Ultrasound Scrotum and Testicles

What seminoma subtype do men in their early 50's tend to get and what is the prognosis?

Spermatocytic subtype Excellent prognosis with orchiectomy only. Tumor markers not elevated.

What type of Nonseminomatous germ cell tumor is rare in adults in the pure form?

Teratoma

What are vascular diseases of the testicle?

Torsion Segmental infarction

What is the cause of cystic dilation of the tubules at the mediastinum testes and what is it called?

Tubular ectasia of the rete testis. Caused by epididymal obstruction. Nonpalpable and asymptomatic and accompanied by epididymal cyst or spermatocele.

What presents as a small, simple, extra-testicular cyst? Tx?

Tunical cyst of tunica albuginea (capsule of testicle). Resembles a BB and is superficial palpable nodule. No Tx necessary.

What is testicular torsion? What is the clinical presentation?

Twisting of testicle around spermatic cord and vascular pedicle. Acute scrotal pain and is a surgical emergency.

What is the typical presentation of Seminoma?

Typically middle-aged men. Uncommonly hCG may be elevated.

What is the classification of testicular teratoma in children usually?

Usually benign, mature subtype

How does segmental infarction of testicle present?

Wedge shaped hypoechoic area w/ no flow on doppler. Presents as pain mimicking torsion or epididymitis.

What are the implications for laterality of a varicocele?

-85% L sided. -If isolated R sided then should prompt search for retroperitoneal mass.

What are two benign testicular tumor mimics?

-Congenital adrenal rests. -Polyorchidism/supernumerary testis.

What are various types of scrotal infections?

-Epididymitis -Epididymo-orchitis -Fournier gangrene

What can a testicular hematoma evolve into and what is made difficult by this transformation?

-Hematoma can evolve into a complex, multiseptated mass-like lesion. -Makes differentiation from testicle difficult. -Must distinguish to avoid mistaking for testicular mass.

What are testicular microlithiases? Clinical implications? Criteria for diagnosis?

-Multiple punctate calcifications. -Controversial assoc b/n microlithiasis and test. neoplasm. -Relative risk may be increased. -No workup (US surveillance) or tumor markers, may perform self exams prn. -5 microlithiases/image. -<5/image = "limited microlithiasis" -Can produce starry sky if numerous.

What is important with testicular rupture and what may be chronic sequela of rupture?

-Prompt dx and repacking of ruptured seminiferous tubules back into capsule imp. for viability of testicle. -Breaks blood-testis barrier, may result in infertility d/t anti-spermatozoa Ab's formed.

What presents as a hypoechoic lesion in the periphery of the testicle in the setting of trauma? What is the proper management?

-Testicular contusion. -May mimic tumor. -Short f/u and re-eval to r/o malignancy.

What are the diagnostic features of a varicocele?

-Tubular serpentine anechoic structures >2mm in diameter in region of upper pole of testis and epididymal head. -Varicocele follows spermatic cord to inguinal canal and is compressible. -Slow venous flow w/in varicocele can be seen.

What is the risk of malignancy in an extratesticular mass and how is it differentiated from malignant mass on US?

16% chance of being malignant. US cannot differentiate.

What is fertility implication of varicocele?

40% of males presenting to infertility clinic have varicocele.

What is the etiology and clinical presentation of epididymitis?

Almost always ascending from urinary tract. Acute unilateral scrotal pain. Normal testicular blood flow differentiates from torsion.

How do supernumerary testis appear? What risks do they carry?

Appear identical to normal testicular echotecture/parenchyma. Sllightly increased risk of torsion and testicular cancer.

How are sex chord stromal tumors distinguished from malignant tumors on US?

Cannot be distinguished. Orechiectomy is tx.

What is testicular rupture?

Capsule disruption w/ protrusion of testicular parenchyma through defect. Often assoc. with hematoma or contusion.

What is the function and anatomy of the epididymis? What is normal and abnormal appearance and size?

Carries sperm away from the testicle to the vas deferens. Composed of head, body and tail. Head up to 10mm in size. Epididymis normally hpoechoic and less blood flow compared to testicle. Incr. flow may be epididymitis.

What testicular tumor always has elevated hCG?

Choriocarcinoma Gynecomastia may occur from elevated chorionic gonadotropins

What type of Nonseminomatous germ cell tumor of the testicle is most aggressive and where does it metastasize usually to?

Choriocarcinoma, rare Metastasizes early and especially to brain and lung.

What is the timeline for tx of testicular torsion?

De-torsion <6 hours excellent prognosis. De-torsion >24 hours poor prognosis for salvaging testicle.

Varicocele Etiology of primary vs. secondary types?

Dilated venous pampiniform plexus in the scrotum. Primary - d/t incompetent valves of the internal spermatic vein. Secondary - d/t incr. venous pressure d/t obstruction lesion.

What are the non-seminomatous germ cell tumors (NSGCT)? which is most common?

Embryonal carcinoma Teratoma Yolk sac tumor Chriocarcinoma Mixed subtypes (most common NSGCT, 2nd most common testicular malignancy after seminoma)

What are the most common components of mixed non-seminomatous germ cell tumors (NSGCT)?

Embryonal carcinoma and teratoma.

What is the most common testicular tumor of infancy? What is elevated?

Embryonal cell carcinoma type called endodermal sinus tumor or yolk sac type AFP is elevated.

What is key finding on US of epididymitis?

Enlarged epididymis w/ incrased dloppler flow relative to testicle (normally, the epididymis has less doppler flow than the testicle). Associated hydrocele may be present which often contains low-level echoes.

What is true of intratesticular and extratesticular masses?

Intratesticular 90-95% are malignant. Extratesticular are benign in adult, pediatric may be malignant.

What type of testicular tumor has a distinctive onion-ring appearance of concentric alternating rings of hypo- and hyperechogenicity? Treatment?

Epidermoid - benign tumor Instead of orchiectomy, local excision performed.

What cyst can occur anywhere in the epididymis and which usually occurs in the epididymal head?

Epididymal cyst can occur anywhere in epididymis. Spermatocele usually occurs in the head.

How do spermatoceles and epididymal cysts present differently on echogenicity?

Epididymal cyst usually completely anechoic. Spermatocele usually have internal low-level echoes within them. Cannot be reliably distinguished always on US.

What are the three functional components of the Scrotal anatomy?

Epididymis Mediastinum testis Rete testis

What is finding of increased bl. flow to testicle with also increased flow to epididymis?

Epididymo-orchitis

What cysts can occur in the epididymis?

Epidydimal cyst Spermatocele

What is a hydrocele? Where is fluid never present?

Excell fluid in scrotum. Most asymptomatic. May be congenital d/t patent processus vaginalis in utero or infancy: idopathic or post-inflammatory. Never fluid at the bare area where testicle attached to tunica vaginalis.

What may be the diagnosis with multiple echogenic reflections in the subcutaneous tissues of the scrotum?

Fournier gangrene

Blood in scrotum d/t trauma or torsion.

Hematocele

What malignancy type tends to be in older patients, causing diffuse, bilateral and infiltrative disease with testicular enlargement?

Hematologic malignancies

What are the types of injuries in scrotal trauma?

Hematoma Testicular contusion Testicular rupture

What is the typical tumor appearance for Nonseminomatous germ cell tumor?

Heterogeneous testicular mass Cystic and solid components with coarse calcifications

What are US presentations of testicular torsion by time?

Hyperacute (w/in a few hours) hyperechoic and shadowing torsion knot of twisted epididymis and spermatic cord, w/ no blood flow in affected testicle. Acute (between a few hours and 24 hours): Affected testicle is enlarged and heterogeneous. Missed Torsion: Affected testicle is enlarged and mottled, with scrotal skin thickening and increased flow in the scrotal wall. A complex or septated hydrocele may be present.

What is primary differential consideration in segmental infarction of testicle?

Hypovascular tumor. Infarcted tissue may make differentiation even harder. MRI may distinguish and spare from orchiectomy.

What is the mediastinum testis location and composisition and function?

In the hilum of the testicle. From which fibrous septa radiate towards the testicular periphery Provides structural support to the rete testis.

What is bell-clapper syndrome?

Increase in risk of torsion d/t small bare area. Bare area test. attachment site and prevents testicle from rotation.

What are most common metastases to the testicles?

Leukemia and Lymphoma. Chemo agents don't cross blood-testis barrier.

What clinical effects are Leydig cell and Sertoli cell testicular tumors associated with?

Leydig - gynecomastia d/t estrogen secretion. Sertoli cell tumor assoc w/ Peutz-Jeghers and Klinefelter syndromes.

What are the sex chord stromal tumors and what is the prognosis and tx?

Leydig cell tumor and Sertoli cell tumor. Orchiectomy Benign

What is the classification of testicular teratoma in adults usually?

Malignant

How is Teratoma classified?

Mature Immature Malignant

How will most scrotal masses present on doppler?

Most will have increased vascularity w/ high diastolic flow producing a low resistance waveform.

What is fournier gangrene?

Necrotizing fasciitis of the scrotum and perineum, highly morbid polymicrobial infection. Surgically emergent.

What types of testicular tumors tend to occur in younger men, typically 20's and 30's? How do they typically behave and grow?

Nonseminomatous germ cell tumors. More aggressive than seminomas Local invasion to tunica albuginea and visceral metastases are common

Who tends to get tubular ectasia of the rete testis and what is true of laterality?

Older patients and tends to be bilateral.

How does testicular Sarcoidosis present and how is it diagnosed?

Painless scrotal enlargement. May involve epididymis or testis or both. Biopsy required. Indistinguishable from malignant solid mass on US.

What is a Burnt-out germ cell tumor? Tx?

Primary testicular neoplasm no longer viable in the testicle. Often viable metastatic disease, retroperitoneal. Tx: Orchiectomy & systemic chemotherapy.

Who get congenital adrenal rests and how do they behave in response to hormone release?

Remnants of adrenal tissue trapped w/in the testis. Typically in nwborns with congenital adrenal hyperplasia. Appear as bilateral hypoechoic masses and classically enlarge with ACTH.

What area of the body should always be examined if intratesticular mass is seen?

Retroperitoneum, to see if adenopathy is present. Conversely, if retroperitoneal adenopathy is present in a male the teesticles should be examined.

What presents as an echogenic, extratesticular mass w/ no doppler flow in the setting of testicular trauma?

Scrotal hematoma.

What can happen with epididymo-orchitis that is dangerous?

Secondary inflammation can cause venous hypertension, which is a risk factor for focal testicular ischemia.

What is the most common testicular malignancy and what is the prognosis?

Seminoma - favorable prognosis.

What are examples of benign extratesticular neoplasm? Most common one?

Spermatic cord lipoma - most common overall. Benign adenomatoid tumor of the tunica albuginea is the most common epididymal neoplasm.

What is the rete testis location and function?

network of tubules carries sperm from seminiferous tubules to the vas deferens. Functions to concentrate sperm.