scrotum pathology

polyorchidism

a rare condition where a patient may have 3 or more testicles

polyorchidism is most often located:

on the left side

in polyorchidism, the supernumerary testicle has an increased risk for:

developing testicular cancer

clinical findings of polyorchidism:

• asymptomatic

• palpable extratesticular mass

• pain if torsion occurs

sonographic findings of polyorchidism:

• smaller, normal-appearing additional testicle

• doppler characteristics should be normal

cryptorchidism

the condition of having an undescended testis

cryptorchidism is associated with what other conditions?

• infertility

• increased risk for malignancy in the involved testis

what is the most common cancer found in an undescended testis?

seminoma

where are undescended testicles most often found?

within the inguinal canal

orchiopexy

surgical correction of an undescended testis

clinical findings of cryptorchidism:

one or both testicles not palpable within the scrotum

sonographic findings of cryptorchidism:

• testis located outside the scrotum → most likely in the inguinal canal

• the cryptorchid testis will appear hypoechoic to the normal testis

testicular torsion/spermatic cord torsion

occurs when the arterial blood supply to the testicle is cut off secondary to the twisting of the testicular axis

the amount of ischemic damage from testicular torsion is directly related to:

the degree of the torsion

testicular torsion occurs more often in what population?

in adolescents, between 12-18 yrs old

in testicular torsion, salvage rates range from:

• 80%-100% if the patient is treated within 6 hrs of symptom onset

• the testicle is usually not salvageable after 24 hrs

testicular torsion can be associated with:

• trauma

• strenuous exercise

• sexual activity

patients who are predisposed to develop testicular torsion have a condition known as:

the “bell-clapper” deformity

Bell-clapper deformity

• congenital abnormality that describes the situation in which the patient lacks the normal posterior fixation of the testis and epididymis to the scrotal wall

• classically bilateral

what is the most common form of testicular torsion?

intravaginal torsion

intravaginal torison

• seen with bell-clapper deformity

• the testis, which is not affixed to the scrotal wall, is permitted to migrate and twist freely within the scrotum

extravaginal torsion

which occurs in the neonatal period or in utero and is related to torsion of the spermatic cord within the inguinal canal

the sonographic appearance of the torsed testis depends on:

the duration of time that has passed since the first sign of symptoms

chronic testicular torsion

torsion that has lasted for more than 10 days

clinical findings of acute testicular torsion:

• acute onset of testicular pain → often during sleep

• possible pain within the lower abdomen and inguinal region

• swollen testis/scrotum

• nausea and vomiting

• higher positioned, painful testis with a horizontal position

sonographic findings of acute testicular torsion:

• enlargement of the spermatic cord, epididymis, and testis

• thickened scrotal wall

• hypoechoic or heterogeneous testis

• reactive hydrocele

• no intratesticular flow

• decreased intratesticular flow → as compared to the asymptomatic testis

sonographic findings of chronic testicular torsion:

• enlargement of the spermatic cord, epididymis, and testis

• no intratesticular flow

• hyperemic flow around the testis

• heterogeneous testis with areas of necrosis

what is the most common cause of acute scrotal pain in prepubertal boys?

torsion of the appendix testis

what are the appendages of the testis?

• appendix testis, appendix epididymis, and appendix vas

• they are embryologic remnants of the Müllerian duct, Wolffian duct, and mesonephric ducts, respectively

where is the appendix testis located?

between the head of the epididymis and the superior pole of the testis

where is the appendix epididymis located?

at the head of the epididymis

where is the appendix vas located?

positioned between the body and tail of the epididymis

after an appendage has undergone torsion, the appendage will likely become displaced and become mobile within the scrotum. The calcification of this free-floating structure will likely result in

a scrotal pearl

“blue-dot” sign

describes the appearance of the torsed appendage as a blue dot just under the skin surface

clinical findings of torsion of the testicular appendage:

• acute testicular pain

• pain localized to the superior pole of the testis

• “blue-dot” sign

sonographic findings of torsion of the testicular appendage:

• normal intratesticular flow

• small, avascular, hypoechoic or hyperechoic mass adjacent to the superior pole of the testis

• reactive hydrocele

• scrotal wall thickening

hydrocele

a simple fluid collection within the scrotum

where are hydroceles found?

between the 2 layers of the tunica vaginalis and often displace the testicles posteriorly

clinical findings of a hydrocele:

• transilluminates light

• painless scrotal swelling

• may present with pain when found in the presence of scrotal infections, testicular torsion, trauma, or a tumor

sonographic findings of a hydrocele:

• simple fluid anterior to the testis

• scrotal wall thickening

• chronic hydroceles may have internal debris and septations

spermatocele

• the most common scrotal mass

• a cyst found most often in the head of the epididymis

what is a spermatocele composed of?

nonviable sperm, fat, cellular debris, and lymphocytes

epididymal cyst

appears similar to a spermatocele and can be seen anywhere along the length of the epididymis

tunica albuginea cysts

located anywhere along the periphery of the testicle, within the tunica albuginea

clinical findings of a spermatocele, epididymal cyst, and tunica albuginea cyst:

• if large enough, they may be palpable

• typically not painful

sonographic findings of a spermatocele, epididymal cyst, and tunica albuginea cyst:

• round, anechoic mass with acoustic enhancement

• may contain some layering debris

varicocele

a dilated group of veins found within the scrotum

varicoceles are caused by:

incompetent or abnormal valves within the pampiniform plexus

what is the most common cause of correctable male infertility?

varicoceles

what are the 2 types of varicoceles?

primary and secondary

primary varicoceles

• most often found on the left

• their high incidence on the left is thought to be caused by the elevated vascular pressure on the left side or possibly as a result of the extended length of the left testicular vein (compared to the right testicular vein) and the sharp angle at which it enters the left renal vein

secondary varicoceles

• found on the right

• may be associated with a hepatic mass, marked hydronephrosis, hepatomegaly, or a retroperitoneal neoplasm like a right-sided renal mass so a prompt investigation of the right upper quadrant and retroperitoneum may be warranted

clinical findings of a varicocele:

• typically painless → large ones can cause discomfort

• palpable extratesticular mass

• possible infertility

sonographic findings of a varicocele:

• a group of anechoic, tubular structures located outside the testis → however, can be intratesticular in location

• distended veins that fill with color flow when the Valsalva maneuver is performed

• dilated veins that measure greater than 2 mm

• possibly associated with hydronephrosis, hepatomegaly, or a retroperitoneal neoplasm if found on the right

scrotal pearl/scrotolith

• extratesticular calculus

• thought to be remnants of a formerly torsed and displaced testicular appendage

sonographic findings of a scrotal pearl:

extremely echogenic, mobile extratesticular structure that produces acoustic shadowing

epididymitis

inflammation of the epididymis

what is the most common cause of acute testicular pain in adults?

epididymitis

orchitis

inflammation of the testis

epididymo-orchitis

the combination of an infection within the epididymis and testis

causes of epididymitis include:

• the spread of bacteria from the prostate or urinary tract

• trauma

Common causes of epididymitis in younger men are:

the sexually transmitted diseases chlamydia and gonorrhea

clinical findings of epididymitis and epididymo-orchitis:

• acute testicular pain

• leukocytosis

• fever

• dysuria

• urethral discharge

• scrotal wall edema

• possible sexually transmitted disease

sonographic findings of epididymitis and epididymo-orchitis:

• enlargement of the entire epididymis (diffuse)

• enlargement of only part of the epididymis (focal)

• hypoechoic echotexture of the affected section(s) of the epididymis

• hypoechoic testis (with orchitis)

• hyperemia within the epididymis and/or testis

• thickened scrotal wall

• reactive hydrocele

testicular abscess

occurs within the testicle and is typically the result of untreated epididymo-orchitis

pyocele

a complex hydrocele that contains pus

clinical findings of a testicular abscess:

• painful, swollen scrotum

• fever

• leukocytosis

sonographic findings of a testicular abscess:

• complex intratesticular mass

• mass that has no flow centrally but increased flow around its margins

• may have a coexisting pyocele

sonographic findings of a pyocele:

• complex fluid collection within the scrotum

• scrotal wall thickening

• may be seen in conjunction with rupture of a testicular abscess

multiple small cysts located along the mediastinum testis represent:

cystic dilation of the rete testis, also referred to as tubular ectasia

epidermoid cysts

• may be noted within the testicle

• often appear to have whorled or onion-skin appearance

sonographic appearance of testicular microlithiasis:

will appear as multiple echogenic foci with no acoustic shadowing within the testis

testicular microlithiasis has been associated with what other conditions?

• malignancies

• infertility

• Klinefelter syndrome

• cryptorchidism

adrenal rests of the testis

• resemble a mass within the testicle and are associated with congenital adrenal hyperplasia or Cushing syndrome

• consist of ectopic adrenal tissue and are caused by the migration of adrenal tissue with gonadal tissue during fetal development

clinical findings of adrenal rests:

• history of congenital adrenal hyperplasia

• elevated adrenocorticotropic hormone

• Cushing syndrome

sonographic findings of adrenal rests:

bilateral, round, hypoechoic, intratesticular masses → most commonly near the mediastinum testis

intratesticular masses are often considered:

malignant until proven otherwise

the majority of extratesticular masses are typically:

benign

non-germ cell malignant tumors include:

• sex cord-stromal tumors

• lymphoma

• leukemia

• metastasis

sonographic appearance of lymphoma and leukemia:

can either appear as focal hypoechoic masses or produce diffuse involvement of the testicles

metastatic disease to the testis is most commonly from:

• melanoma

• lung

• kidney

• prostate cancer

what 2 lab values are helpful to differentiate between benign and malignant intratesticular tumors?

• human chorionic gonadotropin (hCG)

• alpha-fetoprotein (AFP)

An elevation in hCG levels is found in conjunction with:

malignant intratesticular tumors in 60% of the time

An elevated AFP level is most often associated with:

embryonal cell carcinoma, teratomas, and yolk sac tumors

germ cell tumors of the testicles include:

• pure seminoma

• teratoma

• embryonal cell carcinoma

• yolk sac tumor

• choriocarcinoma

• burned-out germ cell tumor

Leydig cell tumor

• sex cord-stromal tumor

• found in younger boys and produce increased levels of testosterone

Sertoli cell tumor

• sex cord-stromal tumor

• found in younger boys and produce estrogens that results in gynecomastia

Granulosa cell tumor

• sex cord-stromal tumor

• found in younger boys and are associated with chromosomal abnormalities

what is the most common malignant neoplasm of the testicles?

seminoma → germ cell tumor

seminomas are often found in patients suffering from:

cryptorchidism

clinical findings of a seminoma:

• painless scrotal mass

• hardening of the testis

• elevated hCG

sonographic findings of a seminoma:

• solid, hypoechoic intratesticular mass

• large seminomas may become heterogeneous

choriocarcinoma

• nonseminomatous germ cell tumor

• malignant

clinical findings of a choriocarcinoma:

• may be palpable

• elevated hCG

sonographic findings of a choriocarcinoma:

heterogeneous mass with areas of hemorrhage, necrosis, and calcifications

embryonal cell carcinoma

• nonseminomatous germ cell tumor

• malignant

clinical findings of an embryonal cell carcinoma:

• may be palpable

• elevated AFP and hCG

sonographic findings of an embryonal cell carcinoma:

heterogeneous mass with cystic components

yolk sac tumors

• nonseminomatous germ cell tumor

• malignant

clinical findings of yolk sac tumors:

• may be palpable

• elevated AFP