon (9%) and kidney (7%)

Seminomas

- Most common pure germ cell tumor - 40-50% of primary testicular neoplasms - occurs most often in 4th and 5th decades - average 40.5 years - 8-30% of patients have HX of undescended testes. - commonly found in patients with TM - AFP level is always normal in patients with pure seminomas - if elevated AFP, tumor is treated as a NSGCT

Leukemia:

- Primary leukemia is rare - blood-testis barrier prevents the accumulation of chemotherapeutic drugs within testis - testes may be "sanctuary organ" for hematologic malignancies such as leukemia and lymphoma - found in 40-65% of acute leukemia pts at autopsy and 20-35% of pts with chronic leukemia - diffusely infiltrates testis -> hypoechoic enlargement - unilateral enlargement of testis with normal echogenicity can also be seen.

Teratoma

- Second most common testicular neoplasm in children (less than 4 yrs of age) - pure teratomas are rare in adults; teratomous components occur in more than 50% of all adult cases of mixed germ cell tumors. - Serum AFP (38%) and beta HCG levels are sometimes elevated - contain multiple tissue elements such as bone, soft tissue, skin and cartilage

Hydrocele

- abnormal accumulation of serous fluid in potential space between visceral and parietal layers of tun vag - most common cause of painless scrotal swelling; may be congenital or acquired - congenital hydro: communicating = due to failure of processus vaginalis to close, allowing serous fluid to communicate between abd cav and scrotum - present in 6% male infants at delivery; less than 1% of adults; most resolve within 18 months of age

Hematocele:

- accumulation of blood between parietal and visceral layers of tun. Vag. - generally result of trauma, surgery, tumor or torsion - acute or chronic

Epidermoid Cyst

- benign teratoma with only ectodermal components and squamous metaplasia of the surface mesothelium of the testis - rare, only account for 1-2% of all testicular neoplasms - Caucasian and Asian 20-40 yrs - slightly higher prevelance in the right testis. - Avascular mass.

Pyocele:

- clinical signs mimic infection and inflammation: hemiscrotal swelling and pain - following trauma, iatrogenic contamination, rupture of testicular abscess - puss fills potential space between pariental and visceral laters of tun. Vag.

Tubular Ectasia of Rete Testis

- dilatation of efferent ductules - common in med older than 50 years - bilateral; assoc with epididymal cysts and spermatoceles; resulting from partial or complete obliteration of efferent ductules due to inflammation, surgery or trauma - has been described in postvasectomy pts

Varicocele

- dilatation of veins of pampiniform plexus >2 mm - located superior and posterior to testis - caused by incompetent valves of internal spermatic vein - 2 tpes: primary (idiopathic) and secondary - idiopathic: approximately 15% of adult men, left side in 98% of cases (length of LTV and angulations of entry of LRV); men aged 15-25 years; bilateral involvement in 30% of men

Sperm Granuloma:

- following trauma, vasectomy or infection - sperm extravasate into surrounding tissues and produce necrosis = granulomatous formation - occur in 40% of pts postvasectomy; only 3% experience pain - Asymptomatic, but can present as painful nodules

Leydig Cell tumors

- gonadal stromal tumors - most common non-germ cell neoplasm of testis - considered in benign group BUT 10-15% malignant - comprise between 1-3% of all testicular neoplasms - occur in men 20-50 yrs - clinical features: endocrine imbalance, impotence, decreased libido, gynecomastia - They comprise 3% of all testicular tumors, and 90% of the time are benign

Simple Intratesticular Cyst

- incidental finding - 10% of male population over age 40 - asymptomatic - sono: true cyst qualifications - range from 2mm-2cm - can be located anywhere within testis; commonly located adjacent to mediastinum testis

Sertoli Mesenchymal Tumors

- less than 1% of all testicular tumors - most common clinical presentation: painless testicular mass - feminization with gynecomastia in malignant sertoli, or those with large cell calcifying variant type - may occur in undescended testes and in pts with feminization, Klinefelter syndrome, Peutz-Jeghers syndrome.

Torsion of Appendages

- more than 90% of torsed appendages involve appendix testis - 20-40% of cases of acute scrotum in pubescent and adolescent males - peak incidence: 7-14 yrs - testis is normal by color duplex

Lipomas (benign)

- most common extra testicular neoplasm that involves spermatic cord. - circumscribed, homogrenous, hypoechoic to hyperechoic structure that alters its shape with TRX compression - Echogenicity vaties depending on the ratio of fat cells to interstitial tissue

Benign adenomatoid tumor

- most common extratesticular neoplasm - 30% of all extratesticular benign lesions - generally located within epididymal tail, but can occur throughout epi, testis, testicular tunica and spermatic cord. - painless mass or incidental finding - any age, most commonly 20-50 yrs

Rhabdomyosarcomas

- most common malignant tumor involving the epididymis and spermatic cord - 6% of al non-germ cell intrascrotal tumors. - Occur predominantly in children and adolescents

Scrotal Abscess

- most often complication of un-treated epididymo-orchitis - less frequently develops in pts with debilitating underlying disease: diabetes, HIV, cancer or alcoholism - clinical presentation: painful, swollen scrotum - association with Fournier syndrome (potentially life-threatening necrotizing infection; over 50 yrs old; idiopathic gangrene of scrotum - mixed bacterial infections e.choli, streptococci, proteus, enterococci)

Sarcoidosis:

- noninfectious, chronic granulomatous disease - infect genital tract - intrascrotal is rare - epididymis more commonly affected - epididymal sarcoidosis more often in African Americans - often asymptomatic

Embryonal cell CA

- primarily in men 25-35 - second most common histologic type of testicular tumor after seminoma - invades tunica albuginea and distorting testicular contour - most aggressive of the primary scrotal malignancies - AFP and beta-hGC levels are elevated in approximately 70% of patients - hypoechoic mass, more heterogeneous than seminoma, poorly defined borders. - cystic components are seen in 1/3 tumors and calcifications or echogenic foci not uncommon.

Choriocarcinoma

- rare germ cell tumor seen in less than 1% patients - 20-30 yrs - ALL patients have elevated levels of beta-hCG - WORST prognosis of any of the germ cell tumors, death occurring within 1 yr of diagnosis

Testicular Rupture:

- rare; capsule of tun albu is torn by trauma - associated with athletic injuries, industrial and mva's - early diagnosis critical; salvage rate changes from 90% to 45% after 72 hours.

Leiomyomas (benign)

- second most common primary benign neoplasm of epididymis - 6% of epididymal tumors - generally asymptomatic - small, slow growing painless, firm, intrascrotial extratesticular masses - 1-4 cm - commonly in 5th decade. - involve tail of epididymis, usually unilateral - associated hydrocele in 50% of cases.

Sono of benign Leydig and Sertoli cell tumors:

- small, less than 1 cm, well-circumscribed masses - Leydig: demonstrate prominent peripheral flow by color and power Doppler.

Tunica Albuginea Cyst

-uncommon - unknown etiology; believed mesothelial in origin - presents as painless scrotal lump - seen in 5th and 6th decades

gray scal is normal, hyperemia is only finding.

20% of pts with EPI-it is and 40% with Orchitis:

Granulomatous Disease

: - results from retrograde spread of TB from prostate, seminal vesicles and kidneys or from hematogenous spread - TB infection of scrotum is rare (7% of pts infected with TB) - genitourinary system is most common affected extrapulmonary site for TB - peak incidence of granulomatous disease in scrotum occurs aged 20-50 yrs - pt presents: painful or painless swelling of scrotum - epididymis affected first -> isolated epididymitis -> later stages can spread to adjacent testes. - isolated testicular infection is rare - TB epididymo-orchitis may be unilateral or bilateral

Coexistent orchitis

develops in 20-40% of pts dur to direct spread of infection - 25% of acute inflammatory processes of scrotum - untreated: can progress to abscess, gangrene, infarct, pyocele infertility and atrophy clinical indications: fever, tenderness,

Scrotal Hematoma:

intratesticular or extratesticular (involving scrotal wall, tun vag, and EPI) - both usually associated with HX of trauma - usually focal but may also be multiple or diffuse - extratesticular: blood collects beneath tun dartos and tun vag - intratesticular: blood is contained within scrotum itself - both: scrotum is swollen, painful, sometimes discolored

Leiomyosarcoma/Liposarcomas/Fibrosarcoma/ Malignant Mesenchymoma

mesenchymal sarcomas arising in paratesticular soft tissues - Most commonly occur in spermatic cord and in patients over 40 yrs - 30% of spermatic cord tumors are malignant.