Pathology of the Scrotum

PG 440

Cryptorchidism describes the condition of

having an undescended testis

Cryptorchidism, which is found in — of full-term births

3% to 4%

Cryptorchidism is associated with

infertility and an increase in the risk for malignancy in the involved testis

— is the most common cancer found in an undescended testis

seminoma

undescended testis are most often found in the

inguinal canal

surgical correction of an undescended testis is referred to as

orchiopexy

sonographfically, the undescended testis will appear — to the normal testis

hypoechoic

clinical findings of cryptorchidism

1. one or both testicles not palpable within the scrotum

Cryptorchidism. This right testicle (calipers) was noted within the inguinal canal.

sonographic findings of cryptorchidism

1. testis located outside of the scrotum (most likely the inguinal canal)

2. the cryptorchid testis will appear hypoechoic to the normal testis

testicular torsion may also be referred to as

spermatic cord torsion

testicular torsion occurs when the —- secondary to the twisting of the testicular axis

arterial blood supply to the testicle is cut off

a — will result in blocked venous drainage and arterial supply

360 degree torsion

a 360 degree torsion will lead to

ischemia within the testis

the amount of ischemic damage is directly related to

the degree of the torsion

testicular torsion occurs more often during the ages of —

12 and 18

with torsion, salvage rates range from 80%-100% if the patient is treated within — of symptom onset

6 hours

with torsion, the testicle is usually not salvageable after

24 hours

testicular torsion can be associated with

trauma, strenuous exercise, and sexual activity

bell-clapper deformity is a

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

ball-clapper deformity is classically

bilateral

intravaginal torsion is the

most common form of testicular torsion

bell-clapper deformity is part of what is termed

intravaginal torsion

with intravaginal torsion, the tesis, which is not affixed to the scrotal wall, is permitted to —

migrate and twist freely within the scrotum

extravaginal torsion occurs when the

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

patients suffering from testicular torsion are often awakened in the middle of the night by —

severe scrotal pain

chronic testicular torsion is torsion that has lasted —

longer than 10 days

Left testicular torsion. Transverse image of both testicles. The left testicle (LT) had no detectable Doppler signals. Note that it has a heterogeneous echotexture compared to the normal right testicle (RT).

Testicle torsion. Left testicle torsion was diagnosed because no intratesticular flow was detected with color Doppler analysis. (Color image provided online.)

A torsed testis can either — compared to the normal testis

lack flow completely or have decreased flow

clinical findings of acute testicular torsion

1. acute onset of testicular pain (often during sleep)

2. possible pain within the lower abdomen and inguinal region

3. swollen testis/scrotum

4. nausea and vomitting

5. higher postioned, painful testis with a horizontal position

sonographic findings of acute testicular torsion

1. enlargement of the spermatic cord, epididymis, and testis

2. thickened scrotal wall

3. hypoechoic or heterogeneous testis

4. reactive hydrocele

5. no intravascular flow

6. decreased intratesticular flow (as compared to the asymptomatic testis)

sonographic findings of chronic testicular torsion

1. enlargement of the spermatic cord, epididymis, and testis

2. no intratesticular flow

3. hyperemic flow around the testis

4. heterogeneous testis with areas of necrosis

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

torsion of the appendix testis

appendages of the testis:

appendix testis, appendix epididymis, and the appendix vas

testicular appendages are structures said to be the embryologic remnants of the

mullerian duct, wolffian duct, and mesonephric duct

the appendix testis is located between the

head of the epididymis and the superior pole of the testis

the appendix epididymis is located at the

head of the epididymis

appendages may be seen in the presence of a

hydrocele or other scrotal fluid collections

Locations of the testicular appendages.

Torsion of the appendix testis. This heterogeneous, avascular mass was seen adjacent to the superior pole of the testis. It was proven to be a torsed appendix testis.

the “blue dot” sign is the observable clinical finding associated with

torsion of the appendix testis

clinical findings of torsion of the testicular appendage

1. acute testicular pain

2. pain localized to the superior pole of the testis

3. “blue dot” sign

sonographic findings of torsion of the testicular appendage

1. normal intratesticular flow

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

3. reactive hydrocele

4. scrotal wall thickening

a simple fluid collection within the scrotum is referred to as a

hydrocele

hydroceles are found between the two layers of the — and often displace the testicles posteriorly

tunica vaginalis

hydroceles can be idiopathic or described as reactive hydroceles when found in the presence of

scrotal infections, testicular torsion, trauma, or tumors

hydroceles are often accompained by

scrotal wall thickening

clinical findings of a hydrocele

1. transilluminates light

2. painless scrotal swelling

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

sonographic findings of a hydrocele

1. simple fluid anterior to the testis

2. scrotal wall thickening

3. chronic hydroceles may have internal debris and septations

Hydrocele. Anechoic fluid can be noted surrounding the testicle. The scrotal wall (arrowheads) appears to be thickened as well.

a —, which is said to be the most common scrotal mass, is a cyst found most often in the head of the epididymis

spermatocele

spermatocele is composed of

momviable sperm, fat, cellular debris, and lymphocytes

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

epididymal cyst

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

tunica albuginea cysts

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

1. if large enough, they may be palpable

2. typically not painful

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

1. round, anechoic mass with acoustic enhancement

2. may contain some layering debris

Spermatocele. Large cystic extratesticular mass (S) is noted superior to the testis (T) and is characteristic of a spermatocele.

a dilated group of veins found within the scrotum is termed

a varicocele

varicoceles are caused by

incompetent or abnormal valves within the pampiniform plexus

because of the increased heat released by excess blood within the scrotum, overheating of the — can occur

fragile spermatoza

varicoceles have been cited as the

most common cause of correctable male infertility

the two types of varicocele

primary and secondary

primary varcioceles are most often found in the — and are palpable during physical examination

left

primary varcioceles 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 exteneded length of the left testicular vein, and the sharp angle at which it enters the left renal vein

if a varicocele is found on the right side it is termed

secondary varicocele

secondary varicoceles may be associated with

a hepatic mass, marked hydronephrosis, hepatomegaly, or retroperitoneal neoplasm like a right sided renal mass

nutcreacker syndrome is an

anomaly where left renal vein entrapment occurs between the SMA and the abdominal aorta

one predisposing facor for a varicocele is

nutcraker syndrome

varicoceles will have a dilated vein measuring greater than —

2 mm

clinical findings of a varicocele

1. typically painless (large varicoceles can cause discomfort)

2. palpable extratesticular mass

3. possible infertility

Varicocele. A. Multiple tubular structures (arrowheads) are seen surrounding the testicle (T). B. Color Doppler confirms flow within these structures during rest. With the Valsalva maneuver, the veins enlarged and there is a dramatic increase in flow. (Color image provided online.)

sonographic findings of a varicocele

1. a group of anechoic, tubular structures located outside of the testis

2. distended veins that fill with color flow when the valsalva maneuver is performed

3. dilated veins that measure greater than 2 mm

4. possibly associated with hydronephrosis, hepatomegaly, or a retroperitoneal neoplasm if found on the right side

a scrotal pearl is an

extratesticular calculus

scrotal pearls are thought to be

remnants of a formerly torsed and displaced testicular appendage

sonographic findings of a scrotal pearl

1. extremely echogenic, mobile extratesticular structure that produces acoustic shadowing

inflammation of the epididymis is referred to as

epididymitis

epididymitis is the most common cause of

acute testicular pain in adults

inflammation of the testis is referred to as

orchitis

the combination of an infection within the epididymis and testis is termed

epididymo-orchitis

frequent cause of epididymitis is the

spread of bacteria from the prostate or urinary tract

common causes of epididymitis in younger men are the

sexually transmitted diseases chlamydia and gonorrhea

chronic epidiymitis may appear as an

enlarged, hyperechoic epididymis with calcifications

clinical findings of epididymitis and epididymo-orchitis

1. acute testicular pain

2. leukocytosis

3. fever

4. dysuria

5. urethral discharge

6. scrotal wall edema

sonographic findings of epididymitis and epididymo-orchitis

1. enlargement of the entire epididymis (diffuse)

2. enlargement of only part of the epididymis (focal)

3. hypoechoic echotexture of the affected section(s) of the epididymis

4. hypoechoic testis (with orchitis)

5. hyperemia within the epi and/or testis

6. thickened scrotal wall

7. reactive hydrocele

an abscess that occurs within the testicle is typically the result of

untreated epididymo-orchitis

a — is a complex hydrocele that contains pus

pyocele

a pyocele is often seen in the presence of a

persistent scrotal infection or ruptured testicular abscess

Acute epididymo-orchitis. A. The grayscale sonographic appearance of the testis reveals a right (Rt) testicle that appears heterogeneous compared to the left (Lt) testicle. B. Color Doppler reveals hyperemia in the right (Rt) testicle compared to the left (Lt) testicle, which is consistent with diffuse right-sided epididymo-orchitis. (Color image provided online.)

although intratesticular abscesses lack detected flow within them, they are often surrounded by

hyperemic flow

clinical findings of a testicular abscess

1. painful, swollen scrotum

2. fever

3. leukocytosis

sonographic findings of a testicular abcess

1. complex intratesticualr mass

2. mass that has no flow centrally but increased flow around its margins

3. may have a coexisting pyocele

sonographic findings of a pyocele

1. complex fluid collection within the scrotum

2. scrotal wall thickening

3. may be seen in conjuction with rupture of a testicular abscess

multiple small intratesticular cysts are often seen

along the mediastinum testis

small cysts seen in the mediastinum are clinically insignificant and may be the result of

tubular ectasta of the rete testes

multiple small cysts in the mediastinum are thought ot represent

cystic dilation of the rete testis

epidermoid cysts often appear to have a

whorled or onion skin appearance

Tubular ectasia of the rete testis. Multiple cysts (arrows) are seen in the area of the mediastinum testes in this testicle (T). A large spermatocele (S) is also noted.

Intratesticular microlithiasis. Multiple echogenic foci with no acoustic shadowing are seen within this testis.