scrotum pathology

What are the 4 lab tests to know in this lecture?

• Urinalysis

• WBC

• Alpha-fetoprotein (AFP)

• Human Chorionic gonadotropin (hCG)

A urinalysis test will test for what 3 things?

• Bacteria

• Pus

• Infection

A WBC test will test for…

Infection

For an AFP lab test:

1. What pathology produces AFP?

2. What pathology does not produce AFP?

1. Non-seminoma germ cell tumor

2. Seminoma germ cell tumor

What 2 pathologies can cause a rise in hCG levels in the blood?

• Seminoma germ cell tumor

• Non-seminoma germ cell tumor

Both Leydig cell tumors and Sertoli cell tumors do not make what two lab tests?

• AFP

• hCG

What 2 pathologies will not rise in tumor markers due to not producing AFP and hCG?

• Leydig cell tumors

• Sertoli cell tumors

What is an orchiectomy?

The surgical removal of the testicle

An inguinal orchiectomy is a procedure that confirms (1)_______ types and prevents the seeding of (2)____________.

1. Cancer types

2. Cancer cells

What procedure is not recommended when it comes to masses/tumors of the testicle?

Biopsy

A hydrocele is when there is (1)________ fluid found between the two layers of the tunica (2)______________.

1. Serous

2. Vaginalis

A hydrocele will displace the teste…

Posteriorly

What is normal when it comes to fluid around the testicle?

A few mL of extra testicular fluid is normal

What sonographic appearance can be seen within a hydrocele?

Low level echoes

Define idiopathic.

‘Cause is unknown’

A hydrocele is often obtained…

Congenitally

What are the 3 causes for hydrocele? (CIR)

• Congenital

• Idiopathic

• Reactive

A reactive hydrocele can be found in the presence of what 4 pathologies?

• Infection

• Torsion

• Trauma

• Tumors

1. The pathology seen here has an idiopathic origin. What can be assumed here?

2. What sonographic finding can be seen amongst the fluid?

1. Hydrocele

2. Low level echoes

A hematocele will contain ______.

Blood

What are the 3 causes of a hematocele?

• Trauma

• Advanced epididymitis

• Advanced orchitis

A fresh hematocele can appear (1)_________, but can often have some (2)__________ components that can be seen moving in real time.

1. Anechoic

2. Echogenic

Overtime, a hematocele can develop (1)__________ and the appearance of blood can increase in (2)__________.

1. Septations

2. Echogenicity

A patient has experienced trauma to the scrotum recently and this image was obtained. What can be assumed here for arrows 1 and 2?

1. Testicle

2. Hematocele

Define leukocytosis.

Elevated WBC count

A patient experiencing pyocele will present with what 2 clinicals findings?

• Fever

• Elevated WBC count (leukocytosis)

Pyocele is when (1)_____ fills the space between the layers of the tunica (2)________________.

1. Pus

2. Vaginalis

A pyocele on US will contain what 3 sonographic findings?

• Internal septations

• Loculations

• Debris

Pyoceles can appear after which two occurrences?

• Trauma

• Surgery

A patient recently had surgery to the testicular area and this was seen on the US. What can be assumed here?

Pyocele

What are the 6 various acute scrotal pain differentials?

• Trauma

• Epididymitis/Orchitis

• Torsion

• Appendix testes OR epididymal appendix torsion

• Varicocele thrombosis

• Incarcerated hernia

Patients dealing with scrotal trauma will present with what 2 symptoms?

• Pain

• Swelling

A scrotal rupture is a __________ emergency.

Surgical

If surgery is performed within 72 hours following a scrotal rupture, what percentage of the testes can be saved?

90%

If surgery is performed after 72 hours following a scrotal rupture, what percentage of the testes can be saved?

45%

These are the 5 sonographic findings of a scrotal rupture…

1. _____ alteration of the testicular parenchyma pattern

2. Interruption of the tunica _________

3. _______ testicular contour

4. Scrotal wall _________

5. ______cele or ______cele

1. Focal

2. Albuginea

3. Irregular

4. Thickening

5. Hematocele or hydrocele

Sonographic findings of a scrotal rupture can also be seen on what 2 pathologies?

• Abscess

• Tumor

The presence of abscess, tumors, or any other clinical conditions combined with a history of _______, can result in rupture.

Trauma

This scan was performed on a patient whose been feeling pain and swelling around the area. What can be assumed here?

Scrotal trauma

This scan was performed on a patient whose been feeling pain and swelling around the area. What can be assumed here?

Scrotal trauma

What pathology is associated with scrotal trauma?

Hematomas

How will a hematoma on a patient with scrotal trauma appear on US?

Heterogenous area

A hematoma can become more (1)_______ overtime and develop (2)_____ components.

1. Complex

2. Cystic

Hematomas seen on patients with scrotal trauma can involve the (1)______ and (2)__________ and will be contained in the (3)_______ wall.

1. Testes

2. Epididymis

3. Scrotal

Define avascular.

No internal blood flow

1. What kind of vascularity do hematomas have?

2. What US feature is helpful in identifying them?

1. Avascular

2. Color doppler

The pathology seen here was seen on a patient whose had trauma to the area. It has become more complex as it sits there. What can be assumed here?

Hematoma

What are the 2 most common conditions causing acute scrotal pain in adults?

• Epididymitis

• Epididymo-Orchitis

Epididymitis is a result of what 3 pathologies?

• Infection

• STI

• Trauma

What 6 sonographic findings can be seen on a scan of epididymitis?

• Enlarged epididymis

• Hypoechoic

• May contain hyperechoic areas

• Heterogenous texture

• Hyperemic blood flow

• Possible scrotal wall thickening

If epididymitis is isolated to just the epididymis, how will the testes appear?

Normal

1. This scan was performed on a patient who has STIs. What can be assumed here?

2. Is this pathology isolated or spread?

1. Epididymitis

2. Isolated, testes appear normal

1. This scan was performed on a patient who currently has an infection at the testicles. What can be assumed here?

2. What sonographic finding can be seen here?

1. Epididymitis

2. Hyperemic blood flow

With orchitis, the affected testes will be __________.

Enlarged

Define focal.

Affects one part

Define diffuse.

Affects entire teste

Orchitis infection can be (1)________ or (2)________.

1. Focal

2. Diffuse

Infected areas of orchitis may appear as what echogenicity compared to the surrounding tissue?

Hypoechoic

A diffusely infected teste (orchitis) will appear (1)________ with a (2)________ echogenicity.

1. Enlarged

2. Hypoechoic

How does arterial resistance appear on a scan of orchitis?

Decreased

1. Which testicle has pathology?

2. What pathology can be assumed?

1. Right testicle

2. Orchitis

What is epididymo-orchitis?

When both epididymis and testicles are infected

What is the most common cause of epididymo-orchitis?

Lower UTI via the spermatic cord

What are 5 less common causes of epididymo-orchitis? (MTVTC)

• Mumps

• Tuberculosis

• Various viruses

• Trauma

• Chemical causes

In cases of epididymo-orchitis, which part of the scrotum is most often involved with the infection?

Epididymis

1. In 20-40% of cases of epididymo-orchitis, where will it typically begin?

2. Where will it then spread to?

1. Epididymis

2. Testes

What are the 3 clinical findings of epididymo-orchitis? (PFD)

• Pain

• Fever

• Urethral discharge

Epididymo-orchitis will appear…

1. ______ epididymis and testicles

2. _______ flow

3. Scrotal wall _________

4. _______

1. Enlarged

2. Hyperemic

3. Thickening

4. Hydrocele

What US features are key tools in differentiating between epididymo-orchitis vs. torsion?

• Color doppler

• Spectral doppler

1. A color doppler of epididymo-orchitis will show what kind of blood flow?

2. A color doppler of torsion will show what kind of flow?

1. Hyperemic blood flow

2. No blood flow

This scan was done on a patient whose recently come down with a fever. What can be assumed here?

Epididymo-orchitis

This scan was done on a patient whose had symptoms of urethral discharge. What can be assumed here?

Epididymo-orchitis

In severe cases of orchitis, what pathology can occur?

Testicular infarction

Color doppler of testicular infarction will show what kind of flow compared to contralateral testicles?

Decreased or absent flow

Decreased flow seen on testicular infarction, will show what kind of waveforms on spectral doppler?

High resistance with little to no diastolic flow

A spectral doppler waveform with reversed diastolic flow of testicular infarction will be what kind of indication?

Serious indication for threatened testicular infarction

Areas of testicular infarction will be…

1. ________ to surrounding testicular parenchyma

2. _______ shaped

3. ________

4. _________ lesion

5. Varies with ____ of infarction

1. Hypoechoic

2. Triangular

3. Avascular

4. Intratesticular

5. Age

When the entire testicle is infarcted, findings cannot be differentiated from what other pathology?

Testicular torsion

1. What pathology is seen here based on the images?

2. What area is presumably the area of pathology?

1. Testicular infarction

2. Hypoechoic area

What pathology is most commonly a complication of epididymo-orchitis?

Scrotal abscess

What are the 2 clinical findings of a scrotal abscess?

• Pain

• Swelling

Fourneir Gangrene is a rare life threatening (1)_______ infection of the (2)___________.

1. Bacterial

2. Scrotus/penis

Scrotal abscess is often associated with what pathology?

Fourneir gangrene

These 4 sonographic findings can be seen on a scrotal abscess…

1. ________ fluid collection

2. _______ borders

3. ________ around the periphery

4. ____ may be present, which can cause echogenic shadowing with ring down artifact

1. Complex

2. Irregular

3. Hyperemia

4. Air

The pathology seen here can be a complication of epididymo-orchitis and can have symptoms of swelling. What can be assumed here?

Scrotal abscess

What is another term for torsion?

Intravaginal testicular torsion

Because torsion is considered a surgical emergency, what should be done as the sonographer?

Images should be obtained as quickly as possible

How does torsion occur?

When the testis and epididymis twist within the scrotum

How will torsion affect the blood supply of the spermatic cord?

Cuts off the vascular supply

Up to 60% of torsion cases will have anatomic _________ on both sides.

Anomalies

Undescended testicles are 10 times more likely to be affected by what pathology?

Torsion

What pathology is 10 times more likely to be affected by torsion?

Undescended testicles

1. What flow is affected first by torsion?

2. As torsion continues, what occurs from there?

1. Venous flow

2. Arterial flow is obstructed and testicular ischemia follows

What 2 US features can be used when documenting torsion?

• Decrease PRF (scale)

• Utilize power doppler for slow flow and rule out complete torsion

1. What is different about the right and left testicles?

2. What can be interpreted of the image on the far right?

3. What pathology can be assumed happening in these pictures?

1. The left testicle no longer has flow

2. That no flow to the testicle after six hours will cause the testicle to have that appearance

3. Torsion

The bell clapper deformity is a _________ abnormality.

Congenital

What is the most common cause of torsion?

Bell clapper deformity

The bell clapper deformity puts the patient more at risk for torsion because they lack the normal (1)______________ of the testis and (2)__________ to the scrotal wall.

1. Posterior fixation

2. Epididymis

The bell clapper deformity is (uni/bi)lateral in most cases.

Bilateral

What are the percentages of salvage rate with torsion for each of the following times:

1. Within the first 6 hours:

2. Within 6-12 hours:

3. Within 12-24 hours:

1. 100%

2. 70%

3. 20%