chapter 23 - scrotum

acute scrotum

• trauma may result of MVA, athletic injury, direct blow to scrotum, or straddle injury

• if surgery is performed within 72 hours following injury, up to 90% of testes can be saved, but only 45% can be saved after 72 hours

acute scrotum (hematoceles)

contain blood; found in advanced cases of epididymitis or orchitis

• presence of a hematocele does not confirm rupture

sonographic appearance of a acute hematocele

• varies with age

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

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

acute scrotum (hematomas)

associated with trauma may be large and cause displacement of the associated testis

• appear as heterogeneous areas within the scrotum

• become more complex with time, developing cystic components

• may involve testis or epididymis, or they can be contained within scrotal wall

epididymo-orchitis

infection of the epididymis and testis

• most commonly results from spread of lower urinary tract infection via spermatic cord

• most common cause of acute scrotal pain in adults

• usually occurs secondary to epididymitis

sonographic findings of epididymo-orchitis

• epididymis appears as enlarged, hypoechoic gland

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

• hyperemic flow confirmed with color doppler

image of epididymo-orchitis

microlithiasis

• benign

• microcalcifications are <3mm

• 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

torsion

• occurs as a result of abnormal mobility of testis within scrotum

• testis and epididymis twist within scrotum, cutting off vascular supply within spermatic cord

• up to 60% of — patients have an anatomic anomaly on both sides

• undescended testes are 10 times more likely than normal testes to be affected by torsion

Bell clapper deformity

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

presenting symptoms of torsion

sudden onset of scrotal pain with swelling on affected side

torsion saves rates

• if surgery is performed within 5 to 6 hours of onset pain, 80% to 100% of testes can be salvaged

• between 6 and 12 hours salvage rate to 70%

• after 12 hours only 20% will be saved

venous flow

is affected first in torsion with occluded veins, causing swelling of scrotal structures on affected side

scrotal hernia

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

• bowel mosy commonly herniated structure, followed by omentum

• peristalsis of the bowel, seen with real-time imaging, confirms the diagnosis of a —

varicocele

abdominal dilation of veins of pampiniform plexus (located within spermatic cord)

• more common in left

• tubes may contain echoes that move with real-time imaging

• measure >2mm in diameter

• tend to increase diameter in response to valsalva maneuver

primary varicoceles

usually caused by incompetent venous valves within spermatic vein

sonographic evaluation of varicocele

shows numerous tortuous tubes of varying sizes within spermatic cord near epididymal head

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 noncompressible veins

sperm granuloma

occurs as a chronic inflammatory reaction to extravasation of spermatozoa

• most frequently seen in patients with history of vasectomy

• may be located anywhere within epididymis or vas deferens

germ cell tumors

• accounts for only 1% of cancers in men

• most common malignancy in men between ages 15 and 35

• one of the most curable forms of cancer

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

• occurs most frequently between ages of 20 and 34

symptoms of germ cell tumors

painless lump, testicular enlargement, or vague discomfort in scrotum

extratesticular masses

usually benign

intratesticular masses

more likely to be malignant

elevated level of hCG and alpha-fetoprotein

germ cell tumors are associated with —-

seminoma

most common type of germ cell tumor, followed by mixed embryonal cell tumors and teratocarcinomas

• tend to be homogeneous, hypoechoic masses with a smooth border

embryonal cell tumors

more aggressive than seminomas, which are the least aggressive form of testicular cancer

types of germ cell tumors

• seminomas

• embryonal carcinoma

• teratoma (teeth & hair)

• choriocarcinoma

• yolk sac tumor (endodermal sinus tumor)

sex cord-stromal tumor

• leydig cell tumor

• sertoll cell tumor

metastatic tumors

lymphoma (secondary)

mixed germ cell tumor

most common malignant tumor overall