chapter 23 - scrotum

measurement of the epididymis

• 6-7 cm tubular structure

• head: 6 - 15 mm width

is the epididymis located superiorly or inferiorly

superior to upper poles of the testies

Sonographic appearance of the scrotum epididymis

• isoechoic or hypoechoic compared with testies

• echo texture coarse

mediastinum

supports vessels and ducts coursing within testes

tunica vaginalis

lines inner wall of scrotum

the 2 layers of the tunica vaginalis

1. parietal layer - inner lining of the scrotal wall

2. visceral layer - surrounds testis and epididymis

vas deferens

continuation of the ductus epididymis

duct of seminal vesicles

What does the vas deferens join in order to form the ejaculatory duct

urethra

Where does the ejaculatory duct empty into

the verumontanum

The junction of the ejaculatory ducts with the urethra is called

centripetal arteries

capsular arteries give rise to

testicular arterial branches

• testicular artery

• capsular artery

• centripetal artery

• recurrent rami

pampiniform plexus

venous drainage of the scrotum occurs through veins of

pampiniform plexus converges into 3 sets of anastomotic veins

1. testicular

2. deferential

3. cremasteric

pelvic veins

the deferential veins drains into the

tributaries of the epigastric and deep pudendal veins

The cremasteric veins drain into the

acute scrotum

may result be a result of MVA, athletic injury, direct blow to scrotum, or straddle injury

72 hours

if a surgery for acute scrotum is performed in — hours following injury, up to 90% of testes can be saved

sonographic appearance of acute scrotum w/ hematocele

• varies with age

• echogenic with numerous, highly visible echoes that can be seen to float or move in real time

• with time, they show low-level echoes and develop fluid-fluid levels or septations

• does not confirm rupture

rupture

blood flow disruption across surface of testis indicates

epididymitis

increased vascularity in epididymis indicates

epididymo-orchitis

infection of epididymis and testis

lower UTI’s usually

results from epididymo-orchitis

Epididymo-orchitis

most common cause of acute scrotal pain in adults

sonographic findings of epididymo-orchitis

• epididymitis appears an enlarged, hypoechoic gland

• if secondary hemorrhage has occurred, epididymis may contain focal hyperechoic areas

• hyperemic flow confirmed with color Doppler

yes

does epididymo-orchitis have more flow than asymptomatic epididymis?

associated findings with epididymo-orchitis

• scrotal wall thickening

• hydrocele

  • found in anterolateral aspect of testes

• may appear anechoic or contain low-level echoes

• complex hydroceles may be associated with severe

  • these will have thick septations and contain low-level echoes

testicular infarction

may occur in severe cases of orchitis

rigid tunica albuginea

where are the swollen testis confined in

torsion

a result of abnormal mobility of testis within scrotum

bell clapper deformity 

tunica vaginalis completely surrounds testis, epididymis, distal spermatic cord, allowing them to move and rotate freely within scrotum

60

up tp — % of torsion patients have anatomic anomaly on both sides

10

undescended testes are — times more likely than normal testes to be affected by torsion

if torsion continues then what will happen

• arterial flow obstructed

• testicular ischemia follows

80

if surgery of a torsion is completeed in between 5 - 6 hours of onset pain, —% - 100% of testes can be salvaged

70%

between 6-12 hours of pain b/c of torsion, the salvage rate is now 

20

after 12 hours of torsion, only —% of testes will be saved

14 yrs old

peak incidence of torsion

presenting symptoms of torsion

sudden onset of scrotal pain with swelling on affected side

spermatoceles

cystic dilations of efferent ductules of epididymis

characteristics of spermatoceles

• always located in epididymal head

• contain proteinaceous fluid and spermatozoa

• may be seen more often following vasectomy

epididymal cysts

small, clear cysts containing serous fluid located within the epididymis

varicocele

an abnormal dilation of veins of pampiniform plexus (located within spermatic cord)

primary varicoceles

usually caused by incompetent venous valves within spermatic vein (more common on the left)

secondary varicoceles

• caused by increased pressure on spermatic vein

• may be result of renal hydronephrosis, abdominal mass, or liver cirrhosis

• abdominal malignancy invading left renal vein may cause varicocele with non compressible veins

2 mm in diameter

measurement of a varicocele

valsalva

—- maneuver tends to increase the diameter of a varicocele

scrotal hernia

occurs when bowel, omentum, or other structures herniate into scrotum

bowel

— is the most commonly herniated structure

peristalsis

— in the bowel, seen with real-time imaging, confirms the diagnosis of a scrotal hernia

hydroceles

• contain serous fluid

• are MOST COMMON cause of painless scrotal swelling

• may be idiopathic, but commonly associated with epididymo-orchitis and torsion

pyoceles , hematoceles

— and — are much less common than hydroceles

pyocele

collection of pus. occurs with untreated infection or when an abscess ruptures into space between layers of tunica vaginalis

hematoceles

collections of blood associated with trauma, surgery, neoplasms, or torsion

sperm granuloma

• chronic inflammatory reaction to extravasation of spermatozoa

• most commonly seen in patients with history of vasectomy

• may be located anywhere within epididymis or vas deferens

tubular ectasia of the Rete Testis

• located at the hilum of testis where mediastinum resides

• uncommon, benign condition

• associated with presence of a spermatocele epididymal, or testicular cyst, or other epididymal obstruction on the same side as dilated tubules

  • this condition is basically just dilated tubules

microlithiasis

• microcalcifications are < 3 mm 

• usually bilateral condition

• reported to have association with testicular malignancy ; extract nature unknown

• has been associated with cryptorchidism, Klinefelter’s syndrome (a male chromosomal defect in which there is an extra X chromosome XXY), infertility, varicoceles, testicular atrophy, and male pseudohermaphroditism

• benign

germ cell tumors

• testicular cancer is uncommon, accounts for only 1% of cancers in men

• is MOST COMMON malignancy in men between ages 15-35

• is one of the most curable forms of cancer

• occurs most frequently between ages 20-34

• undescended testes are 2.5 to 8 times more likely to develop cancer

more about germ cell tumors

• symptoms: painless lump, testicular enlargement, or vague discomfort in scrotum

• primary goal: determine mass location; differentiate between cystic and solid composition

extratesticular masses

usually benign

testicular tumors

categorized as germ cell and non-germ cell tumors

germ cell tumors:

associated with elevated level of human chorionic gonadotropin and alpha-fetoprotein

95

approx. —% of all testicular tumors are germ cell type and highly malignant

non germ cell tumors are

usually benign

most common type of germ cell tumor

seminoma, followed by mixed embryonal cell tumors and teratocarcinomas

sonographic appearance of germ cell tumors

focal, hyperechoic masses

embryonal cell tumors

more aggressive kind of testicular cancer

seminomas

least aggressive form of testicular cancer

sonographic appearance of seminomas

• homogeneous

• hypoechoic masses w/ smooth border

• do not often contain calcification or cystic components

sonographic appearance of Embryonal Cell Carcinoma

• heterogenous & less well circumscribed

• may contain areas of increased echogenicity resulting from calcification, hemorrhage, or fibrosis

choriocarcinoma is a

rare & highly malignant type of testicular germ cell tumor and arises from germ cells in the testicular parenchyma

more about choriocarcinoma

• does not form a testicular mass as prominently as other tumors and often presents with early metastasis to the lungs, liver, and brains, even when the primary tumor in the testis is small or occult

• MOST COMMONLY occurs in young adult males between the ages of 20-30 years old. it is very aggressive and has a poor prognosis

metastasis

• primary tumor may originate from prostate or kidneys; less common sites include lung, pancreas, bladder, and colon, thyroid, or melanoma

• — to testes is bilateral, with multiple lesions found

sonographic appearance of metastasis

solid hypoechoic mass, although it has been reported as hyperechoic or a mixture of both

malignant lymphoma

1%-7% of all testicular tumors; MOST common bilateral secondary testicular neoplasm affecting men >60 years old

leukemia

— involvement of testicle is next MOST COMMON secondary testicular neoplasm; most often found in children

cryptorchidism (undescended testicle)

• during fetal growth, testes first appear in retroperitoneum near kidneys

• testes should descend into scrotum from inguinal canal shortly before birth or early in neonatal period

testicular ectopia

• very rare condition

• ectopic testicle cannot be manipulated into correct path of descent

• MOST COMMON site for ectopic testicle to rest is superficial inguinal pouch

• other sites include perineum, femoral canal, suprapubic area, penis, diaphragm, and other scrotal compartment

anorchia

• rare condition

• unilateral, or monorchidism, found in 4% of patients with nonpalpable testis

• MORE COMMON on the left side'; definitive diagnosis depends on surgical diagnosis

• causes: intrauterine testicular torsion or other forms of decreased vascular supply to testicle in utero

polyorchidism (testicular duplication)

• very rare disorder- MORE COMMON on left side (75%); bilateral in 5% of cases

• usually found in the scrotum; has also been found in inguinal canal or retroperitoneum

• increased incidince: malignancy, cryptochidism, inguinal hernia, torsion with polyorchidism

• usually small; efferent spermatic system completely absent

testes 

symmetric, oval shaped glands residing in the scrotum

measurement of the testis (adult)

3-5 X 2-4 X 3 cm

stores and matures sperm

what does the epididymis do