small parts chapter 23 scrotum

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

Sperm granulomas

cystic dilatations of efferent ductules of epididymis. Always located in epididymal head Contain proteinaceous fluid and spermatozoa May be seen more often following vasectomy

Spermatoceles

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

Tubular ectasia

lines inner walls of scrotum, covering each testis and epididymis.

Tunica vaginalis

Torsion can occur at any age; peak incidence at age ___, presenting symptoms: Sudden onset of scrotal pain with swelling on affected side. Severe pain causes nausea and vomiting in many patients.

14

Undescended testes are ___ to __ times more likely to develop cancer.

2.5-8

Each testis divided into > ____ to _____ conical lobules containing the seminiferous tubules.

250-400

Rare condition, unilateral ______ , or monorchidism, found in 4% of patients with non palpable testis, more common on left side; definitive diagnosis depends on surgical diagnosis and Causes: Intrauterine testicular torsion or other forms of decreased vascular supply to testicle in utero.

Anorchia

Small protuberance from head of epididymis

Appendix of the epididymis

____________ vein drains into tributaries of epigastric and deep pudendal veins.

Cremasteric

these accompany testicular artery within spermatic cord to supply extratesticular structures .Have anastomoses with testicular artery and may provide some flow to testis. It branches from inferior epigastric artery (branch of external iliac artery) and provides flow to cremaster muscle and peritesticular tissue

Cremasteric and deferential arteries

Undescended testis may be located in abdomen, inguinal canal, or other ectopic location, testis usually found in inguinal canal; often palpable and is bilateral in 10% to 25% of cases.

Cryptorchidism

more common in men over 40 years of age, associated with extratesticular spermatoceles, located near mediastinum, single or multiple and of variable size

Cysts

tumors more aggressive than seminomas, is heterogeneous and less well circumscribed and may contain areas of increased echogenicity resulting from calcification, hemorrhage, or fibrosis

Embryonal cell carcinoma

is next most common secondary testicular neoplasm; most often found in children, testicle may become enlarged; tumor bilateral or unilateral.

Leukemia involvement of testicle

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

Malignant lymphoma

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, this to testicle is bilateral, with multiple lesions found.

Metastasis

Intratesticular masses:

More likely to be malignant

shows numerous tortuous tubes of varying sizes within spermatic cord near epididymal head, tubes may contain echoes that move with real-time imaging, they measure > 2 mm in diameter, tend to increase diameter in response to Valsalva maneuver.

Sonographic evaluation of varicocele

is a collection of pus and occur with untreated infection or when an abscess ruptures into space between layers of tunica vaginalis.

Pyocele

drains into head of epididymis through efferent ductules.

Rete testis

is located at hilum of testis where mediastinum resides.

Rete testis

these arise from abdominal aorta below level of renal arteries.

Right and left testicular arteries

occur when bowel, omentum, or other structures herniate into scrotum, clinical diagnosis usually sufficient; sonography helpful in cases of equivocal findings, bowel most commonly herniated structure, followed by omentum.

Scrotal hernias

are caused by increased pressure on spermatic vein, may be result of renal hydronephrosis, abdominal mass, or liver cirrhosis, abdominal malignancy invading left renal vein may cause varicocele with noncompressible veins.

Secondary varicoceles

appears as enlarged, hypo echoic gland, if secondary hemorrhage has occurred, epididymis may contain focal hyper echoic areas, and hyperemic flow confirmed with color Doppler.

Sonographic Findings of Epididymitis

Solid hypoechoic mass, hyper echoic or mixture of both

Sonographic Findings of Metastasis

Smaller and less echogenic than normal testis, usually oval with homogeneous texture and mediastinum rarely seen.

Sonographic Findings of Undescended testis

Extratesticular masses:

Usually benign

these form the spermatic cord:

Vas deferens, testicular arteries, venous pampiniform plexus, lymphatics, autonomic nerves, and fiber of cremaster

Non-germ cell tumors are generally

benign

Capsular arteries give rise to _______ _______, which course from testicular surface toward mediastinum along septa.

centripetal arteries

Duct is known as

ductus epididymis

what forms in the space between the layers of tunica vaginalis?

hydroceles

left testicular vein joins the

left renal vein

supports vessels and ducts coursing within testis.

mediastinum

often seen on sonography as bright hyperechoic line coursing craniocaudad within testis.

mediastinum on sonography

Posterior aspect of tunica albuginea reflects into testis to form vertical septum known as

mediastinum testis

Testis are covered by dense, fibrous tissue termed

tunica albuginea

is an abnormal dilation of veins of pampiniform plexus (located within spermatic cord). Primary usually caused by incompetent venous valves within spermatic vein. More common on left

varicocele

It then becomes the ____ _____________ and continues in spermatic cord, these are thicker and less convoluted (continuation of ductus epididymis)

vas deferens

The junction of ejaculatory ducts with urethra is called the...

verumontanum.

surrounds testis and epididymis

visceral layer

of the bowel, seen with real-time imaging, confirms the diagnosis of a scrotal hernia.

Peristalsis

tubules converge at apex of each lobule and anastomose to form _______ in mediastinum.

rete testis

Testicular cancer is uncommon; accounts for only __% of cancers in men

1

Pampiniform plexus converges into three sets of anastomotic veins:

1.Testicular 2. Deferential 3. Cremasteric

epididymis contains __ to __ efferent ductules from rete testis, which converge to form single duct in body and tail

10-15

Adults: Testis measure

3-5 x 2-4 x 3 cm

Torsion of spermatic cord is surgical emergency, if surgery performed within 5 to 6 hours of onset of pain, ___% to ___% of testes can be salvaged, Between 6 and 12 hours salvage rate is ___%. After 12 hours only ___% will be saved.

80-100, 70, & 20.

If surgery performed within 72 hours following injury, up to ___% of testes can be saved, but only ___% can be saved after 72 hours.

90, 45

occurs when tunica vaginalis completely surrounds testis, epididymis, distal spermatic cord, allowing them to move and rotate freely within scrotum.

Bell clapper deformity

has a varied sonographic appearance because of mixed cell types and its appearance is determined by the dominant cell type, but it typically has irregular borders.

Choriocarcinoma

arises from vesicle artery (branch of internal iliac artery) and mainly supplies epididymis and vas deferens

Deferential artery

are small, clear cysts containing serous fluid located within the epididymis.

Epididymal cysts

is infection of epididymis and testis, most commonly results from spread of lower urinary tract infection via spermatic cord, most common cause of acute scrotal pain in adults, usually occurs secondary to epidiymitis.

Epididymo-orchitis

are collections of blood associated with trauma, surgery, neoplasms, or torsion.

Hematoceles

these contain blood; found in advanced cases of epididymitis or orchitis.

Hematoceles

these are associated with trauma may be large and cause displacement of the associated testis, appear as heterogeneous areas within scrotum, become more complex with time, developing cystic components, may involve testis or epididymis, or they can be contained within scrotal wall.

Hematomas

what probe will you use for this exam?

High-frequency(10 to 14 MHz)

contain serous fluid, are most common cause of painless scrotal swelling and may be idiopathic, but commonly associated with epididymo-orchitis and torsion

Hydroceles

right testicular vein drains into the

IVC

Formed from tunica albuginea at mediastinum and course through testis and separate it into lobules

Multiple septa (septa testis)

Isoechoic or hypoechoic compared with testis and the echo texture is coarser

Normal epididymis

exits from mediastinum testis and courses in spermatic cord and venous drainage of the scrotum occurs through veins of

Pampiniform plexus

Very rare condition, testicle cannot be manipulated into correct path of descent, most common site for this type of testicle to rest is superficial inguinal pouch and other sites include perineum, femoral canal, suprapubic area, penis, diaphragm, and other scrotal compartment.

Testicular Ectopia

______ hematocele is echogenic with numerous, highly visible echoes that can be seen to float or move in real time

acute

vas deferens dilates at terminal portion near seminal vesicles, which is termed

ampulla of the deferens

then the centrifugal arteries branch further into ________ and ______

arterioles and capillaries

Blood vessels, lymphatics, nerves, spermatic ducts travel through this area:

bare area(posterior)

Vas deferens joins duct of seminal vesicles to form _________ _______, which empties into urethra.

ejaculatory duct

6- to 7-cm tubular structure beginning superiorly and then coursing posterolaterally to testis

epididymis

Most scrotal cysts are _________, found in tunica albuginea or epididymis. Include spermatoceles, epididymal cysts, tunica albuginea cysts

extratesticular

Is most common malignancy in men between ages of 15 and 35, is one of most curable forms of cancer and occurs most frequently between ages of 20 and 34

germ cell tumor

elevated level of human chorionic gonadotropin and alpha-fetoprotein and approximately 95% of all testicular tumors are of germ cell type and highly malignant.

germ cell tumors are associated with

is largest part, 6 to 15 mm in width.

head

the epididymis is divided into the.....

head, body, and tail

Microcalcifications are < 3 mm, usually bilateral condition, reported to have association with testicular malignancy; exact nature unknown, has been associated with cryptorchidism, Klinefelter's syndrome, infertility, varicoceles, testicular atrophy, and male pseudohermaphroditism.

microlithiasis

tunica vaginalis consists of 2 layers:

parietal and visceral

is inner lining of scrotal wall

parietal layer

Deferential vein drains into the

pelvic veins

Scrotal wall also supplied by branches of _________ artery.

pudendal

Severe cases: _____ may be present, occurs when pus fills space between layers of tunica vaginalis, usually contains internal septations, loculations, debris, and same appearance can occur following trauma or surgery.

pyocele

Before the centripetal arteries reach the mediastinum, they curve backward forming the..

recurrent rami (centrifugal arteries).

Most common type of germ cell tumor is ________, followed by mixed embryonal cell tumors and teratocarcinomas, tend to be homogeneous, hypoechoic masses with a smooth border and they do not often contain calcification or cystic components.

seminoma

what 3 things do you want to evaluate when scanning the testes? Testicular parenchyma should be uniform with an equal echogenicity between sides.

size, echogenicity and structure

the body of the epididymis is _____ than the head

smaller

Sonographically, testes appear as

smooth, medium gray structures with fine echo texture.

focal, hypoechoic masses.

sonographically tumors appear as

Cord extends from scrotum through inguinal canal and internal inguinal rings to pelvis and it suspends testis in scrotum.

spermatic cord

epididymis is located _________ to upper pole of testis

superior

Painless lump, testicular enlargement, or vague discomfort in scrotum

symptoms of germ cell tumor

Slightly larger and positioned posterior to lower pole of testis

tail of the epididymis

Symmetric, oval-shaped glands residing in the scrotum

testes

Very rare disorder; more common on left side (75%); bilateral in 5% of cases, usually found in scrotum; has also been found in inguinal canal or retroperitoneum, increased incidence: Malignancy, cryptorchidism, inguinal hernia, torsion with this and are usually small; efferent spermatic system completely absent.

testicular duplication: Polyorchidism

Occurs as result of abnormal mobility of testis within scrotum, testis and epididymis twist within scrotum, cutting off vascular supply within spermatic cord, up to 60% of patients have anatomic anomaly on both sides, undescended testes are 10 times more likely than normal testes to be affected by this

torsion