Scrotum and Prostate 6/16 exam

counter clockwise (first 6):

vas deferens, epididymal head, efferent ductules, rete testis (in mediastimun tesis), body of epididymus, tail of epididymus,

counter clockwise (last 7):

capsule (tunica albuginea), tunica vaginalis- visceral layer, cavity, parietal layer, seminiferous tubule, straight tubule

What is the reservoir for sperm?

Epididymis

Seminal fluid is produced by?

Prostate, Seminal Vesicles, and Cowper’s Glands

Location of Seminal Vesicles to the prostate gland

Superior and Posterior

The _____ zone of the prostate is the largest and most lateral zone

peripheral

Vascular Supply to the testicle waveforms are

low resistive vessels

Venous drainage in the testicle is via

the pampiniform plexus (veins in the spermatic cord)

RT drains into the IVC

LT drains into the LT renal vein.

veins and structures within the spermatic cord?

vas deferens, Rt/Lt testicular arteries, veins, lymph vessels

Mediastinum testes- location and sonographic appearance

runs through the length of the testicle. (middle)

appears as a hyperechoic line.

Rete testis location and sonographic appearance

tubules that connect the mediastinum to efferent ducts

seen as tiny tubules adjacent to epididymal head - usually only seen if dilated.

sm tubular structures seen near the mediastinum testes.NO COLOR DOPPLER- tubes not veins

Importance of using doppler

to rule out: torsion, varicoceles, orchitis

and in prostate- abnormal cells

epididymis is located

superiorly then courses posterolateral to the testis

sonographic appearance of epididymis

medium echogenicity; usually isoechoic to hypoechoic compared to the testis, echogenicity is courser.

Vas Deferens

connects the epididymis to seminal vesicles.

in the spermatic cord.

continuation of ductus epididymis. thicker and less convoluted. dilates at the terminal portion near the seminal vesicles

joins w/ duct of seminal vesicles to form ejaculatory ducts.

Tunica Vaginalis

lines the inner walls of the scrotum, covering each testis & epididymis.

consists of 2 layers the parietal and visceral

parietal lines the scrotal wall

visceral surrounds testis and epidid.

where do hydroceles, pyoceles, and hematoceles form?

in the layers of the Tunica Vaginalis

Pampiniform Plexus

drains the testicles

associated with varicoceles

Tunica Albuginea

dense fibrous tissue that completely covers the testis

transition zone

small area located on the lateral sides superior to the verumontanum near the center of the prostate

Cryptorchidism

undescended testicle, typically in newborns.

CF of cryptorchidism

asymptomatic, or a palpable mass in the pelvic/groin region

USF or cryptorchidism:

small, less echogenic, oval and homogeneous, mediastinum is not usually seen

risks of cryptorchidism

testicular cancer, torsion, infertility

cryptorchidism

Epididymitis

infection/inflammation of the epididymis

most common cause of acute scrotal pain and tenderness

CF of epididymitis

scrotal pain/ possible discharge

fever and painful urination

severe infection

USF of epididymitis

enlarged, hypoechoic gland (decreased echogenicity)

increased vascularity on affected side.

reactive hydrocele

doppler waveforms show increased velocities with a low resistive waveform

body and tail not usually seen unless pathology is present

what structure connects the epididymis to the seminal vesicles?

Vas Deferens

Orchitis

infection that has spread to the testicle

can be focal or diffuse

CF of orchitis

fever, testicular pain on affected side.

increased WBCs

N & V

USF of orchitis:

decreased echogenicity & vascularity throughout entire testicle

orchitis (chronic/ acute; diffuse/ focal)

infarction

tissue death due to lack of blood flow

CF of infarction

pain

USF infarction

hypoechoic wedge shaped area (may be round), decreased or complete abscence of doppler

hydrocele

found around the anterolateral aspect of the testes. collection of fluid between the two layers of the tunica vaginalis

may be congenital or acquired

idiopathic or secondary (infarction, inflammation, neoplasm trauma,

CF hydrocele

asymptomatic or scrotal enlargement

USF hydrocele

anechoic fluid in scrotal sac

may contain low level echoes, septations or debris

\complex may be due to infection

what can be confused with a complete infarction of the testis?

cannot be differentiated from testicular torsion

hydrocele

hematocele

fluid in the scrotal sac containing blood

usually due to trauma

CI for hematoceles

injury

USF hematocele

fluid may have mixed echogenicity, debris, may contain internal septations/ loculations

testicular torsion

most common cause of acute scrotal pain in adolescents

undescended are 10x more likely to be affected than normal testes

can be complete, incomplete, or intermittent

CF of testicular torsion

sudden onset of severe testicular pain

N&V

USF of testicular torsion

hypoechoic and enlarged after 4-6 hrs

decreased vascularity when compared to asymptomatic side

early stages: may appear normal

torsion

testicular torsion

what appears sonographically similar to an epididymal cyst?

spermatocele

Epididymal cyst:

small, clear cysts that contain serous fluid

can be found anywhere w/in the epididymis

Spermatocele:

cystic dilations of the efferent ducts of the epididymis

almost always located in the epididymal head.

sono appearance of spermatocele/ cyst

cyst: simple fluid filled structures, thin walls, post. enhancement.

spermato: simple cyst or multilocular cystic collection, containing internal echoes.

CF of spermatocele vs cyst:

palpable mass in upper region of scrotal sac unrelated to testicles.

usually painless

spermatocele/ cyst

testicular abscess

Usually, it is secondary to untreated infection, and will require surgical intervention/drainage

differential dx for testicular abscess:

complex hydrocele, cystic teratoma, Fournier’s Gangrene, Mass

CF testicular abscess

pain, fever, N & V

swelling and redness

^ WBCs

USF testicular abscess

round/oval mass w/ irregular shaggy borders, anechoic or mixed, with or without enhancement

may have “ring of fire” sign

testicular abscess

scrotal abscess

varicoceles:

abnormal dilation of the veins of the pampiniform plexus

usually caused by incompetent valves w/in spermatic vein

most common on left side due to angle of spermatic vein and left renal vein.

impaired fertility

Varicoceles CF

palpable tubular areas

infertility

Varicoceles USF

extratesticular fluid filled tubular structures

increased vascularity w/ val salva

measures > 2mm diameter

scan upright to increase visibility

varicocele

varicocele w/ vascularity shown

Dilated Rete Testis

dilated tubules, not vessels

USF of dilated rete testis

small tubular structures seen near the mediastinum testes.

No color/ doppler

dilated rete testis

Scrotal Hernia

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

CF scrotal hernia

pain usually after a lifting injury

USF scrotal hernia

peristalsis from the bowel

bowel will appear both echogenic and anechoic

hernia

Germ cell tumor

highly malignant

most intratesticular masses are cancerous

extratesticular are mostly benign

types of germ cell tumors

seminoma, embryonal, teratocarcinoma

Labs with germ cell tumor

Elevated HCG, elevated AFP

Seminoma

most common type of germ cell tumor

ages 30-40

most favorable prognosis

seminoma USF

solid/homogeneous and hypoechoic with smooth well defined borders

embryonal cell tumor

second most common germ cell tumor

more aggressive than seminoma

yolk sac tumor is a form and most common in infants

USF embryonal cell tumor

heterogenous, hypoechoic, irregular borders, may contain calcifications

CF embryonal cell tumor

palpable mass

microlithiasis

uncommon condition characterized by tiny calcifications within the testis

usually bilateral

USF microlithiasis

multiple tiny echogenic foci throughout the testicle

with or without shadowing

“speckling”

microlithiasis

lymphoma USF

enlarged testicles w/ diffuse or focal areas of decreased echogenicity

appears patchy

CF lymphoma

mass that may or may not be palpable

weight loss, anorexia, weakness

choriocarcinoma

less common

highly malignant

metastasizes rapidly

USF choriocarcinoma

complex, irregular borders,no calcifications

labs associated with choriocarcinoma

elevated HCG and AFP

teratoma

mostly benign in children

usually malignant in adults

second most common in infants and children

USF teratoma

Complex appearance and dense focal areas w/ shadowing

teratoma

BPH (benign prostatic hypertrophy)

common in older men

bladder outlet obstruction & increased resistance to urine flow

enlarged prostate constricts the urethra

occurs in the transition zone

bph usf

enlarged homogeneous prostate

transitional zone

prostattitis

acute: hypoechoic mass, may look cystic, thick walls, septations

chronic: heterogeneous with areas of increased echogenicity, enlarged venous plexus and seminal vesicles, may have thickened bladder neck

occurs in peripheral zone

CF prostatitis

acute: sudden fever, chills, voiding discomfort, pain in lower back, perineum, and rectum. increased vascularity

chronic: may be same as acute. may also have urinary frequency, dysuria, urgency and hematospermia

labs associated w/ prostate

PSA- prostate specific antigen

should be less than 10.

greater than 10 is suspicious

PSA density: divide PSA by volume of the gland

adenocarcinoma

most common malignant tumor of the prostate

located in the peripheral zone

elevated PSA and phosphatase

sono appearance: variable but usually seen as a hypoechoic area

the ejaculatory ducts descend inferiorly through the ______ portion of the gland and open into the _______ near the verumontanum

posterior, prostatic urethra

what structure lies anterior to the prostate?

Bladder