Scrotum

Teratoma Sonographic Appearance

-large -markedly inhomogeneous masses -Cystic components are common. -echogenic foci may or may not shadow, which may represent calcification, cartilage, immature bone, and fibrous tissue

body of epididymis location

-lies adjacent to the posterolateral margin of the testis

normal adult testis size

-measures 3 to 5 cm in length and 2 to 3 cm in the transverse and AP diameters -size of both the testis and the epididymis decreases with increasing age

sonographic appearance of testicular lymphoma

-nonspecific -One or both testes may be enlarged -there are areas of decreased echogenicity -either diffuse or focal as lymphomatous tissue replaces normal testicular tissue

sonographic appearance of yolk sac tumor

-nonspecific -tumors are usually inhomogeneous -may contain echogenic foci secondary to hemorrhage -or hypoechoic areas due to necrosis

sonographic appearance of an undescended testis

-oval or elongated -well circumscribed -hypoechoic -homogeneous soft tissue structure -smaller than the normal descended intrascrotal testis

what are the most common primary tumors to metastasize to the testis?

-prostate (35%) -lung (19%) -malignant melanoma (9%), -colon (9%) -kidney (7%)

what is the range of severity of testicular torsion? Twisting of the spermatic cord results in ____

-severity of testicular torsion ranges from 180 to 720 degrees or greater -venous congestion

sonographic appearance of a leiomyosarcoma, fibrosarcoma, or liposarcoma

-solid -ill-defined -inhomogeneous -disorganized mass with echogenic and anechoic areas representing necrosis

Grayscale images are often nonspecific for evaluating ____ and often appear ___ when torsion is acute

-testicular torsion -normal

sonographic appearance of pyocele

-thick hemiscrotal wall -echogenic fluid collections with septations -occasionally focal mural calcifications

sonographic appearance of a spermatocele and location

-thin-walled hypoechoic mass located in the epididymal head -Spermatoceles characteristically contain low-level echoes, due to the proteinaceous fluid and spermatozoa -posterior acoustic enhancement

sonographic appearance of tunica albuginea cyst and size

-well circumscribed anechoic areas -measuring 2 to 5 mm in size -meets all the characteristics of a simple cyst -cysts are small and may be single, multiple, unilocular, multilocular, or septate

sonographic appearance of an epididymal leiomyoma

-well-circumscribed -homogenous -solid mass -variable echogenicity with or without cystic spaces -On color Doppler evaluation, there is minimal flow within the mass

sonographic appearance of epididymal cyst

-well-defined -thin-walled -anechoic mass with good posterior acoustic enhancement -no internal echoes

sperm granuloma sonographic appearance and location

-well-defined solid -hypoechoic or heterogeneous masses -located anywhere in the ductal system

What is the most common age for testicular torsion?

12-18

what size is the normal scrotal wall thickness?

2 to 8 mm, depending on the state of contraction of the cremaster muscle

what role does sonography play in examining the scrotum?

Sonography is used to determine whether a palpable mass is cystic or solid and differentiate between intratesticular and extratesticular

what is the second most common testicular neoplasm in children, usually occurring in children less than 4 years of age?

Teratoma

which of the following is the fibrous sheath that covers and protects the testis and also makes up the mediastinum testis?

Tunica albuginea

sonographic appearance of an adenomatoid tumor

well circumscribed solid mass with variable echogenicity compared with the adjacent testis

what are the most common causes of acute scrotal pain?

-Epididymitis -epididymo-orchitis

sonographic appearance of testicular atrophy

-a small or shrunken -heterogeneous -testis displaying increased echogenicity due to fibrosis -A uniform hypoechoic testis may be seen with associated concurrent ischemia (lack of oxygenated blood)

what is testicular rupture associated with?

-athletic injuries -industrial and motor vehicle accidents

Acute hematomas sonographic appearance

-avascular hyperechoic areas compared with adjacent testicular parenchyma -As the hemorrhage ages, the hematoma appears hypoechoic or complex with cystic components

Acute scrotal hematoma sonographic appearance

-avascular hyperechoic areas compared with adjacent testicular parenchyma -As the hemorrhage ages, the hematoma appears hypoechoic or complex with cystic components

Scrotal blood flow is supplied by

-bilateral testicular -cremasteric -deferential arteries

sonographic appearance of lipomas

-circumscribed -homogeneous -hypoechoic to hyperechoic structure -alters its shape with transducer compression -echogenicity of lipomas varies depending on the ratio of fat cells to interstitial tissue

sonographic appearance of a rhabdomyosarcoma and size

-circumscribed -unilateral -hypoechoic lesion -without a capsule -measuring 1 to 2 cm in size

Sonographic appearance of chronic hematoceles

-complex -heterogeneous collection -thick septations -debris -scrotal wall thickening -occasionally focal mural calcifications

sonographic appearance of scrotal abscess

-complex fluid collection -irregular borders -hyperemia around the periphery -Gas may be present, causing echogenic shadowing with ring down artifact. -Scrotal wall thickening with hyperemia, in conjunction with a history of immunosuppressive conditions, warrants consideration for the diagnosis of Fournier gangrene

what are some benign intratesticular masses that can mimic malignancy?

-hematomas -focal orchitis -infarction -granuloma

Choriocarcinoma sonographic appearance

-heterogeneous -show extensive hemorrhagic necrosis in the central portion of the tumor with a mixed echo pattern

sonographic appearance of teratocarcinoma

-heterogeneous mass with echogenic foci -cystic areas secondary to hemorrhage and calcifications

sonographic appearance of the scrotal wall

-homogeneous -slightly echogenic compared to the testis

echogenicity of normal body and tail of the epididymis

-homogeneous -largely isoechoic to or slightly more echogenic than the testis

sonographic appearance of embryonal cell carcinoma

-hypoechoic mass -more heterogenous than seminoma -poorly defined borders -cystic components are seen in 1/3 of tumors -calcifications or echogenic foci are not uncommon

you detect a mass w/in the L testis on a 43 y/o male what is a sign indicative of malignancy?

-irregular shape of testis -intratesticular location of the mass

tunica vaginalis

-peritoneal sac -composed of two layers, the visceral and parietal layers, that cover and surround the testis and epididymis except for a small posterior area

what are the lab values may be elevated w/ testicular malignancy?

AFP and HCG

Acute hematoceles sonographic appearance

Acute hematoceles are usually more echogenic

what carcinoma has the worst prognosis of any of the germ cell tumors? with death occurring within 1 year of diagnosis

Choriocarcinoma

What are the parts of the epididymis?

Head, body, tail

______ is present with acute bacterial epididymitis

Hypervascularity

what will spectral doppler demonstrate on sonography in patients presenting with acute epidymo-orchitis?

In patients presenting with acute epididymo-orchitis, spectral Doppler demonstrates decreased vascular resistance (resistive index [RI] <0.5) compared with the normal contralateral testis and epididymis.

what is important to consider for intratesticular solid masses?

Intratesticular solid masses must be considered malignant until proven otherwise

what are the 2nd most common primary benign neoplasm of the epididymis?

Leiomyomas

what are the most common extratesticular neoplasm that involves the spermatic cord?

Lipomas

what are the complication of vasectomy?

Patient had a vasectomy in the past, they have -spermatocele -Epididymal cyst -dilation of the rete testis

In young men, what is the most cause of epididymitis?

STD

under what circumstance should we perform valsalva maneuver when evaluating the scrotum?

Since primary varicoceles may decompress when the patient is supine, perform the Valsalva maneuver or scan the patient in the upright position to increase venous blood flow

why is it important to differentiate the distinction between an intratesticular lesion and extratesticular lesion?

The distinction between an intratesticular lesion and an extratesticular lesion is an important one considering most intratesticular solid masses are considered malignant until proven otherwise

when does torsion become more frequent?

Torsion becomes more frequent after puberty because the testis is larger than its mesentery

when does torsion occur most commonly?

Torsion occurs most commonly during adolescence, between 12 and 18 years of age, with a peak incidence occurring at 14 years

when evaluating patients for acute scrotal pain, what do we do?

When evaluating patients for acute scrotal pain, *scan the asymptomatic side first*, adjusting the gray scale, color, and power Doppler settings to allow for comparison with the symptomatic side

testicular artery is a branch of what artery?

abdominal aorta

what is not routinely visualized by sonography? why?

appendix testis and appendix epididymis are embryologic remnants. They are not routinely visualized by sonography unless a hydrocele is present

what is the most common extratesticular neoplasm?

benign adenomatoid tumor

Hydroceles form in what potential space?

between the two layers of the tunica vaginalis

You have a 42 y/o patient with painless right scrotal mass, sonography shows 2.5 cm irregular, hypoechoic mass in the rete testis. Color doppler demonstrated hyperemia and the remainder of the scrotum, including the scrotal wall looks normal. What is the most likely diagnosis? a. orchitis b. abscess c. seminoma d. varicocele

c. seminoma bc it's painless, irregular, hypoechoic mass, and color represents hyperemia

intratesticular arteries that arise from the capsular artery are known as?

centripetal arteries

What artery courses within the testicular parenchyma?

centripetal artery

sonographic appearance of a hematocele and location

complex heterogeneous collection within the tunica vaginalis

what is the most common sonographic appearance of a malignant testicular mass? a. hyperechoic with diffuse calcifications b. complex mass with thick septations c. cystic mass with ring calcifications d. hypoechoic mass

d. hypoechoic mass

sonographic appearance of an inguinal hernia

depends on the contents

sonographic appearance of the scrotal ligament and location

echogenic band extending from the caudal end of the testis to the scrotal wall

Sonographic appearance mediastinum testis

echogenic line -echogenic band running in a cephalocaudal orientation within the testis in the longitudinal plane -In the transverse plane, it is seen as an ovoid echogenic structure in the 3 or 9 o'clock position

sonographic appearance of the testis In infants and children

echogenicity of the testis is hypoechoic compared to that of the adult

Granulomatous Disease sonographic appearance

epididymis is either diffusely enlarged or nodular and enlarged

26 y/o patient has fever, scrotal pain, and swelling, sonography shows enlarged hypoechoic epididymis w hyperemia, small hydrocele is noted, testis appears normal. What is this?

epididymitis

sonographic appearance of the postvasectomy can mimic ______

epididymitis Clinical history and the use of color Doppler imaging differentiates between the two entities

what is the most common cause for acute scrotal pain?

epididymitis or epididymo-orchitis

what kind of blood flow signals will we see in the peripheral zone of tuberculous epididymitis

focal linear or spotty blood flow signals may be seen in the peripheral zone of tuberculous epididymitis

what is the common location of spermatocele?

head of epididymis

epididymal head sonographic appearance

homogeneous and largely isoechoic to or slightly more echogenic than the testis

sonographic appearance of the normal adult testis

homogeneous with medium level echoes similar to the thyroid gland, with a smooth contour

what is the collection of serous fluid found between the 2 layers of the tunica vaginalis?

hydrocele

sonographic appearance of the normal rete testis

hypoechoic area with striations, located adjacent to or within the mediastinum testis

when can the incidence of serminoma increase?

incidence of seminoma is 2.5 to 8 times higher in the patient with an undescended testis than in the general population

33 y/o male has been reffered for a scrotal US study on a 27 y/o male w/ scrotal pain to rule out epididymo-orchitis versus torsion, what is consistent with epididymitis?

increased flow by color doppler

right testicular vein drains into the

inferior vena cava while

sonographic findings and appearance of acute epididymitis, epididymo- orchitis, and orchitis include

inflammation, enlargement, anechoic compared to other structures -enlargement and variable echogenicity of the affected structure -epididymis and/or testis are usually hypoechoic due to edema, with areas of hyperechogenicity, secondary to hemorrhage and infection -Scrotal wall thickening and reactive hydrocele (fluid between the parietalis and vaginalis fascia) are common associated findings

when is hyperemia seen?

inflammations either epididymitis or epididymo orchitis

You recieved a request to evaluate a child with undescended testis, where are the majority of undescended testis located?

inguinal canal

sonography is considered the primary imaging modality to assess _____

intratesticular arterial perfusion

Appendages of the testis and epididymis sonographic appearance and location

isoechoic to echogenic protuberances superior to the testis and the epididymis

left testicular vein drains into the

left renal vein

the tail of the eipdidymis (globus minor) location

lies on the inferolateral surface of the testis

you are performing a doppler evaluation of the testis. which of the following describes the waveform you will see w/in an artery of the testicular parenchyma if the testis is normal?

low resistance

sonographic appearance of seminoma

malignant tumor solid homogenous mass -well-defined -homogeneous -hypoechoic mass -without calcification or tunica invasion

body of epididymis size

measures 2 to 4 mm in AP diameter

tail of the epididymis size

measures 2 to 5 mm in superior to inferior diameter

rete testis is located in the

mediastinum testis

sonographic appearance of nontuberculous epididymitis

more likely to be homogeneous

venous drainage from the scrotum, inclusive of the mediastinum, epididymis, and scrotal wall, is via.. and empties into..

pampiniform plexus, which empties into the testicular veins

Malignant testicular tumors sonographic appearance

predominantly hypoechoic (92%) compared with the normal testicular parenchyma

what is the most common malignant tumor in the epididymis and spermatic cord?

rhabdomyosarcomas, representing 6 % of all non-germ cell intrascrotal tumors

incidence of _____ is 2.5 to 8 times higher in the patient with an undescended testis than in the general population

seminoma

what is the most common germ cell testicular tumor in the testis?

seminoma

what is the most common germ cell testicular tumor?

seminoma

vascular components of the spermatic cord

spermatic cord is composed of: -arteries (the testicular, cremasteric, and deferential), -veins of the pampiniform plexus, nerves, lymphatics, vas deferens, and connective tissue

head of the epididymus location and size

superolaterally to the testis and measures 10 to 12 mm in AP diameter

The capsular artery of the testis is a branch of what artery?

testicular

Patient in the clinic with very sharp pain onset, nausea, vomiting, you scan and see large hyperechoic with decreased arterial flow. What is this?

torsion

Undescended testes are at increased risk for

torsion and commonly associated with malignant degeneration

patient has scrotal sonograhy, history of vasectomy and scrotal discomfort. Multiple cystic structures are seen both testis along the mediastinum testis.. Color doppler doesn't demonstrate any flow in these cystic regions. What is this?

tubal ectasia (dilation) of the rete testis (cyst)

sonographic appearance of TB epididymitis

usually heterogeneous or nodular

33 y/o male has been referred for a scrotal US as a part of an infertility work up. You will tailor your exam to include an evaluation for?

varicocele

Patient has scrotal sonography and has history of infertility, testis look normal bilaterally, superior to the testis you will see multiple cystic structures, the largest of the cystic structure is about 4mm. color doppler shows flow w/in the structure and increase flow when the patient is asked to perform valsalva maneuver?

varicocele

what is the most common cause of correctable infertility?

varicocele

when talking about fluid what is the first thing you want to check for

varicocele

sonographic appearance of scrotal hematomas and size

varies with size and duration