superficial scrotal pathology exam 2

Cryptorchidism

Undescended testicle

Testicle typically descend into scrotum by 8 months GA

Most likely location: inguinal canal

Increased chance of malignancy and infertility

Cryptorchidism US appearance

Mispositioned testicle situated along normal track of descent

Increased echogenicity compared to muscle

Testicular torsion

Twisting of spermatic cord resulting in loss of blood supply

Blocks venous drainage first

Requires surgical treatment within 4-6 hours

Testicular torsion most common for

Patients 12-18 years of age

Testicular torsion caused by

Developmental weakness of mesenteric attachment of spermatic cord to the testicle and epididymis

Acute testicle torsion

Sudden onset of extreme pain

Patient may have nausea and vomiting, low grade fever

Pain disappears 24-48 hours after onset; may indicate testicle death

Which testicle is more affected by acute testicular torsion?

Left testicle

acute testicular torsion US appearance

Varies with duration of symptoms

Enlarged, inhomogeneous, decreased echogenicity

Thickened scrotal wall

Ischemia- absence of blood flow

Chronic testicular torsion

Acute becomes complete after 10 days no blood flow

Severe acute pain

Chronic testicular torsion US appearance

Heterogeneous testicle

Peripheral rim or normal appearing testicular tissue

Decreased testicle size

No blow flow

Partial torsion

Aka torsion-detorsion

Acute and intermittent sharp testicular and scrotal pain with long intervals of no symptoms in between

Twisting on itself and un twisting

Partial torsion US appearance

During detorsion: increased perfusion demonstrated as hypervascularity with low resistance flow

Testicles may be enlarged

Focal infarcts may or may not be present

-Hypoechoic areas within testicle

Torsion of the appendages

Loss of blood supply to the appendix testis or epididymis

acute scrotal pain-mimics torsion symptoms

Torsion of appendages more common for testis or epididymis?

Appendix testis

Torsion of appendages more common for?

Ages 7-14 years

Torsion of the appendages US appearance

Normal appearing testicle

Large, circular, Hypoechoic mass with central hypoechoic areas

Enlarged, circular, heterogeneous,ass adjacent to normal testicle or epi

Increased peri appendiceal flow and absent central flow

Testicular rupture

Rare- occurs when the tunica albuginea is torn by trauma

Associated with athletic injuries, industrial, or motor vehicle accidents

Testicular rupture US appearance

Contour abnormality- irregular tunica albuginea

Extrusion of testicular contents into scrotum

Hematocele or hematoma

Infarction of testicular contents

What is the most common cause of acute scrotal pain

Epididymitis

Epididymitis

Retrograde spread of bacteria from bladder to prostate

Associated with prostatitis

Sexually transmitted organism- most common cause in younger population

Epididymitis S/S

Fever, chills, “heaviness” of affected testicle, enlarged testicle, pelvic pain, blood in urine, painful urination, urinary frequency

Acute epididymitis US appearance

Enlarged, Hypoechoic

Mainly involves the epi head

Edema

Increased vascularity

Chronic Epididymitis US appearance

Thickened, Echogenic epi

Calcifications

Orchitis

Inflammation of the testicle due to trauma, metastases, mumps, or other infection

Usually occurs secondary to Epididymitis

Can involve entire testicle, or just part

Acute pain with or without fever, similar symptoms to epididymitis

Acute orchitis US appearance

Decreased echogenicity and increased size

Focal areas of decreased echogenicity

Hypervascularity

Chronic orchitis US appearance

Thickened tunica albunginea

Echogenic, thick, irregular epi

Calcification

Affected testicle is smaller

Granulomatous orchitis

Multiple focal Hypoechoic lesions

Epididyo-orchitis

Inflammation of the testicle and epididymis

20% of Epididymitis involves the testicle

May be focal or diffuse involvement of the testicle

Epididymo-orchitis US appearance

Hypoechoic area extended from epididymal region

Hypervascularity in affected testicle and epididymis

Hydrocele

Abnormal collection of serous fluid between layers of tunica vaginalis

May be congenital or acquired, or associated with another pathological process (Epididymitis, trauma, torsion)

What is the most common cause of painless scrotal swelling

Hydrocele

Hydrocele US appearance

Anechoic fluid collection within scrotum

Typically surrounds the anterolateral aspect of the testicles

Scrotal pearl

Aka scrotoliths

Calcifications on the tunica vaginalis that have separated from the lining

Typically the result of inflammation or long standing infection

Often mobile within the scrotum

Scrotal pearl US appearance

Echogenic, free floating calculus

May show posterior shadowing

Spermatocele

Benign cyst arising from the Rete testis that connect to the testicle with the epi head

Varies in size and appearance, may be unilateral or bilateral, may calcify

Cystic structure, not a true cyst

Contains non viable spermatozoa

Patient usually asymptomatic

Spermatocele US appearance

Superior to testicle and epididymis

Round or over anechoic mass

May reposition testicle anteriorly

Epididymal cyst

Benign, clear, serous containing cyst

Similar in appearance to Spermatocele

Usually located in epi head

Result from cystic dilation of epididymal tubules

Epididymal cyst US appearance

Varies- usually anechoic, may be hyperechoic or calcified wall

Tubular ectasia of Rete teste

Dilation of the efferent ductules

Focal enlargement of the Rete testis due to obstruction at level of epi

Often bilateral and seen in patients 50 years or older

Tubular ectasia of Rete testis US appearance

Appears as a cluster of Hypoechoic, small, cystic spaces within or next to mediastinum testis

Tubular ectasia of epididymis

Common post-vasectomy

Cluster of Hypoechoic, cystic spaces in epi area

Varicocele

Collection of dilated, tortuous veins arising from pampiniform venous plexus

Can be a cause of infertility

What is varicocele caused by

Incompetent valves

Is varicocele more common on left or right side, why?

Left side

Left testicular vein empties into left renal vein

Varicocele US appearance

Dilated tubular structures greater than 2mm in the superior aspect of scrotum

Vessels increase in size with valsalva maneuver- color doppler

Hernia- scrotal

Inguinal hernia that enters the scrotum

Intestine or omentum herniates and extends into scrotum

Indirect scrotal hernia

External

Bowel passes through external inguinal ring into inguinal canal, then into scrotum

Direct scrotal hernia

Caused by weakness in floor of inguinal canal

Is direct or indirect scrotal hernia more common

Indirect

Scrotal hernia symptoms

Persistent or intermittent scrotal mass

Abd pain

Blood in stool

Swollen scrotum containin firm palpable mass

Scrotal hernia US appearance

Mass that may contain air or fluid filled loops of bowel

Peristalsis- bowel movement

Echogenic and anechoic areas

Abscess

Localized encapsulated area of infection

Recurrent scrotal pain

Swelling and tenderness of scrotum

What is an abscess most often a complication of?

Untreated epididymis orchitis

Predisposing factors for abscess

Diabetes, HIV, cancer, TB

Abscess complicated by:

Pyocele, fistula formation, epididymo-orchitis

Abscess US appearance

Complex, irregular fluid collection

Irregular borders

Increased vascularity peripherally

Hematoma

History of trauma

Typically focal, but can be multiple or diffuse

May be intratesticular (blood contained within scrotum itself) or involve scrotal wall

Scrotal swelling, pain, discoloration

Hematoma US appearance

Acute- a vascular, Hypoechoic are

Chronic- Hypoechoic or complex with cystic components

Hematomas of focal wall may appear as focal thickening of the wall or as fluid collection within the wall

Hematocele

Abnormal collection of blood in potential space between the two layers of the tunica vaginalis

Typically due to trauma, surgery, tumor, or torsion

Scrotal enlargement

Pyocele

Abnormal collection of pus

Hematocele US appearance

Complex, heterogeneous

Acute- Echogenic

Chronic- complex, heterogeneous with thick septations

Distorts contour of testis

Tunica albuginea cyst

Uncommon with unknown etiology

Well defined, single or multiple, uni or multilocular

Occur in 5th or 6th decade of life

Painless scrotal lump

Tunica albuginea cyst US appearance

Well circumscribed, anechoic area

Typically 2-5 mm

Mets characteristics of simple cyst

Adenomatoid tumor

Most common extra testicular neoplasm

Benign

Typically located in epi tail

Patients 20-50 yrs

Painless mass, typically incidental finding

What is the most common extra testicular neoplasm?

Adenomatoid tumor

Adenomatoid tumor US appearance

Well circumscribed, solid mass

Variable echogenicity

Minimal flow within and in periphery

Leiomyoma

Second most common benign neoplasm of epididymis

Often involves epi tail

Commonly manifest in 5th decade of life

Generally asymptomatic

Painless scrotal mass

Second most common benign neoplasm of epididymis

Leiomyoma

Leiyoma US appearance

Well circumscribed, homogeneous solid mass

Variable echogenicity

Minimal flow within mass on color Doppler

Lipoma

Most common extra testicular neoplasm that involves the spermatic cord

Lipoma US appearance

Well circumscribed, homogeneous mass that alters shape with US compression

Variable echogenicity

Rhabdomyosarcoma

Most common malignant tumor involving epi and spermatic cord

Occurs predominantly in children

rhabdomyosarcoma US appearance

Well circumscribed, unilateral

Hypoechoic lesion without capsule

1-2 cm

Intratesticular cyst

Rare and benign

Typically an incidental finding

May be the result of trauma, surgery, or prior inflammation

Commonly associated with extra testicular Spermatocele

Asymptomatic

Intratesticular cyst US appearance

Well circumscribed anechoic area within testicular parenchyma

Smooth walls, posterior enhancement

Leydig cell tumor, aka:

Gonadal stromal tumor

Most common non-germ cell neoplasm

Leydig cell tumor

Leydig cell tumor

Most common non-germ cell neoplasm

Usually benign, but 10-15% malignant

Ages 20-50

May produce excessive amounts of estrogen - feminization

Endocrine imbalance

Painless enlargement of testicle

• Leydig cell tumor US appearance

Benign:

• solid, well circumscribed

• Typically less than 1 cm

• Prominent peripheral flow

Malignant:

• larger in size, often >5 cm

• Hypoechoic with less well defined boarders

Sertoli cell mesenchymal tumor

<1% of all testicular tumors

May occur in undescended testicles

Associated with feminization, Klinefelter syndrome, Peutz -jeghers syndrome

Painless testicular mass

Sertoli cell mesenchymal tumor US appearance

Benign:

• solid, well circumscribed intratesticular

• Typically <1 cm

Malignant:

• larger in size, often >5 cm

• Less well defined boarders

• Usually Hypoechoic

Epidermoid cyst

Benign teratoma

Rare- 1-2% of all testicular neoplasms

20-40 years of age

Caucasian and Asian individuals

Asymptomatic

Epidermoid cyst US appearance

Sharply circumscribed, encapsulated, a vascular mass

Variable echogenicity

May contain Hypoechoic concentric rings with Echogenic center- bulls eye or target appearance

May contain alternating Hypoechoic and hyperechoic concentric rings

Microlithiasis, aka:

Intratesticular tubular calcification

Microlithiasis

Defective Sertoli cell phagocytes of degenerating tubular cells causing calcifications of seminiferous tubules

Associated with an increased risk of malignancy

Microlithiasis US appearance

Multiple 1-3 mm Echogenic foci throughout testicle

Common bilaterally

No posterior shadowing (typically)

Semiminoma

Most common type of testicular neoplasm- 40-50%

4th - 5th decade of life

Rare before puberty

Most common malignant disease associated with undescended testes

Commonly found in patients with Microlithiasis

AFP normal

Elevated FSH levels

Most common type of testicular neoplasm

Seminoma

Most common malignant disease associated with undescended testes

Seminoma

Embryonal cell carcinoma

2nd most common germ cell tumor

25 to 35 years

Invades tunica, distorting testicular contour

Most aggressive scrotal malignancy

Elevated AFP and hCG

Most aggressive scrotal malignancy

Embryonal cell carcinoma

Second most common germ cell tumor

Embryonal cell carcinoma

Embryonal cell carcinoma US appearance

Hypoechoic mass in testicle

Inhomogeneous

Poorly defined boarders

May have areas of increased echogenicity

Cystic components in 1/3 of tumors

May distorted normal contour of testicle

Choriocarcinoma

Rare form of germ cell tumor

20-30 years

Worst prognosis of all germ cell tumors

Elevated hGC

Gynecomastia

What has worst prognosis of all germ cell tumors

Choriocarcinoma

Choriocarcinoma US appearance

Heterogenous mass with high likelihood to metastasize

Mixed echogenicity with extensive hemorrhagic necrosis

Teraroma

5-10% of primary testicular neoplasm

Second most common neoplasticism in children 4 and younger

May contain bone, teeth, soft tissue, hair

Elevated AFP

hCG sometimes elevated

Three types of teratoma

Mature

Immature

Malignant

Teratoma US appearance

Appearance depends in which tissue components are contained

Tend to be large and inhomogeneous

Variable echogenicity, but cystic components are common

Yolk sac tumor

80% of childhood testicular tumors

Most occurs before age 2

Exclusively produce AFP in more than 90% of cases