Gu -- Male

Front 1

1. Is there an increased risk of testicular cancer in the descended testicle in a pt with cryptoorchidism?
2. What kind of testicular malignancy is most common in cryptorchid testis?
3. What are the different types of cryptorhid testis?

Back 1

Yes. The descended normal testicle is also at risk for testicular malgnancy.
2. Testicular tumors after orchidopexy most frequently are nonseminomatous germ cell tumors.
3.
- Retractile: moves intermittently between the groin and scrotal base
- Canalicular: present b/w internal and external inguinal rings
- Abdominal: present proximal to the internal ring
- Ectopic: remote from the normal pathway of descent.

Front 2

1. What is the DDX of focal intratesticular mass?
2. What are the imaging findings in segmental testicular infarct?

Back 2

1.
- Focal testicular tumor
- Granulomatous orchitis (TB)
- Lymphoma
- Metastases
- Segmental testicular infarct
- Testicular hematoma
- Sarcoidosis
2.
- Wedge-shaped or geographic area of low echogenicity which mimics focal neoplasm.
- On MRI, low SI on T1 and T2WI, unless there is hemorrhagic infarction.
- Surrounding enhancing rim on post-Gd images (specific for testicular infarct).

Front 3

1. If retroperitoneal LAD is seen in a young male, what is the next step in management?
2. What is the imaging appearance of testicular seminoma?

Back 3

1. Testcular US.
2.
- Seminomas are homogeneous intratesticular masses
- Hypoechoic on US and T2 hypointense on MRI.

Front 4

1. What is the most common extratesticular tumor?
2. What are the imaging findings?
3. What is the DDX of extratesticular mass?

Back 4

1. Adenomatoid tumor. Usually arises from the epididymis but may arise from the testicular tunica or spermatic cord.
2.
- Well-defined, extratesticular mass with heterogeneous echotexture.
- Doppler flow may be seen.
3.
- Scrotal hematoma
- Scrotal pearl
- Inguinal hernia
- Epididymal cystadenoma

Front 5

1. What is the most common testicular tumor in elderly males?

Back 5

1. Lymphoma. Usually seen in pts with known history of lymphoma.
2.
**Hypoechoic vascular intratesticular lesion in a pt > age 60.
- Heterogeneous enlargement of the testis.
- Locally aggressive and can infiltrate the epididymis, spermatic cord, or scrotal skin.
- Increased intralesional blood flow.

Front 6

1. What is the criteria for testicular microlithiasis?
2. Are pts w/ microlithiasis associated with increased risk of malignancy?

Back 6

1. Presence of 5 or more microliths in either or both testes on at least one image.
2. Possibly associated with increased risk of germ cell tumor.
Testicular microlithiasis is seen in about 0.5% of the population and may be limited ( < 5 echogenic foci per testis) or diffuse. Both forms are associated with germ cell tumors, both seminomas and nonseminomatous germ cell tumors, leading some experts to recommend ultrasound and/or urologic followup, though this is somewhat controversial. Microlithiasis may be associated with prior trauma or infection, as well as some syndromes (Klinefelter syndrome, Down syndrome, male pseudohermaphroditism) and subfertility.

Granulomas can mimic teticular microlithiasis, however, the calcifications are more coarse.

Front 7

1. What is the mechanism of tuberculous infection?
2. What are the imaging findings?

Back 7

1.
- Occurs in 7% of pts with TB
- Infection results from retrograde extension from the prostate and seminal vesicles as well as form hematogenous spread.
- Usually affects the tail of the epididymis first. Tuberculous orchitis usually occurs as a result of contiguous extension from the epididymis.
2.
EPIDIDYMIS:
- Diffusely enlarged, hypoechoic epididymis
- Nodular appearing heterogeneous epididymis.
TESTICLE:
- Diffusely enlarged hypoechoic testis.
- Nodular enlarged, heterogeneous testis.
- Multiple small hypoechoic nodules

Front 8

1. What are the imaging findings of prostate CA?
2. What findings suggest extracapsular extension?
3. How is prostate cancer treated?
4. What can mimic prostate CA on imaging?

Back 8

1.
- T2WIs are the mainstay of diagnosis.
- Focal area of low T2SI in the peripheral zone of the prostate (in the absence of recent bx).
2. Extracapsular extension is suggested by
- obliteration or or blunting of the rectoprostatic angle.
- nodular extension of tumor outside of the gland.
- asymmetry of the NVB
- invasion of the seminal vesicles
- Enlarged lymph nodes
- Bone mets
- Invasion into the bladder or rectum
3.
- If confined to the prostate = prostatectomy
- If extracapsular extension = radiation therapy
- If distant spread = hormonal therapy.
4.
- Prostatitis (most prostate cancers are resistant to bleeding after bx)
- Hemorrhage (low on T2, high on T1)
- Radiation (usually diffuse)

Front 9

What are the imaging findings in penile fracture?

Back 9

- Focal area of discontinuity in the low SI tunica albuginea (fibroelastic sheath that surrounds the corpus cavernosum)
- Rupture of the corpus cavernosum may be transversely or longitudinally oriented.
- Accompanying penile hematoma is high SI on T1WI.
- Uncommonly, there may be injury to the corpus spongiosum and the urethra.

Front 10

1. What are the imaging findings of tubular ectasia of the rete testis?
2. What is the etiology of tubular ectasia of rete testis?
3. How do you differentiate from malignant cystic testicular neoplasms?

Back 10

1.
- Cystic and braching tubular opacities located in the testicular mediastinum.
- No flow on color doppler.
- No solid components\
- Presence of ipsilateral spermatocele or epididymal cyst.
2. Tubular ectasia is associated with obstruction at the epididymal level as the majority occur with spermatocele or epididymal cysts. Other pts have history of vasectomy, ipsilateral hernia repair, or epididymitis.
3. Malignant cystic neoplasms are usually associated with soft tissue component and they can be located anywhere (i.e. they do not have to be confined to the testicular mediastinum).

Front 11

1. What is the DDX of fat containing scrotal mass?
2. What is the most common extratesticular mass?
3. What is the most common benign tumor of the epididymis/spermatic cord?
4. What is the most common extratesticular malignant tumor in adults/children?

Back 11

1.
- Lipoma
- Inguinal hernia containing omental fat
- Liposarcoma
2. Lipoma
3. Adenomatous tumor
4. Liposarcoma in adults; rhabdomyosarcoma in children.

Front 12

Prostatic utricle cysts

Back 12

Prostatic utricle cysts are due to dilation of the prostatic utricle in the male pelvis. Unlike the provided images, they are midline cysts found at the level of the verumontanum that do not communicate with the bladder.

Front 13

Hydrocele

Back 13

Case Pearl
The best diagnostic clue of a hydrocele is scrotal fluid surrounding the testis, except for the "bare area" where the tunica vaginalis does not cover the testis and is attached to the epididymis. Congenital hydroceles are due to incomplete closure of the tunica vaginalis. Acquired hydroceles are typically associated with epididymitis, torsion, trauma, and rarely, tumor. Chronic hydroceles may contain mobile, low-level echoes.

Front 14

Urethral anatomy

Back 14

- Urethra can be divided into the posterior and anterior urethra.
- The posterior urethra is further subdivided into the prostatic urethra (contains verumontanum and may visualize the prostatic utricle) and membranous urethra (portion of urethra that goes through the urogenital diaphragm).
- NOTE: the bulbourethral glands are located in the urogenital diaphragm but their ducts drain into the bulbous urethra.
- The anterior urethra is divided into the bulbous urethra and penile urethra. The penoscrotal junction marks where the bulbous urethra ends and the penile urethra begins.

Front 15

Urethral stricture

Back 15

URETHRAL TRAUMA:
- Straddle injury: usually involves the bulbous urethra.
- Iatrogenic: instrument related typically occurs at the bulbomembranous urethra and penoscrotal jxn.
- Posterior urethral injury: usually result of trauma from pelvic fxs or surgery (prostatectomy).
POSTINFECTIOUS/POST-INFLAMMATORY STRICTURE:
- Gonococcoal and chlamydia account for majority of cases.
- typically affects the bulbous urethra
- may lead to dilation of Littre glands
- involvement of membranous urethra is important for the urologist as it serves as the external urethral sphincter; the disruption of which would lead to incontinence.
URETHRAL CARCINOMA
- MC = SCC
- focal irregular narrowing
- typically low SI on both T1 and T2WI.

Front 16

How do you evaluate urethral strictures.

Back 16

Retrograde urethrography is used to diagnose anterior strictures and simultaneous retrograde urethrography and antegrade cystourethrography helps depict the length of posterior urethral stricture.

Front 17

Prostatic utricle

Back 17

- Congenital cystic lesion 2/2 failure of regression of mullerian ducts.
- Connects to the prostatic urethra.
- Associated with hypospadias and cryptorchidism.