scrotum

high res test 3

80% of undescended testicles are located where

inguinal canal

what can MRI be used for when evaluating the scrotum

intra-abdonimal testes

when would we use a curvilinear transducer to evaluate the scrotum

patients with severe scrotal swelling

what are the 3 major internal structures of the scrotum

spermatic cord, epididymis, testes

average measurement for adult testes

3-5 × 2-4 × 3cm

each teste is divided into _____ lobules

conical

tubules converge at the apex of each lobule to form the _________ in the medistinum

rete testes

where does the rete testes drain

in the head of epididymis through efferent ducts

normL sonographic appearance of the testes

smooth, medium grey, fine echotexture

normal sonographic appearance of rete testes

tiny tubules adjacent to epididymis head and testis mediastinum

how long is epididymis

6-7cm

how does the epididymis course

superiorly and then posterolateral to the testes

what is largest portion of epididymis

head

the tail of epididymis is ______ to the lower pole of the testes

posterior

what is the duct of the epididymis called

ductus epididymis

what does the epididymis become to converge with the spermatic cord

becomes vas deferens

what is normal sono appearance of epididymis

iso/hypo to testes, coarser echotexture

the testes are covered by a fibrous tissue called

tunica albuginea

what does the tunica albuginea reflect into the testis to form

mediastinum testis

what is the normal sono appearance of the mediastinum

bright hyper line, courses alone edge of testis

what type of tissue lines the inner walls of scrotum

tunica vaginalis

what are the 2 layers of the tunica vaginalis

parietal and visceral

the scrotum is divided into 2 compartments which are divided by which structure

median raphe

where do hydroceles form

space between layers of tunica vaginalis

where is the small bare area of the scrotum

on the posterior side

where does the testicle sit on the the bare area

against the scrotal wall to prevent torsion

what does the vas deferens join to form the ejaculatory duct

seminal vesicles

what is the verumontanum

junction of the ejaculatory duct with the urethra

where does spermatic cord start and end

start at scrotum, goes through inguinal canal and ends at internal inguinal rings in the pelvis

the spermatic cord suspends the _____

testes

what structures are in the spermatic cord

• vas deferens

• testicular arteries

• venous pampinoform plexus (nerves, vessels, etc)

which arteries supply the testes

testicular arteries (gonadal)

which arteries give rise to the centripedal arteries

capsular arteries

how do centripedal arteries coarse

towards the mediastinum along the septa

what happens to centrifugal arteries before they reach the mediastinum

curve backwards to form recurring rami, which make them now centrifugal

normal waveform pattern for intratesticular arteries

low resistance flow pattern

what does venous drainage of the scrotum occur through

veins of pampiniform plexus

where does pampiniform plexus exit through

mediastinum testis- courses through spermatic cord

what does the right testicular vein drain into

IVC

what does the left testicular vein drain into

left renal vein

what pathology would you have pt do valsalva for

varicocele

if surgery performed within 72 hours of scrotal trauma, up to __% of testes can be saved

90

what are complications of scrotal trauma

• hydrocele

• hematocele

what does scrotal trauma look like on US

• alteration of normal texture

• interruption of tunica albuginea

• hematocele— with time

does hematocele confirm a scrotal rupture

no

what do scrotal hematomas look like on US

• can be large and displace normal anatomy

• heterogenous

• avascular

• can look more complex with time

what is the most common cause of acute scrotal pain in adults

epididymo-orchitis

what are the s/s of epididymo-orchitis

• gradual onset of pain

• fever

• urethral discharge

which structure typically becomes infected first with epididymo-orchitis

epididymis

what is the treatment for epididymo-orchitis

antibiotics

what is the most common cause for epididymo-orchitis

spread of lower UTI through spermatic cord

what does epididymo-orchitis look like on US

• enlarged

• hypo

• hyperemia with colour

what does orchitis look like on US

• enlarged

• diffuse or focal

• hypo

• heterogenous

• hyperemia

which patho can be associated with severe epididymis and orchitis

complex hydrocele

what do complex hydrocele look like on US

• thick septation

• low level echoes

what is pyocele

occurs when pus fills space between layers of tunica vaginalis

what does pyocele look like on US

• internal septations

• locualations

• debris

what is a key differential between epididymo-orchitis and torsion

colour doppler.

how does torsion occur

result of abnormal mobility of testes within scrotum

what is the deformity describing abnormal mobility of testes within scrotum

bell clapper deformity

why is torsion so dangerous

it cuts off blood supply in spermatic cord and can cause testicle death

is arterial or venous flow affected first in torsion

venous (due to swelling)

arterial obstruction due to torsion causes

testicular ischemia

what is the success rate of saving testicles if torsion surgery is performed within 6 hours

80-100%

what is the success rate of saving testicles if torsion surgery is performed within 12 hours

20%

what is the age of peak incidence for torsion

14 yrs

what is the most common cause of acute scrotal pain in adolescents

torsion

what are the s/s of torsion

• sudden onset scrotal pain

• swelling on 1 side

• severe N & V

• hx of previous pain episodes

what does early torsion look like on US

normal

what does torsion look like on US after 4-6 hrs

• hypoechoic due to edema

• swollen

what does torsion look like on US after 24 hrs

• heterogenous due to hemorrhage

• infarction

• necrosis

• vascular congestion

what general signs on US do we see with torsion

• reactive hydrocele

• skin thickening

• enlarged, twisted spermatic cord

• hypoechoic enlarged epididymis

what can spontaneously occur during an US for torsion

detorsion

• show as blood rushing back into testes

which patients usually have torsion of the appendages

prepubertal boys, 6-12 yrs

what clinical sign is associated with torsion of the appendages

blue dot sign

what is the blue dot sign

• small, firm, round, mobile, tender

• paratesticular mass with bluish discolouration visible through skin

what does torsion of the appendages look like on US

• solid oval mass

• hypoechoic center with hyper rim

• no flow

what are the most common types of cysts

extratesticular cysts

what are s/s of extratesticular cysts

asymptomatic

can be palpable

what are spermatoceles

cystic dilations of ductules of epididymis

where are spermatoceles always located

epididymal head

spermatoceles are associated with what surgical procedure

vasectomies

what does spermatocele look like on US

• simple or multiocular cysts

• internal echoes

what is a small extratesticular cyst that contains serous fluid

epididymal cyst

what do epididymal cysts look like on US

simple cyst

what is a patho that is an abnormal dilation of veins of the pampiniform plexus

varicocele

what complication is associated with varicocele

infertility

what are primary varicoceles caused by

incompetent valves in the spermatic vein

which testicle is varicocele more common in

left

what causes nutcracker syndrome

compression of LRV between aorta and SMA

what are the s/s of nutcracker syndrome

• hematuria

• back or pelvis pain

what causes secondary varicoceles

increased pressure on the spermatic vein, can be due to:

• hydronephrosis

• abdo mass

• cirrhosis

what does varicocele look like on US

• tortuous tubes near epididimal head

• echogenic tubes

• veins measure over 2mm

• diameter of veins increase with valsalva

when do scrotal hernias occur

when bowel, omentum or other structures herniate into scrotum

what structure most commonly herniates into the scrotum

bowel

what confirms the diagnosis of scrotal hernia

peristalsis of bowel seen in real time scrotum

what is the most common cause of painless scrotal swelling

hydroceles

what does hydrocele look like on US

• anechoic fluid

• low level echoes (debris)

• septations with infection

how does pyocele occur

untreated infection or ruptured abcess

what do pyoceles and hematoceles look like on US

they are indistinguishable

• internal echoes thick septations

• lobulations