Scrotum
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spunkychic81 on February 20, 2011
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141 terms
Terms | Definitions |
|---|---|
 Anatomy covered in male pelvis | *Scrotum & contents *Penis *Prostate |
| Where do the testicles develop? | Fetal abdomen near kidneys |
| Testicular Development (up until 7th month) | ~ 4th month, testicles descend to level of bladder Remain here until 7th month |
| Testicular Development (after 7th month) | Testicles descend thru inguinal canal to scrotum (after 7th month, usually during last month of gestation) |
| What causes the testicles to descend? | Hormones |
| Process vaginalis | Evagination of peritoneum traels thru inguinal canal from abdomen into scrotum |
| Testicular Development (5th week) | *Testis begin primary descent *Kidneys begin ascent |
| Testicular Development (8th - 9th week) | Kidney reaches adult position |
| Testicular Development (7th month) | *Testis at internal inguinal ring *Gubernaculum (in inguinal fold) thickens & shortens |
| Testicular Development (Postnatal life) | *Testis in scrotum *Processus vaginalis closed *Gubernaculum (vestigial) |
| Scrotum | *Pouch of skin continuous w/ abdomen *Suspended from base of male pelvis btw perineum & penis |
| What is the scrotum derived from? | Labioscrotal folds -- swells under influence of testosterone to form scrotal sacs |
| Median raphe | point of fusion of twin sacs |
| Purpose of Scrotum | *Protective casing *Maintain testicular temperature (2° C below intrabdominal temp) |
| Contents of Scrotum | *Testicles *Epididymis *Proximal part of vas deferens |
| Testicles (Testes) | Male gonads Oval shaped, symmetric |
| US Appearance of Testes | Appear as smooth medium gray structures w/ fine echo texture |
| What is each testis made of | Divided into ~ 250-400 lobules that contain seminiferous tubules |
| Tubuli recti | formed by seminiferous tubules 20-30 larger ducts |
| Size of Testes | Length: 3 - 5 cm A-P: 3 cm Width: 2 - 4 cm (size & wt decrease w/ age) |
| Function of testes | *Produce sperm & testosterone *95% of testosterone is secreted by Leydig cells in testicles *Endocrine (testosterone) & Exocrine functions |
| TUnica albuginea | *Echogenic, dense fibrous capsule surrounding testes (covered by tunica vaginalis) *Multiple septa are formed from tunica albuginea & converge at mediastinum testis *Form lobules in tests |
| Mediastinum testis | *Posterior portion of tunica albuginea reflects into testis forming vertical septum *Supports testicular vessels & ducts |
| US appearance of Mediastinum Testis | *Sometimes seen as echogenic band going thru testicle *Echogenic line that runs from superior to inferior pole of testicle *Parallel to epididymis longitudinally |
| Tunica vaginalis | Serous membrane (formed by peritoneum) that partially covers testicle *Small amount of fluid btw 2 layers nml *Layers not normally seen on US |
| 2 layers of tunica vaginalis | Inner (visceral) layer Outer (parietal) layer |
| Visceral layer of tunica vaginalis | Covers: *Testis *Epididymis *Lower spermatic cord |
| Parietal layer of tunica vaginalis | Lines wall of scrotal pouch |
| Seminiferous Tubules | *Contained w/in tests *Converge at apex of each lobule & anastamose |
| Tubuli recti | Enter mediastinum to form rete testis in medastinum testis |
| Rete testis | drains into head of epididymis thru efferent ductule |
| Epididymis | *Single, tightly wrapped tube *6-7cm *Begins superiorly & courses posterolateral to testis |
| Parts of epididymis | Composed of: *Head *Body *Tail *Appendix |
| Function of epididymis | Aids in sperm maturing as well as concentrates, stores, & transports sperm |
| Epididymal Head | AKA Globus Major *Measures 10-12mm diameter *Adjacent to superolateral pole of testis *Largest portion of epididymis *Formed by 10-15 efferent ductules from rete testis joining together |
| Epididymal Body | *Smaller than head *Posterolateral margin of testicle |
| Epididymal Tail | AKA Globus Minor *Slightly larger than body *Inferior to testis |
| Appendix Testis | *Small protuberance on head *Commonly seen when hydrocele present (excess fluid in scrotum) *Susceptible to torsion |
| Seminal Vesicles | *Convoluted pouchlike structures that empty into distal ductus deferens to form ejaculatory ducts *Paired glands, encapsulated by connective tissue |
| US Appearance of Seminal Vesicles | Appear as low level echoes SUPERIOR to prostate |
| Vas Deferences | *Continuation of ductus epididymis *Thicker & less convoluted *Dilates at terminal end near seminal vesicles |
| What forms the spermatic cord | *Vas deferens *Testicular arteries *Venous pampiniform plexus *Lymph system *Nerves *Fiber of cremaster |
| Spermatic cord | *Connects abdomen & scrotum (suspends testis in scrotum) *Bound by fibrous shealth *Lies directly under skin |
| Arterial supply of spermatic cord | *Testicular artery (from aorta) *Deferential artery |
| Venous drainage of spermatic cord | Pampiniform venous plexus |
| Verumontanum | Junction of ejaculatory ducts & urethra |
| Capsular arteries | *Tunica vasculosa *Branch over surface of testis |
| Centripetal arteries | *Arise from capsular arteries *Course from surface to mediastinum along septa *Curve backwards forming recurrent rami (centrifugal arteries) *Arterioles to capillaries |
| Cremasteric artery | Provides flow to cremaster muscle & peritesticular tissue |
| Deferential artery | Supplies epididymis & vas deferens |
| Cremasteric & Deferential arteries | *Accompany tescticular artery w/ spermatic cord *Supplying extratesticular structures *Anastomose w/ testicular artery to provide some flow to testis |
| Venous Drainage: Pampiniform plexus | *Exits from mediastinum testis into spermatic cord *Converges into 3 veins (testicular, creamsteric, deferential) |
| Right testicular vein | Drains directly into IVC |
| Left testicular vein | Drains into LRV |
| US Appearance of Testis | *Homogeneous texture (echogenicity increases w/ age) *Oval glands measure: - Long 3 - 5 cm - Wide 2 - 4 cm -AP 3 cm *Wt: 12.5 - 19 g *Volume: 15 - 20 cc |
| Volume formula | (Length x Width x AP) x .523 |
| Clinical History | *Palpable lesions should be palpated *Does pt have pain? Which side? When doing what activity? *Lumps, swelling, etc should be noted *Any recent illness? UTI, etc. |
| Testicular Ultrasound | *Utilize high frequency linear transducer (>7.5 MHz) *One image to compare both testes (size & echogenicity) *Both testicles scanned completely *Spermatic cord area should be scanned from inguinal canal to scrotum *? Free fluid *Layers not normally seen *Important to scan nml protocol plus dedicated images labeled "area of interest" if indicated |
| Images Required for Testicular Ultrasound | -Longitudinal -- lateral, middle, & medial portions -Transverse -- upper, middle, & lower planes |
| Epididymal Ultrasound | *Head, body, & tail should be images -Head superior to upper pole of testicle *Slightly hyperechoic *More coarse than testicle |
| Hydrocele | *Space between layers of tunica vaginalis contains excess serous fluid *Most common cause of painless swelling *Epididymis attaches to testicular wall posteriorly, fluid only in anterolateral portion |
| Simple Hydrocele | Completely anechoic |
| Reactive Hydroceles | *Contain echoes in fluid *Caused by trauma, infection, torsion, or tumor |
| Hematocele | *Less common than hydroceles *May contain septations *Wall of scrotum becomes thickened |
| Causes of hematocele | *Surgery *Trauma *Diabetes *Torsion *Neoplams |
| Pyoceles | Abscesses that rupture |
| Cryptorchidism | *Normal variant *Testicles fail to descend into scrotum *Normal testicle is larger & more echogenic than undescended one |
| Reasons for cryptochidism | *Short spematic cord *Narrow inguinal canal *Fibrosis *Adhesions |
| Locations of undescended testicles | *Abdomen *Inguinal canal (most common, 62%) *External Inguinal ring |
| 2 possible complications of cryptochidism | *Infertility *Cancer |
| Treatment of cryptochidism | *Orchipexy for infants & children *Orchiectomy for pubertal & young adults |
| US of Testicles in children | *Very high frequency transducer due to superificial nature of inguinal canal |
| Polyorchidism | *Supernumary testis - many testis *Can be found anywhere along descent path *Attached to normal testis by duplicated vas deferens *Functions normally if within scrotum |
| Varicocele | *Dilated veins from obstruction of venous return *Always larger on left than right *Most palpable & not always painful |
| 2 types of varicocele | *Idiopathic *Secondary |
| Idiopathic Varicoceles | *Most common correctible cause of infertility *98% occurs on left side in ages 15-25 *70% have bilateral varicoceles |
| Ways to show Varicoceles on US | *Increase venous preassure to show dilated veins *Valsalva manuever in upright position (veins relax when pt is supine) *Color flow doppler can show change in direction of flow when pt strains, indicating no valves in veins |
| Secondary Varicoceles | *From extreme pressure on spermatic vein, enlarged liver, abdominal masses or retroperitoneal mass compressing veins (left renal cell ca) *Pt position does not affect secondary varicoceles |
| US apperance of Varicoceles | *Numerous anechoic structures *Measure more than 2 mm in diameter *Occurs in pampniform plexus medially *Varicoceles follow spermatic cord to inguinal canal *Can be compressed easily by transducer |
| Microlithiasis | *Scattered, tiny, punctate foci thru/o testicle *May be unilateral or bilateral *Found to have significant associated w/ testicular cancer |
| Hernia | *Scrotal hernias are from inguinal hernias that slip into scrotum *Excessive straining or lifting heavy things are common causes |
| 2 types of hernias | *Direct (caused by weakening of flood of inguinal canal) *Indirect - most common (occur when intestines escape from abdominal cavity thru inguinal canal into scrotum) |
| Symptoms of hernia | *Scrotal swelling *Palpable, firm area w/in scrotum *Lower abdominal pain |
| US Appearance of Hernias | *Scrotal mass w/ both echogenic & anechoic areas *Peristaltic motion can be detected w/in mass |
| Caution with US of Hernias | *WARNING: -Hydroceles & hematoceles w/ fibrous septations may appear like fluid filled bowel loops -Inflammed spermatic cord also mimics hernia *SO: -Document peristalsis & use color flow |
| Epididymitis | *Inflammation of epididymis *Most common cause of acute scrotal pain in adults *Mostly unilateral *May be focal or whole epididymis involved |
| Causes of epididymitis | *Lower UTI infection (most common) spread thru spermatic cord *Mumps *Syphillis *Virsues *STDs (very common) |
| US Appearance of Epididymitis | *Thick, enlarged epididymis, decreased echoes in affected area *Thickening of scrotal skin *Reactive hydrocele *Doppler shows increased blood flow in affected area *May be isolated to head or tail |
| Epididymo- Orchitis | *Infection of both epididymis & testicle *Epididymitis spreads to testicle 20-40% of cases *Compare Left & Right sides (2d & color doppler) *Testis enalrged *May be focal abnormality or be entirely affected *Hydrocele, hematocele, or pyocele may be present *Scrotal wall thickening *May lead to infarct or abscess formation |
| Fournier's Gangrene | *Uncommon type of gangrene affecting soft-tissue of genital organs *Type of necrotizing fasciitis |
| Causes of Fournier's Gangrene | *Infection (UTI) *Urethral injury/stricture *Trauma (piercings) *HIV |
| Treatment of Fournier's Gangrene | *Debridement of entire scrotum, & occasionally penis *Usually requiring major reconstructive surgery w/ skin grafts |
| Epididymal Cysts | *Symptomatic *Can develop thru/o epididymis |
| Spermatocele | *Retention cysts of small tubes that hold sperm *May cause anterior or inferior displacement of testicle *Single or multiple *Asymptomatic, no clinical significance until symptomatic, then surgically corrected *Most common type of epididymal cyst *Cystic mass that cause anterior displacement of testicle *May have septations *May include fat, cell debris, sperm *Can appear identical to epididymal cysts -True epididymal cysts contain only serous fluid -Needle aspiration can differentiate *Range from .2 to 9cm in size |
| Tunica Albuginea Cysts | *Size range from 2-5mm *Present as palpable lumps *Usually asymptomatic *50-60 years old males *Cause unknown |
| Torsion | *Results from weakening of attachment of mesenteric from spermatic cord to testicle *Must be treated w/in 5-6 hours of onset *Occurs when remnant stalk of tunica vaginalis is twisted causing restriction/obstruction of blood flow to testicle *Surgical emergency in acute phase *Testis must be untwisted to restore blood flow |
| Symptoms of Torsion | *Sudden onset of extreme scrotal pain begins while resting *Some experience nausea/vomitting |
| Who is torsion most common in? | Children & teenage boys but can occur at any age |
| Bell-clapper deformity | Tunica vaginalis completely surrounds testis, epididymis & spermatic cord, can rotate freely in scrotum |
| Attachment of scrotum & testicle | Testicle attached to scrotum by remnant stalk of tunica vaginalis at barea area |
| Classifications of torsion | *Classified by time elapse since onset *Acute *Subacute *Chronic |
| Acute torsion | *Doppler flow shows decreased arterial flow to testis *No venous flow (unless torsion-detorsion situation) *1-6 hours, epididymis & testis enlarge, hypoechoic, scrotal skin edema & hydrocele may appear |
| Subacute torsion | *24 hours to 10 days *Anechoic areas seen in testis, epididymis has mixed echogenicity w/ increased & decreased echoes |
| Chronic torsion | *after 10 days onset *Doppler shows no flow, testis is not salvageable *Testis atrophies but epididymis stays larger & hyperechoic |
| US of torsion | *MUST doppler both intratesticular artery & vein *Doppler of peripherally located vessels not acceptable --must be intratesticular *Difficult to r/o torsion/detorsion *In acute phase, occluded veins cause swelling of affected testicle *As torsion continues, arteries affected *Arterial occlusion followed by ischemia *Salvage rate determined by time of diagnosis *Missed torsion diagnosis common cause of lawsuits |
| Salvage rate | *W/in 5-6 hours -- 80-100% salvageable *Btw 6-12 hours - 70% salvageable After 12 hours - 20% salvageable |
| Incomplete torsion | Venous flow may be obstructed by there is enough arterial presure to allow arterial flow into testicle |
| Testicular Rupture | *Must be diagnoses early *Blunt trauma is most common cause *90% can be saved if surgery is performed w/in 72 hours *Treamtent - repair or removal *Several scrotal pain & swelling |
| US Appearance of Testicular Rupture | *Focal areas of altered echogenicity --hemorrhage --infection *Contour of testicle is irregular *Color flow can be used to avoid mistaking complex hematoma for rupture |
| Scrotal Pearls | *Calcifications seen floating rreely w/in scrotal sac or on tunica *Unknown cause *Usually no clinical significance |
| Infarction | *May be due to torsion, trauma, infection *Have varying echo pattern *Neoplams may be difficult to distinguish from infarcts however infarcts decrease over time & neoplams enlarge |
| Infraction echo patterns | *Initially hypoechic mass in testis, testis normal size & echo texture *Later area of infarct decreases in size w/ areas of increased echogenicity due to fibrosis or calcification |
| Malignant Tumors | *Detection rate of intratesticular masses by US in near 100% *US can distinguish btw intratesticular & extratesticular masses w/ high accuracy (98-100%) *All intratesticular masses malignant until proven otherwise |
| Malignant Tumors Appearance | *Hypoechoic *Painless, unilateral scrotum enlargement *Palpable scrotal mass *Hardness of testicle *May mimic benign processes as well *Highly vascular w/ normal testicular parenchyma (in focal cancers) *Scrotal wall usually not thickened *Focal malignancies have distinct borders |
| Germ cell tumors | *Some have elevated hCG and/or AFP *Generally highly malignant |
| Malignant Tumor Facts | *1-2% of cancers in men *But most common malignancy in 15-35 year olds *Of germ cell tumors, 60% of one type only, & rest are more than one type *Risk factor: undescended testes - 2.5-8X higher *95% are of germ cell origin |
| Germ cell tumors: 2 types | *Seminomas *Non-seminomatous GCT |
| Subtypes & frequencies of GCT | *Seminomas (40%) *Embryonal (25%)--NSGCT *Teratocarcinoma (25%)--NSGCT *Teratoma (5%)--NSGCT *Choriocarcinoma (pure) (1%)--NSGCT |
| Non-seminomatous germ cell tumors (NSGCT) | *Affect younger men (20s-30s) *More aggressive than seminomas *Frequently have visceral metastases |
| Seminoma | *Most common malignant tumor of testicle *most common component of mixed GCTs *40-50% primary testicular tumors *Peak incidence 4th & 5th decades *Least aggressive of testicular tumors, best prognosis of all testicular tumors (close to 100%) *Most common cancer in cryptorchid testes |
| US appearance of Seminoma | *Solid homogeneous, hypechoic mass *Varies in size & shape *Scattered hyperechoic areas may be w/in mass *Margins are grossly not irregular but contour varies *External anatomy enlarged & distorted |
| Mixed germ cell tumors | 8Most common NSGCT tumor *Contain various combinations of germ cell elements *Teratocarcinanoma (teratoma + chorichocarcinoma) most common combination *Mixed GCTs are second most common 1° testicular malignancy, second only to seminomas *40% of all germ cell tumors |
| Embryonal cell Carcinoma | *Pure embryonal cell cancer is rare *Usually small but can replace some or all of testicle w/o enlargement *When small, hypoechoic *With enlargement, become heterogeneous *More aggressive than seminomas, invading tunica albuginea |
| US Appearance of Embryonal cell carcinoma | *Hypechoic mass in testicle *Homogeneous *Margins poorly defined *Focal hyperechoic areas may be seen due to hemorrhage or necrosis *Children w/ this tumor demonstrate rapid testicular enlargement |
| Teratoma | *5-10% of 1° of testicular tumors *Tissue matter can be found w/in mass (bone, soft tissue, skin, teeth, fat, hair, fluid) *Once thought to be benign, untreated, 1/3 metastasize in 5 yrs *5-year survival 70% *Tend to be malignant in adults |
| US Appearance of Teratoma | *Well-defined *Markedly heterogeneous appearance w/ regions of shadowing *Cystic & solid parts *Shadowing due to bone, teeth, matted hair |
| Choriocarcinoma | *Least common *Pure chorcio ca. very rare (< 0.5%) *1-3% primary *Affects men 20-30 years old *Elevated hCG levels which leads to gynecomastia *Highly aggressive malignant tumors *Mass too small to palpate, but pts complain of scrotal pain |
| US Appearance of Choriocarcinoma | *Small mass w/ mixed echoes - heterogeneous echo texture *Prognosis is poor *Rapid mets *Radiation & chemo not effective |
| Occult Primary Tumors | *Some pts present w/ METs &/or DVT *Scanning of testicles reveals one or more coarse foci of calcifications *Called burnt out tumors as they are cancers that have regressed *Tumor grows & spreads so fast that it burns out its own blood supply |
| Metastatic disease | *METs to testicle rare *If happens, usually men 60-70 years old *Most common is prostate & kidney *Less common: bladder, bowel, lung *Appearance varies dependent upon primary lesion |
| Lymphoma | *Make p 1-7% of all testicular tumors *Most common bilateral 2ndary neoplasm of testicle > 60 years of age *Leukemia also may involve testicle (usually in children) *Homogeneous, hypoechoic masses, often multiple |
| Staging of tumor: Stage 1 | Confined to testis w/ or w/o adnexal invasion |
| Staging of tumor: Stage 2 | Mets to retroperitoneal lymph nodes but not beyond |
| Staging of tumor: Stage 3 | Mets beyond retroperitoneal lymph nodes to other sites |
| Scrotal Sonography: Scanning Techniques | *Testes scanned in 2 planes: long & transverse *Views to include: superior, middle, & inferior portions as well as medial & lateral *Adjacent epididymis should be seen *Size, echogenicity of each testicle & epididymis should be compared to other side *2D & color should be compared, w/ both tests on same image if possible *Scrotal skin thickness should be noted *Blood flow should be documents in testes & surrounding scrotal contents *Use of color & doppler for differentiating torsion & epididymitis in "acute scrotum" setting *Comparison of both sides should be done * Contents of scrotal sac should be examined for extratesticular mass, fluid collection, other abnormalities |
| Scrotal Sonography: Room Settings | *Valsalva manuever or upright position for better visualization *Room should be kept comfortable *Use warm gel (prevents cremaster muscle from contracting, drawing up testicle) *Scrotum should be draped & supported using towels (protect modesty as much as possible) *Pt in comfortable supine position, semi-frog legged *Thorough history taken including palpation of scrotal area if palpable mass is present |
| What is least common testicular cancer? | Choriocarcinoma |
| Most common malignant tumor of testicle? | Seminoma |
| Most common type of epididymal cyst? | Spermatocele |
| What is most common correctable cause of infertility? | Idiopathic Varicoceles |
| Most common location of cryptorchidism? | Inguinal canal (62%) |
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