Diagnostic Sonography Chp 23: The Scrotum

Front 1

Symmetrical oval shaped glands residing in the scrotum.

Back 1

testicles

Front 2

What are the average size measurments

Back 2

length 3.5-5cm
width 2-3 cm
depth (ap diameter)2-3 cm

Front 3

What type of glands are the testicles

Back 3

endocrine (blood) and exocrine (ducts)

Front 4

Network of channels drain into the epididymis

Back 4

rete testis

Front 5

A single tightly wrapped tube that empties into the ductus deferns. Consist of three parts; head, body and tail. Isoechoic or hyperechoic compared to the testis

Back 5

epididymis

Front 6

A continuation of the ductus epididymis. Joins with the seminal vesicle to form the ejaculatory duct

Back 6

vas deferens

Front 7

A small protuberance from the head of the epididymis. Attached to the upper epididymis

Back 7

appendix testis

Front 8

Derived from the peritoneum surrounding the testes as they descend from the abdomen to the scrotum. Lines the inner walls of the scrotum covering each testis and epididymis

Back 8

tunica vaginalis

Front 9

Tunica vaginalis consist of 2 layers. What are they

Back 9

parietal layer is the inner lining of the scrotal wall
visceral layer surrounds the testis and epididymis

Front 10

A fibrous capsule that surrounds the tunica vaginalis

Back 10

tunica albuginea

Front 11

The posterior aspect of the tunica albuginea reflects into the testis to form a vertical septum known as

Back 11

mediastinum testis

Front 12

Extends from the sup. to near the inf. portion of the gland. Narrows in width as it travels inf. Ant and lat, numerous septa are given off which radiate to the glands surface and are attached to the tunica albuginea.

Back 12

mediastinum

Front 13

Divide the int of the testis into numerous cone shaped spaces that have a wide base at the glands surface and narrow as they converge

Back 13

mediastinum

Front 14

Sonographic appearance of the mediastinum

Back 14

bright hyperechoic line coursing within the teste

Front 15

The junction of the ejaculatory ducts with the urethra

Back 15

verumontanum

Front 16

Carries vessels and nerves to and from the testes and suspends the testis in the scrotal sac. Contains the vas deferens, testicular arteries, venous pampiniform plexus

Back 16

spermatic cord

Front 17

Vascular supply Arteries

Back 17

Aorta
testicular arteries
capsular arteries
centripetal arteries
recurrent arteries

Front 18

What arteries are the primary source of blood flow to the testis

Back 18

right and left testicular arteries

Front 19

The capsular arteries give rise to

Back 19

centripetal arteries

Front 20

The centripetal arteries give rise to

Back 20

recurrent rami (centrifugal arteries)

Front 21

What type of appearance does the recurrent rami may give

Back 21

candy cane appearance

Front 22

These arteries accompany the testicular artery within the spermatic cord to supply the extratesticular structures

Back 22

cremasteric and deferential arteries

Front 23

This artery branches from the inf. epigastric artery (a branch of the external iliac artery). It provides flow to the cremaster muscle and peritesticular tissue

Back 23

cremesteric artery

Front 24

This artery arises form the vesicle artery (a branch of the internal iliac artery). It mainly supplies the epididymis and vas deferens.

Back 24

deferential artery

Front 25

This artery supplies the scrotal wall

Back 25

pudendal artery

Front 26

Venous drainage system of the scrotum occurs through the veins of the

Back 26

pampiniform plexus

Front 27

The pampiniform plexus converges into three sets of anastomotic veins. What are they

Back 27

testicular
deferential
cremasteric

Front 28

This vein drains into the IVC

Back 28

right testicular vein

Front 29

This vein joins the left renal vein

Back 29

left testicular vein

Front 30

This vein drains into the pelvic veins

Back 30

deferential vein

Front 31

This vein drains into the tributaries of the epigastric and deep pudendal veins

Back 31

cremasteric

Front 32

What is the patient positing and scanning protocol

Back 32

patient history should be obtained (palpable mass, sroctal pain, swollen scrotum)
supine position
penis is positioned on the abdomen and covered w/ a towel
pt is asked to keep legs close together or a rolled towel is placed b/t thighs
10MHz or higher transducer
always bilateral

Front 33

Sonographer tips

Back 33

explain procedure and let pt prepare in private
take images of both testis together
perform valsalva when varicocele is suspected
sensitize color Doppler for slow flow when evaluating for torsion
torsion is a surgical emergency so perform exam in timely manner

Front 34

What are the trv images taken

Back 34

spermatic cord area
epididymal head (w/ and w/o color)
superior, mid and inf testis
(take measurement at mid and color)
compare lt and rt testis
Doppler of art. and vein

Front 35

What are the sag images taken

Back 35

spermatic cord area
epididymal head (showing sup pole of testicle)
long axis mid (w/ and w/o measurement)
medial long axis
lateral long axis

Front 36

Composed of 3 circular masses of tissue. 1&2 corpora cavernosa-dorsal/lat segment of erectile tissue. 3 corpus spongiosum-middle area that contains the urethra. Main art supply from the paired internal pudendal art. main venous drainage form superficial and deep dorsal vein

Back 36

penis

Front 37

Presents a challenge to sonographer. Can occur from motor vehicle accident, athletic injury, direct hit, straddle injury.

Back 37

scrotal trauma

Front 38

What is the main goal in scanning the scrotum related to trauma?

Back 38

to determine if a rupture has occured

Front 39

What is the importance of determining a rupture?

Back 39

Surgical emergency
90% success rate within 72 hours
45% success rate after 72 hours

Front 40

Sonographic finding of scrotal trauma

Back 40

focal alteration of the tissue
interruption of the tunica albuginea
irregular testicular contour
scrotal wall thickening
hematocele-collection of blood b/t the visceral and parietal layers of the tunica vaginalis

Front 41

Hematocele may be associated with

Back 41

surgery
neoplasms
torsion

Front 42

Associated with trauma may be large and may cause displacement of the associated testis. Appear as heterogeneous areas w/in the scrotum. More complex over time developing cystic components. May involve the testis or epididymis

Back 42

hematomas

Front 43

Inflammation of the epididymis

Back 43

epididymitis

Front 44

Sonographic appearance of epididymitis

Back 44

appears as an enlarged hypoechoic gland. May contain focal hyperechoic areas if secondary hemorrhage has occurred. Doppler waveforms demonstrate increased velocities in both systole and diastole

Front 45

Focal area of inflammation of the testicle

Back 45

focal orchitis

Front 46

Overall inflammation of the testicle

Back 46

diffuse orchitis

Front 47

Infection of the epididymis and testis. Most common cause of acute scrotal pain in adults.

Back 47

epididymo-orchitis

Front 48

Epididymo-orchitis can result from what

Back 48

low uti that spreads via the spermatic cord
mumps, syphilis, tb, viruses, trauma, chemical causes

Front 49

Other findings associated with epididymo-orchitis

Back 49

Scrotal wall thickening, hydrocele and Pyocele-

Front 50

Found around the anterolateral aspect of the testis. May appear anechoic or have low level echos.

Back 50

hydrocele

Front 51

Occurs when pus fills the space b/t the layers of the tunica vaginalis . Usually contain internal septations, loculations and debris. Same appearance may be noted following trauma or surgery

Back 51

pyocele

Front 52

The most common cause of acute scrotal pain in adolescents. Results when the testis and epididymis twist within the scrotum, cutting off the vascular supply within the spermatic cord.

Back 52

torsion

Front 53

Who is more likely to be 10x affected by torsion

Back 53

patients with undescended tetes

Front 54

Which flow is affected first concerning torsion

Back 54

venous flow. then arterial flow if torsion continues and testicular ischemia follows

Front 55

Torsion is a surgical emergency. What are the times and rate of success of salvaging the testes

Back 55

5-6 hours of the onset of pain 80-100%
6-12 hours 70%
after 12 hours 20%

Front 56

Sonographic appearance of torsion b/t 4-6 hrs

Back 56

swollen and hypoechoic

Front 57

Sonographic appearance after 24 hrs

Back 57

heterogeneous. The epididymal head appears enlarged and may become heterogeneous

Front 58

Small clear cysts that contain serous fluid. Can be found anywhere w/in the epididymis . Patient is asymptomatic and cyst may be palpable

Back 58

epididymal cyst

Front 59

Cystic dilations of the efferent ductules of the epididymis. located w/in the epididymal head. Contains proteinaceous fluid and spermatozoa. Seen more often following a vasectomy.

Back 59

spermatoceles

Front 60

Sonogrpahic appearance of spermatoceles

Back 60

may be seen as simple cysts or multilocular cystic collections with internal echoes

Front 61

An abnormal dilatation of the veins of the pampiniform plexus. Caused by incompetent venous valves w/in the spermatic vein. More common on the left. Associated with infertility. Intratesticular and extratesticular

Back 61

varicocele

Front 62

Sonographic appearance of varicocele

Back 62

numerous tortuous tubes of varying sizes within the spermatic cord near the epididymal head. Tend to increase diameter in response to the valsalva maneuver

Front 63

Occurs when bowel, omentum, or other structures herniate into the scrotum. Bowel most common herniated structure.

Back 63

scrotal hernia

Front 64

Sonographic appearance of scrotal hernia

Back 64

peristalsis of the bowel seen on real time imaging but may not always be seen. Fluid filled bowel loops easily seen. Air or stool bowel loops difficult to visualize

Front 65

Occur as a chronic inflammatory reaction to extravasation of spermatozoa. Most frequently seen in patients with a history of vasectomy. May be located anywhere w/in the epididymis or the vas deferens. painful

Back 65

sperm granuloma

Front 66

Uncommon benign condition. Associated with the presence of spermatoceles, epidiymal cysts, testicular cysts, other epididymal obstruction. More commonly seen in patients over 45 yrs old

Back 66

tubular ectasia of the rete testis

Front 67

Sonographic appearance of tubular estasia of the rete testis

Back 67

prominent hypoechoic channels near the echogenic mediastinum and avascular

Front 68

Most common in men over 40. Associated with extratesticular spermatoceles. located near the mediastinum. solitary or multiple. varies in size and incidental findings

Back 68

cyst

Front 69

Uncommon condition characterized by tiny calcifications w/in the testis. Smaller than 3mm. Usually a bilateral condition.

Back 69

microlithiasis

Front 70

Microlitiasis has been associated with

Back 70

testicular malignancy, cryptorchidism, klinefelter's syndrome, infertility, varicoceles, testicular atrophy and male psudohermaphroditism

Front 71

Sonographic appearance of microlithiasis

Back 71

multiple bright nonshadowing foci scattered throughout the testis. Considered abnormal unless more than five appear

Front 72

1% of cancers in men. Most common malignancy in men b/t ages 15-35 yrs old. One of the most curable forms of cancer. More common in white men. undescended testes are 2.5-8 X more likely to develop cancer. Usually no symptoms

Back 72

Testicular malignancies in general.

Front 73

Associated with an elevated HCG level and alpha-fetroprotein. Approx 95% of all testicular tumors.

Back 73

germ cell tumor
Most common type of germ cell tumor is seminoma

Front 74

Sonogrpahic appearance of seminoma

Back 74

homogeneous
hypoechoic masses
smooth borders
no calcifications or cystic components

Front 75

2 types of germ cell tumors

Back 75

teratomas and choriocarcinomas

Front 76

heterogeneous well defined borders usually benign in children but malignant in adults

Back 76

teratoma

Front 77

Appearance varies, mixed cell types. Appearance is determined by dominant cell types. Irregular borders

Back 77

choriocarcinomas

Front 78

Rare normally occurring later in life. primary originates from prostate, kidneys, lungs, pancreas, bladder, colon, thyroid, melanoma. Affects testicles bilaterally with multiple lesions

Back 78

metastasis

Front 79

Makes up 1-7% of all testicular tumors. most common bilateral secondary testicular neoplasm. Affects older men in their 60's

Back 79

lymphoma

Front 80

Next common secondary testicular neoplasm. most often found in children.

Back 80

leukemia

Front 81

Sonographic findings of lymphoma and leukemia

Back 81

homogeneous hypoechoic contains multiple focal areas of decreased echogenicity

Front 82

Undescended testicle.

Back 82

cryptorchidism

Front 83

Very rare condition. Cannot be manipulated into the correct path of descent. Most common site to rest is superficial inguinal pouch

Back 83

testicular ectopia

Front 84

Rare. Absence of 1 or both testicles found in 4% of patients with a non palpable testis. More common on the left side. definitive diagnosis depends on surgical diagnosis

Back 84

anorchia

Front 85

Rare. only 80% of cases reported . More common on the left side 75% and bilateral 5% of cases. Testicular duplication usually found in the scrotum but also has been found in inguinal canal.

Back 85

polyorchidism