Week 12: Male Reproductive System Pathology

BPH: sonographic appearance

-AP dimension increased -rounded appearance -volume > 20cc -may exceed > 4 times normal size -stromal hyperplasia -PZ compression -associated with hydronephrosis

congenital anomalies

-Cryptorchidism (Undescended testicle) -Testicular Ectopia -Anorchia -Polyorchidism (Testicular duplication)

benign prostatic pathology

-Cysts -Calcifications -Prostatitis -BPH (Benign Prostatic Hypertrophy)

cysts (prostatic pathology)

-Mullerian duct/ SV ipsilateral renal agenesis associated -Utricle - midline, hypospadias -prostatic retention, BPH, parasites, CA, abscess *prostatic utricle small indentation on the prostatic urethra at the apex of the urethral crest and is considered a midline cystic mass*

indications: prostate biopsy

-abnormal digital rectal examination (DRE) -elevated PSA -PIN (Prostatic Intraepithelial Neoplasia) -pathological finding found inn previous prostate biopsy

Rupture: sonographic appearance

-abnormal testicular parenchymal pattern -interrupted tunica albuginea -irregular testicular contour -scrotal wall swelling -hematocele -can go associated with any other pathologies

Testicular Cyst: sonographic appearance

-anechoic -hypoechoic -posterior enhancement -smooth border

Hydrocele: sonographic appearance

-anechoic with through transmission -thin scrotal wall (acute) -diffuse scrotal wall thickening (chronic) -may demonstrate internal echoes or septations -may be unilateral or bilateral

Hematocele: sonographic appearance

-appearance varies with time -acute: echogenic with highly visible floating echoes -over time: low-level echoes with fluid-fluid levels and/or septations -it does not confirm testicular rupture

Cysts

-benign fluid collections -intra or extra testicular location -extratesticular: tunica Albuginea or epididymis -asymptomatic but palpable most times includes: spermatoceles, Epididymal cysts, and tunica Albuginea cysts

calcifications (prostatic pathology)

-common benign finding -corpora amylacea (aging process) -fluid stasis -blocked ducts -prostatitis

Testicular Cyst

-commonly seen -benign testicular mass -mostly in men >40 y/o -associated with extratesticular Spermatoceles -incidental findings -no treatment required

Germ Cell tumors

-elevated levels of human chorionic gonadotropin (HCG) and Alpha-fetoprotein -produced in the testicles that specialize in making sperm -95% of all testicular tumors -highly malignant -most common (descending frequency) -non-germ cell usually benign -two main types: seminoma and nonseminomatous germ cell histopathological subtypes: 1. SEMINOMA (slow growing) 2. Embryonal Cell Tumor 3. Teratocarcinomas 4. Less common: yolk sac 5. Choriocarcinomas, teratomas

BPH: treatment

Medications: combination of alpha-blockers with a 5-alpha reductase inhibitor. Inhibitor , such as tadalafil (Cialis) may help to reduce CoBPH symptoms Microwave therapy: microwave antenna is inserted through the tip of the penis to the area of the urethra surrounded by the prostate -a dose of microwave energy heats up and destroys the excess prostate tissue (replace by newer treatments) Cryotherapy: freezing the tissue, which ultimately destroy the excess tissue Balloon Urethroplasty: nonsurgical procedure where an inflatable balloon in inserted into the prostate -when inflated it relieved the pressure on the urethra TURP (transurethral resection prostate) aka (roto-rooter): -gold standard -minimal invasive procedure -over grown prostate tissue is cut away from the inside using electric current

What is seen in this ultrasound image?

Testicular contusion -transverse gray scale image

Benign Prostatic Hyperplasia (BPH)

benign growth of cells within the prostate gland (enlargement) -TZ nodular growth -unknown etiology -non inflammatory enlargement of the prostate gland - > 40 yrs. age -higher incidence around 60"s -periurethral zone may be involved urinary symptoms: -frequency -retention -weak urinary stream -difficulty starting -split stream -nocturia -UTI

Hematocele

blood in scrotal sac (trauma) -history of trauma or surgery or malignancy clinical findings: -painful scrotal mass -mimics infection or torsion sonographic findings: -anechoic when acute -thick or septated when chronic

Choriocarcinoma (germ cell)

cancerous tumor of the chorion; germ cell cancer -rare -20-30 years of age -elevated HCG varied sonographic appearance: -small nodules -mixed components -irregular borders usually

Spermatocele

cystic dilatations of the efferent ductules of the epididymis -retention cyst arising from rete testis -located in epididymal head -made of spermatozoa and proteninaceous fluid -commonly seen post-vasectomy -asymptomatic (but palpable most times)

What is seen in this ultrasound image?

epididymal cyst

What is seen in this ultrasound image?

epididymitis: increased vascularity

What is seen in this ultrasound image?

epididymitis: swollen- edematous epididymis

What is seen in this ultrasound image?

epididymo-orchitis

What is seen in this ultrasound image?

epididymo-orchitis with hypervascularization

What is seen in this ultrasound image?

focal orchitis (longitudinal -> transverse -> increased flow)

What is seen in this ultrasound image?

hematocele

Ultrasound is 100% sensitive for tumors, but cannot confirm ________.

histology

What is seen in this ultrasound image?

hydrocele

What is seen in this ultrasound image?

hypoechoic areas in right testicle

Epididymo-Orchitis

infection of the epididymis and testis -originates from spread of UTI, STD's via spermatic cord -acute scrotal pain, fever, discharge -most common cause of acute scrotal pain in adults -elevated WBC -common causes: STD's -less common causes: mumps, TBC, Viruses, trauma, chemical -epididymis is affected first and ONLY 20-40% spreads to the testis

Prostatitis

inflammation/infection of the prostate -increased white cells in prostatic fluid classification: -Acute bacterial -Chronic bacterial -Non bacterial -Prostatodynia (non bacterial)

What is seen in this ultrasound image?

inguinal hernia

Embryonal Cell Cancer (germ cell)

malignant tumor (cancer) of an embryonal cell that does not mature and differentiate like a normal cell; grows in adolescence -type of germ cell ancer -heterogeneous -less well circumscribed -may contain calcifications, hemorrhage, or fibrosis -cystic components up to 1/3 of cases -MORE AGGRESSIVE than Seminomas -distortion of testicular contour

Lymphoma

malignant tumor of lymph nodes and lymph tissue -lesion has slightly lobulated margins and is predominantly hypoechoic. -many areas of punctuate midlevel echoes similar in echogenicity to those of the surrounding normal parenchyma

What is seen in this ultrasound image?

microlithiasis

Epididymal Cyst

small, clear cysts found in the epididymis, between layers of tunicas -asymptomatic but palpable most times -difficult to differentiate between Spermatoceles and Epididymal cysts

Stromal Tumors

solid malignant masses that arise from the sex cords -approximately 10% are malignant -Leydig cell -may cause gynecomastia -20-50 years of age sonographic findings: -homogenous with area of necrosis or hemorrhage -small, solid and hypoechoic

What is seen in this ultrasound image?

spermatocele

Teratocarcinoma

teratoma + embryonal carcinoma -second most common testicular neoplasm -made up of teratomas and embryonal cell carcinoma cells -aggressive sonographic findings: -complex -anechoic areas-hemorrhage or necrosis

What is seen in this ultrasound image?

testicular cyst

What is seen in this ultrasound image?

testicular torsion

What is seen in this ultrasound image?

testicular torsion: diminished testicular flow

What is seen in this ultrasound image?

testicular torsion: left testis with absence of flow

What is seen in this ultrasound image?

testicular torsion: normal testicular flow

What is seen in this ultrasound image?

testicular torsion: snail sign

What is seen in this ultrasound image?

thickening of scrotal wall in right testicle

What is seen in this ultrasound image?

tubular ectasia of rete testis

What is seen in this ultrasound image?

tubular ectasia of rete testis: no vascularity

What is seen in this ultrasound image?

(left spermatic cord torsion in adolescent with a history of scrotal pain of duration greater than 24 hours) -normal perfusion to right testis -absent flow on left testis

What is seen in this ultrasound image?

(left spermatic cord torsion in adolescent with a history of scrotal pain of duration greater than 24 hours) -sagittal view of left testis -the infarcted testis has a mixed echo pattern caused by the hemorrhage, necrosis, and vascular congestion associated with spermatic cord torsion exceeding 24 hours

What is seen in this ultrasound image?

(left spermatic cord torsion in adolescent with a history of scrotal pain of duration greater than 24 hours) -transverse view of both testes -left testis is enlarged and heterogeneous

Epididymo-Orchitis: sonographic appearance

-enlarged, hypoechoic epididymis -'Inferno" pattern with Color Doppler (compare both sides using same color settings) -may contain hemorrhagic aspect in some areas -Spectral Doppler: increased systolic and diastolic velocities -if testis is affected: enlarged testis -hypoechoic diffuse (homogeneous & hypoechoic) or focal (heterogeneous) -scrotal wall thickening / Hydrocele /Pyocele -up to 20% of cases will have a normal appearing epididymis and testis other associated findings: -thickened scrotal wall -hydrocele -pyocele -Testicular Infarction (Color and Spectral Doppler *) -Doppler waveform demonstrating reversed diastolic flow is a serious finding, indicating threatened testicular infarction -areas of infarction: hypoechoic with heterogeneous surrounding areas.

Scrotal Trauma (Acute Scrotum)

-history of trauma -pain & swelling -examination objective: rule out ruptured testicle -critical time for surgery: 72 hours -surgery in: < 72 hrs. = 90% success > 72 hrs. = 45% success -includes: rupture, hematocele, hematoma

Prostatitis: sonographic appearance

-hypoechoic halo in Periurethral area -heterogeneous PZ -abscess formation

Testicular Torsion: surgery

-if surgery is performed within 5 to 6 hours of the onset of pain, 80% to 100% of testes can be salvaged -between 6 and 12 hours, the salvage rate is 70% -after 12 hours, only 20% will be saved -the degree of torsion (or number of twists) also affects testicular salvage surgery in: 5-6 hours = 80-100% (salvage rate) 6-12 hours = 70% (salvage rate) > 12 hours = 20% (salvage rate)

Prostate carcinoma

-most common cancer in USA -second most common cause of male cancer deaths -approximately one-third of men will develop prostate cancer -incidence increases with age 70% occurs in the PERIPHERAL ZONE (PZ) 20% located in the TRANSITIONAL ZONE (TZ) 5-10% originate in the CENTRAL ZONE (CZ)

Hydrocele

-most common fluid collection of the scrotum -abnormal accumulation of fluid between the two layers of tunica vaginalis (visceral and parietal) -maybe congenital or idiopathic -usually due to epididymitis -may be seen with orchitis, spermatic cord torsion, and trauma clinical findings: -asymptomatic -enlarged scrotum -scrotal mass -scrotal pain

testicular cancer

-most frequenct between 20-34 years -malignant -highly curable -incidence is greater in white -cryptorchidism: 2.5 to 8 times more likely -mostly asymptomatic -painless lump -testicular enlargement -mild scrotal discomfort -ultrasound must indicate LOCATION and presence of CYSTIC and SOLID COMPONENTS -mimicking benign conditions: hematoma, focal orchitis, abscess, infarction, sperm granuloma

Microlithiasis: sonographic appearance

-multiple bright, no shadowing foci dispersed throughout the testis. -more than five in a single image: abnormal -usually bilateral

Scrotal Trauma: Color Doppler

-presence of hematomas/ hematoceles -vascular disruption (superficial) -vascular compromise within the testicle -testicular torsion

Metastases

-rare -age of incidence: over 50- -Lymphoma, leukemia most common -prostate, lung and kidneys are the most common non-lymphomatous primaries sonographic findings: -solid -hypoechoic (less frequently hyperechoic) -multiple lesions and bilateral -any tumor finding should include a thorough investigation of the pelvic and retroperitoneal lymph nodes and for liver metastatic invasion

Granulosa Theca Cell Tumor (stromal tumor)

-rare; malignant -type of stromal tumor -most common tumor within the first 6 months of life

Spermatocele: sonographic appearance

-simple or multilocular cysts with internal echoes -anechoic mass superior to testis -round or oval in shape -does not compress testis -epididymal: simple cysts -difficult to differentiate between Spermatoceles and Epididymal cysts

Hematoma: sonographic appearance

-small or large -may cause displacement of testis -heterogeneous appearance within scrotum -may involve epididymis, scrotum, -avascular: Color Doppler shows no flow

Snail sign

-sonographic sign for testicular torsion -Swollen Testis & Twisted, Bulky Spermatic Cord

malignant testicular masses

-testicular cancer accounts for 1% of cancer in men -more common in men between the ages of 20-34 years -extra-testicular masses are usually benign -intra-testicular masses are usually malignant includes: -germ cell tumors: seminoma, teratoma, choriocarcinoma, embryonal cell -stromal tumors: sertoli cell, granulosa theca cell -teratocarcinoma

Varicocele: sonographic appearance

-tortuous venous structures exceeding 2mm -most commonly located on left and in inferior portion of scrotum -veins increase in size with Valsalva maneuver or standing -increased color Doppler flow with Valsalva maneuver

Microlithiasis

-uncommon -tiny calcifications < 3mm ; bilateral -potentially associated with testicular malignancy and cryptorchidism, Kleinfelter's syndrome, infertility, varicoceles, atrophy, and male pseudo hermaphroditism -etiology still remains unknown -calcified vessels -granulomatosis -follow-up required -asymptomatic

Tunica Albuginea Cysts

-usually small -may grow and distort testis

Testicular Torsion: sonographic appearance

-varies depending on time elapsed since torsion until time of examination -early stages: normal > 4 hours: swollen / hypoechoic/lobes well identified due to edema > 24 hours: heterogeneous (hemorrhage, infarction, necrosis, and vascular congestion -enlarged epididymal head /hypoechoic or heterogeneous -twisted spermatic cord knot: round or oval extratesticular mass -scrotal skin thickening -reactive hydrocele -Doppler evaluation is crucial to diagnosis -absence of perfusion in the symptomatic testis with normal perfusion on the asymptomatic side is considered to be diagnostic of torsion. USE SAME SETTINGS FOR BOTH

Sperm Granuloma: sonographic appearance

-well-defined solid mass -hypoechoic or isoechoic compared to the epididymis -mostly heterogeneous -calcifications are not common -Color Doppler: increased flow when inflammation is present.

What is seen in this ultrasound image?

Complex hematoma in a patient with hemophilia following scrotal trauma -transverse ultrasound scan of both testes shows a large heterogeneous mass adjacent to the left testis

What is seen in this ultrasound image?

Fractured right testicle

What is seen in this ultrasound image?

Hematocele in right testicle

What is seen in this ultrasound image?

Ruptured testicle post trauma

Hypospadias

a birth defect of the urethra in the male where the urinary opening is not at the correct location on the head of the penis

Sperm Granuloma

a lump of extravasated sperm that appears along the vasa deferentia or epididymides -chronic inflammatory reaction -extravasation of spermatozoa -commonly seen after vasectomy -main goal: extra or intra testicular? -extra testicular: lower chance of malignancy -intra testicular: higher chance of malignancy -ultrasound cannot differentiate from Epididymal tumors

Bell Clapper deformity

abnormal attachment of testis in the scrotum (risk factor for torsion)

Varicocele

abnormal enlargement of the Pampiniform venous plexus in the scrotum -primary correctable cause for male infertility -occurs when valves within the veins along the spermatic cord do not work properly -same process of varicose veins -treated by surgery or non-surgical treatments (surgical treatment varicocelectomy; non-surgical -embolization) -can reliable be diagnosed with ultrasound - > 2mm -Valsalva maneuver signs and symptoms: -visible or palpable -dragging-like or aching pain -feeling of heaviness -atrophy of the testicle -low testosterone levels -benign prostatic hyperplasia -occur in 15% to 20% of all males -typically occur between 15-30 years of age -more prominent on the left side

Sertoli Cell Tumor (stromal tumor)

androblastoma from sex cord stroma; type of stromal tumor -painless testicular mass -may cause gynecomastia -small and hypoechoic

Valsalva maneuver

attempting expiration against a closed airway

What is seen in this ultrasound image?

seminoma with a vascularized hypoechoic mass

What is seen in this ultrasound image?

septations in right testicle

What is seen in this ultrasound image?

normal left testis

Cryptorchidism (undescended testis)

occurs when a boy is born with one or both testicles in the lower abdomen rather than the scrotum -also known as undescended testicles -primary risk factor for testicular cancer

Pyocele

pus in scrotal sac -caused by trauma or ruptured abscess clinical findings: -swelling and pain -possible fever and/or leukocytosis sonographic findings: -echogenic fluid with thick walled septations and calcifications

What is seen in this ultrasound image?

pyocele

What is seen in this ultrasound image?

pyocele with orchitis

What is seen in this ultrasound image?

rupture of albuginea of right testicle

What is seen in this ultrasound image?

ruptured left testicle with herniation of Testicular Tissue

What is seen in this ultrasound image?

ruptured left testis with hematoma

Testicular Torsion

twisting of the spermatic cord on itself obstructing the blood vessels supplying the epididymis and testis -abnormal motion of the testicle within the scrotum (free moving and rotation) -Bell Clapper deformity is where the Tunica Vaginalis joins high on the spermatic cord; this allows the testis free to rotate -restricted or no blood supply -most common cause of scrotal pain in adolescents and young adults -nausea, vomiting -up to 60% of patients with torsion will have an anatomic anomaly on both sides -undescended testes are 10 times more likely to be affected by torsion than normal testes -venous flow is affected first, with occluded veins causing swelling of the scrotal structures on the affected side. If torsion continues, the arterial flow is obstructed, and testicular ischemia follows -difficult to differentiate from Epididymo-orchitis clinical findings: -sudden onset of groin or scrotal pain -lower abdominal pain -nausea/vomiting -scrotal swelling

Teratoma (germ cell)

type of germ cell cancer -may contain dense foci with acoustic shadowing -malignant -heterogeneous -well-defined borders -usually BENIGN in CHILDREN -usually MALIGNANT in ADULTS

Seminoma (germ cell)

type of germ cell tumor; most common testicular tumor -focal -hypoechoic mass -homogeneous -smooth border -rarely with calcification or cystic component

Tubular Ectasia of rete testis

uncommon, benign testicular mass -dilatation of efferent ductules -bilateral -associated with Spermatoceles, Epididymal or testicular cysts -results from trauma or inflammation - >45 years old -Rete Testis difficult to see normally -high resolution: tiny tubular structures -Ectasia: prominent hypoechoic tubular structures at hilum within or adjacent to mediastinum testis -Color Doppler: Avascularity -clinically: asymptomatic

What is seen in this ultrasound image?

varicocele

Inguinal Hernia

weakening of the abdominal wall -1/3 are bilateral -If unilateral usually on right side Two Types: 1. Indirect: arise through the deep ring and enter the inguinal canal -have a path that typically allows the bowel to enter the scrotal sac -more common in boys and young men 2. Direct: weakness of the posterior wall of the inguinal canal -seen in elderly men due to chronic conditions which increase abdominal pressure -COPD -bladder outflow obstruction -chronic constipation etc. -susceptible to strangulation