Male Pelvis
Clinically Findings of Hydroceles
1. Transilluminates light 2. Painless scrotal swelling 3. May present with pain when found in the presence of scrotal infections, testicular torsion, trauma, or a tumor
Normal Head Epididymis
10-12mm in size - it's either isoechoic or slightly more echogenis than the testi
Torsion varies between
180-540 degrees
The time between onset of pain and performance of torsion and salvage rate
< 6 hours: 90-100% salvage rate 12-24 hours: 20-50% >24 hours: 0-10%
Sonographic appearance of Spermatocele
A cyst in the head of the epididymis that may contain layering debris
Dartos
A layer of muscle fibers lying beneath the scrotal skin and dividing the scrotum into two chambers.
What is the Rete Testis?
A network of delicate tubules located in the hilum of testicle (mediastinum testis) that carries sperm to the epididymis.
What is an Appendix Testi?
A remnant of the Mullerian duct, it's a small ovoid structure located beneath the head of the epididymis.
What might a partial or incomplete torsion be seen on ultrasound?
A resistive index > .75 or a biphasic waveform.
Hydrocele
A simple fluid collection within the scrotum, serous fluid that accumulate within the tunica vaginalis
Where is the Head of the Epididymis located?
Adjacent to the Superior pole of the testis and is the largest part of the epididymis.
Where are undescened testicles also found?
Although they might be found within the abdomen, undesceneded testicles are often found above the scrotum or within the inguinal canal.
How is the mediastinum teste seen on ultrasound?
An echogenic linear band extending longitudinally within the testes.
Epididymal Cyst
Appears similar to spermatocele and can be seen anywhere along the length of the epididymis
Tunica Albuginea Cyst
Are located anywhere along the periphery of the testicle, within the albuginea
Congenital Hydroceles
Are noted in boys ages 1-2yrs. They are caused by failed closure of the processes vaginalis at the internal ring
The appendages of the testis are
Are remnants of the Mullerian Duct, Wolffian duct and Mesonephric duct.
Where is the Appendix epididymis located at?
At the head of the Epididymis
Where is the Appendix vas positioned?
Between the body and tail of the epididymis
Where is the Appendix testi located?
Between the head of the Epididymis and the superior pole of the testis
Hematocele
Blood fills the scrotal chamber associated with trauma
When do the testicles descend in the Scrotum?
By 28 weeks
The testicular Artery Divides into...
Capsular and Centripetal (intratesticular) branches
What are epididymal cyst composed of?
Clear fluid whereas spermatocele are filled with spermatozoa
Centripetal Arteries
Course along the Septula converging on the mediastinum testi
Visceral Layer of Tunica Vaginalis
Covers the testis and Epididymis
What's a tip to use while scanning a testicular torsion?
Decreasing PRF (color scale) will better optimize slow blood flow to rule out a complete torsion
Blue dot Sign
Describes the appearance of the torsed appendage as a blue dot under the skin surface
Bell Clapper Deformity
Describes the situation in which the patient lacks of normal posterior fixation of the testis and epididymis to the scrotal wall. It's also part of the intravaginal torsion.
What is the Tunica Vaginalis?
Each Testi is surrounded by a Double Layer of the tissue
The testes function as both...
Endocrine and Exocrine functions
Where would pain occur in patients with appendix torsion?
Focal testicular pain often localized to the superior pole of the testicle
How is the Sperm transported after the vas deferens?
From the vas deferens, sperm is transported to the seminal vesicles. - They help secrete fluid that helps produce semen
The Head of the Epididymis is also referred to as
Globus Major
What is the epididymis composed of?
Head, Body and Tail.
Where are Hydroceles located?
In between the 2 layers Tunica Vaginalis
Where are hydroceles found?
In the tunica vaginalis or between the tunica vaginalis layers (visceral & parietal)
What are some complications with cryptorchidism with?
Infertility and an increase risk for malignancy. - cancers and infertility
What is the most common location of the Crypotochid?
Inguinal Canal
Tunica Vaginalis
Is a Saccular extension of the peritoneum scrotum chambers, it consists of the Parietal and Visceral Covering
How is the Epididymis seen on ultrasound?
Isoechoic or slightly hyperechoic than the testi
Where does the Sperm transport to?
It transports the sperm into the Ductus (vas) Deferens
Describe the Epididymis
It's a Coiled structure that is attached to the testicle and the posterior scrotal wall.
When is Crypotorchidism found?
It's found in 3% or 4% of full term birth's.
Where is the cremaster muscle located, and what does it do?
It's located within the spermatic cord and alters the position of the testicle within the scrotum which aids in their protection and temperature control.
How is the venous drainage performed?
It's performed through pampiniform plexus, which empties into the testi veins. - Right testicular vein: Drains into the Ivc - Left Testicular Vein: Drains into Left Renal Vein
Where is the Epididymis position?
It's position is parallel to the testicle
How would hydroceles be seen sonographically?
Low level echoes from fibrin or cholesterol crystals may be visualized
Spermatocele
Most common scrotal mass is a cyst found most often in the head of the epididymis
What forms the Mediastinum teste?
Multiple septations (septula) arise from the tunica albuginea come together to form the mediastinum
Spermatocele are composed of
Nonviable sperm, fat cellular debris and lymphocytes
When does testicular torsion occur?
Occurs in adolescents between 12-18 years and neonates. - It's observed in male younger than 30
Appendix Testi Torsion
Occurs in boys aged 7-12 years and it is associated with Blue Dot Sign
Extravaginal torsion
Occurs in neonatal period or in utero and is related to torsion of spermatic cord within inguinal canal
Extravaginal Testicular Torsion
Occurs outside of the tunica vaginalis, when the testis & gubernaculum can rotate freely. - This occurs in newborns presenting with scrotal swelling, discoloration and a firm mass in the scrotum
What is Testicular Torsion?
Occurs when the arterial blood supply to the testicle is cut off secondary to the twisting of the testicular axis.
Is extratesticular fluid normal?
Only a few milliliters of fluid is
Where are the Seminal Vesicles located?
Posterior to the male urinary bladder and above the prostate gland.
Endocrine Function : Released directly into bloodstream
Produce: Testosterone: Determines male characteristics
Exocrine Functions: ( released through ducts)
Produces Sperm: Permits reproduction.
Appendix Epididymis
Representing a detached efferent duct, is a small stalk projecting off the epididymis, this structure is derived from the Wolffian Duct
How are Spermatocele Formed?
Results from dilation of the epididymal tubules
What is the division of the two chambers called?
Scrotal Raphe
What is the Normal Measurement of the Scrotal wall?
Scrotal Wall thickness is between 2-8mm
What is the most common cancer found in an undescended testi?
Seminoma
What is Testicular Torsion referred to?
Spermatic Cord torsion
Which two lesions results from prior episodes of epididymitis
Spermatocele cyst and Epididymal cyst
What is the epididymis responsible for?
Storing sperm, in order for them to mature
What is Orchiopexy?
Surgical correction of an undescended testis, it's performed on patients age 2-10 years of age.
Where does the testicles receive most of their blood from?
Testicular arteries, that arise from the abdominal aorta just below the level of the renal arteries.
What connects to the rete testis?
The Tubuli Recti or Tubuli Seminiferi recti connects the seminiferous tubule to the rete testis
How is the Seminal Fluid carried to the Epididymis?
The efferent ductules carries the seminal fluid from the rete testis to the epididymis.
Parietal Layer of the Tunica Vaginalis
The outer layer that lines the scrotal chamber
Describe the scrotum externally
The scrotum is externally at the midline into two compartments by a structure called the Median Raphe (Scrotal Raphe)
How is the Tubuli Recti formed?
The seminiferous tubules converge to form the tubuli recti
Seminiferous Tubules
The septula forms a wedge-shaped compartments that contains the seminiferous tubules
Where does the Spermatic cord enter from?
The spermatic cord enters the scrotum through the inguinal canal, which includes vascular supply.
Testicular Ischemia
The testicle becomes enlarged and hypoechoic compared to the contralateral testicle.
What happens with Intravaginal testicular torsion?
The testicle is attached to the tunica vaginalis, without the attachment or a high attachment, the testicles can rotate freely on the Spermatic Cord (bell clapper deformity)
Cryptochidism
The testicles may be trapped anywhere along the path and consequently never descend into the scrotum.
Describe Intravaginal Torsion
The testis is not affixed to the scrotal wall, is permitted to migrate and twist freely within the scrotum
When does testicles usually descend?
They descend before birth
Rete Teti
Tiny Tubules, converge into a structure, which is located at the mediastinum testi.
What is the most common scrotal pain in prepubertal boys?
Torsion of the Appendix testi
What is the testicle surrounded by?
Tunica Albuginea
How is the scrotum divided internally?
Tunica Dartos
What is Cryptorchidism
Undescended testis (hidden testi)
Chronically Acquired or Secondary hydroceles
Usually occur in men older than 40 years. - They may be idiopathic or the result of trauma, torsion, neoplasms, epididymitis or orchitis
Sonographic Findings of Spermatocele
1. Round, anechoic mass with acoustic enhancement 2.May contain some layering debris 3. Spermatoceles usually occurs on the epididymal head
Sonographic Findings of Hydroceles
1. Simple fluid anterior to the testis 2. Scrotal wall thickening 3. Chronic hydroceles may have internal debris and septations
Sonographic Findings of Cryptorchidism
1. Testicles located outside of the scrotum (most likely inguinal canal) 2. The cryptorchid testis will appear hypoechoic to the normal testes
Name the appendages of the testis
- Appendix testis - Appendix Epididymis - Appendix Vas
Testicular Blood flow is supplied by..
- Deferential Artery - Cremasteric (external Spermaric) Artery - Testicular Artery
What is Testicular torsion associated with?
- Fever, Nausea, vomiting, history of trauma or sexual activities. - Absence of cremasteric reflex high position of testicle and horizontal lie of testicles
The Tail and Body of the Epididymis referred to as
- Globus Minor - It forms an acute angle and courses cephlad as the Vas Deferens ( ductus deferens)
Testicle Measurement in Adult
-3-5cm in lenfth - 2-4cm in Width - 3 cm in thickness - Normal U/S testes appears isoechoic and small amount of extratesticular fluid is typically notes
What is the Bulbourethral Gland?
-Also referred to as Cowper Gland. - It Secretes Pre-ejaculate (precum) fluid that lubricates the penis before orgasm.
Tunica Albuginea
-Beneath the layers of the tunica vaginalis, the testis is also surrounded by a dense fibrous layer. - The Tunica Albuginea extends posteriorly and enters each testicle to help form the mediastinum testi.
What is the Ductus Vas Deferens do? & What is it referred to?
-Deferent Duct - It connects the Epididymis to the Seminal Vesicle
Chronic Testicular Torsion
-Is the torsion that has lasted for more than 10 days. -The epididymis, testi and spermatic cord will become enlarged and heterogenous. - Areas of necrosis will be seen and hyperemic flow around.
Name the extratesticular cyst
-Spermatocele - Epididymal - Tunica Albuginea Cyst
When and how does the testicle begin to develop?
-They begin to develop in the upper abdomen in the fetus near the kidneys. - They descend into the pelvis until the 4th week of gestation.
Clinical findings of Acute Testicular Torsion
1. Acute onset of testicular pain (often during sleep 2. Possible pain within the lower abdomen and inguinal region. 3. Swollen testis/scrotum 4. Nausea and vomiting 5.Higher positioned, painful testis with a horizontal position
Clinical Findings or Torsion of the Testicular Appendage
1. At the head of the Epididymis 2. Pain localized to the superior pole of the testis 3. "Blue dot" sign
Sonographic findings of Chronic Testicular Torsion
1. Enlargement of the spermatic cord, epididymis, and testis. 2. No intratesticular flow 3. Hyperemic flow around the testis 4. Heterogeneous testis with areas of necrosis
Sonographic findings of Acute Testicular Torsion
1. Enlargement of the spermatic cord, epididymis, and testis. 2. Thickened scrotal wall 3. Hypoechoic or heterogeneous testis 4. Reactive hydrocele 5. No intratesticular flow 6. Decreased intratesticular flow (as compared to the asymptomatic testis)
Clinical Findings of epididymal, tunica and spermatocele cyst?
1. If large enough, they may be palpable. 2. Typically not painful
Sonographic Findings of Torsion of the Testicular Appendage
1. Normal intratesticular flow 2. Small, avascular, hypoechoic or hyperechoic mass adjacent to the superior pole of the testis 3. Reactive hydrocele 4. Scrotal wall thickening
Clinical Findings of Cryptorchidism
1. One or both testicles not palpable within the scrotum
The Spermatic Cord Consists of
Vas deferens Cremasteric, deferential, testicular arteries Pampiniform plexus of veins Lymphatics Nerves
What might Testicular Torsion lead to?
Venous and Arterial occlusion
What happens in a 360 degree angle testicle torsion?
Will result in blocked venous drainage and arterial supply and will result in ischemia testis
Where are the normal adult testicles located?
Within a sac of cutaneous tissue called the scrotum
Where does Spermatogenesis occur?
Within the Seminiferous tubules that are found through each testicle
partial testicular torsion
torsion-detorsion syndrome, intermittent testicular torsion are other names - It's challenging to diagnose as arterial waveform changes
How is the ejaculatory duct formed?
union of the vas deferens with the duct from the seminal vesicle