Male Reproductive Health Quiz

The Scrotum: Physical Exam, Fluid Collections, and Inflammation

• The scrotum is the sac of skin that holds the testicles.
• A physical exam involves palpating for two testes in the scrotal sac. Absence might indicate an undescended testicle.
• Additional masses, lumps, or swellings should be palpated. These could be hernias, neoplasms, hydroceles, or varicoceles.
• Transillumination is used to assess for fluid collections, such as a hydrocele.
• Prostate assessment is part of the male pelvic exam, done through a digital rectal exam.

Infertility

• Infertility is defined as failure to achieve pregnancy after one year of regular unprotected intercourse.
• Infertility can be caused by male factors, female factors, or a combination of both.
• Initial investigation for male infertility is a semen analysis, including sperm counts.
• Azoospermia (low or no sperm) may be evaluated using transrectal ultrasound (TRUS). Possible causes include ejaculatory duct obstruction, undescended testicles, or varicoceles.

Hematospermia

• Hematospermia is the presence of blood in the seminal fluid.
• Acute bleeding is indicated by red blood, while dark brown indicates older blood.
• Common causes include prostatitis, a prostate biopsy, and less commonly, bladder/prostate neoplasms, infection or calculi, but it often resolves spontaneously.
• Persistent hematospermia should be investigated.

Testicular Prostheses

• Testicular prostheses are artificial devices that replace missing testicles. These are typically made of saline or silicone.
• Causes of testicular loss include malignancy, torsion, orchitis, trauma, undescended testicles, or psychological/cosmetic reasons.

Fluid Collections

• Fluid collections in the scrotum include hydroceles, hematoceles, pyoceles, and varicoceles.

Hydroceles

• Hydroceles are the most common cause of painless scrotal swelling.
• They are serous fluid collections located between the visceral and parietal layers of the tunica vaginalis, primarily in the anterolateral scrotum.
• The tunica vaginalis is absent in the posterior area, known as the "bare area".
• A small amount of fluid is normal; larger amounts indicate pathology.
• Clinical manifestations include diffuse scrotal enlargement and may show trans-illumination on exam.
• Hydroceles can be congenital (incomplete closure of the processus vaginalis) or acquired (trauma, neoplasms, epididymitis, epididymo-orchitis, torsion, or excessive fluid production). Congenital hydroceles usually resolve by 18 months.
• Sonographic appearance typically shows anechoic fluid collection around the anterolateral aspects of the testicle, with no fluid posterior to the testicle. A "bare area" is observable. Fluid is generally medium-low level, mobile, with possible septations

Hematoceles and Pyoceles

• Hematoceles are collections of blood, while pyoceles are collections of pus; both frequently occur in the same location as hydroceles.
• Causes include trauma, surgery, diabetes, neoplasms, torsion, and atherosclerotic disease.
• Sonographic appearances include anechoic fluid collections, which may contain septations and loculations that can change appearance over time.

Varicoceles

• Varicoceles are collections of abnormally dilated veins (pampiniform plexus) within the scrotum.
• These veins become tortuous and elongated, and are located posterior to the testicle and adjacent to the epididymis and vas deferens.
• Two types exist: primary (idiopathic), and secondary varicoceles.
• Idiopathic varicoceles are caused by incompetent valves leading to retrograde blood flow into the pampiniform plexus. They are most commonly found on the left side in young adults (15-25 years old), may cause infertility; and resolve with a patient lying down, but may visibly worsen with the Valsalva maneuver.
• Secondary varicoceles occur from increased pressure in the spermatic vein or tributaries (from conditions like hydronephrosis, abdominal/retroperitoneal/hepatomegaly masses, nutcracker syndrome, etc). Their presence frequently warrants further investigation for tumors. These are unlikely to resolve or change appearance with the Valsalva maneuver.
• Sonographic presentation of varicoceles includes multiple, serpentine, anechoic structures, greater than 2mm in diameter, and usually located outside the testicle. The presence and distribution of the veins (and filling /emptying) may change with Valsalva, as well as the visualization of other (particularly moving) structures (RBCs) within.

Inflammation and Infection

• Inflammation and infection conditions include epididymitis, orchitis, scrotal abscesses, sperm granulomas, and fibrous pseudotumors.

Inflammatory Processes: Epididymitis

• Epididymitis is inflammation of the epididymis, the most common cause of acute scrotal pain in post-pubertal males (75% of acute scrotal cases) occurring most often between 40-50 years of age.
• Causes include ascending infection (from the lower urinary tract), spread of distant infection, trauma, surgery, urine reflux into ejaculatory ducts, and idiopathic processes.
• Common causative agents include E. coli, Pseudomonas, Klebsiella, Chlamydia, Gonorrhea, Tuberculosis, Mumps, and Syphilis.
• Symptoms include increasing pain, fever, dysuria, and urethral discharge.
• Sonographic appearance shows thickened and enlarged epididymis, often starting in the tail region and spreading throughout, with decreased echogenicity, coarse, heterogeneous echotexture, and potential reactive hydrocele or pyocele. The color Doppler will often show increased blood flow compared to the unaffected side.

Inflammatory Processes: Epididymo-orchitis

• Epididymo-orchitis involves direct extension of inflammation to include both the testicle and epididymis, occurring in up to 20% of epididymitis cases.

Inflammatory Processes: Orchitis

• Orchitis is isolated inflammation of the testicle, without involvement of the epididymis.
• Increased blood flow to the testicle is often a prominent feature.
• Orchitis can be focal (localized hypoechoic area with increased vascularity) or diffuse (whole testicle enlarged and hypoechoic), with possible venous infarction as a complication. Testicular torsion can be possible to differentiate based on presence or absence of blood flow.

Inflammatory Processes: Scrotal Abscesses

• Scrotal abscesses are collections of pus, often resulting from complications of epididymitis, epididymo-orchitis, undiagnosed torsion, or infected neoplasms. They can be located either within (intra) or outside (extra) the testicle.
• Sonographic appearance typically includes a fluid-filled, hypoechoic mass, internally filled with debris at varying levels, and often exhibit features of gas.

Inflammatory Processes: Sperm Granuloma

• Sperm granuloma is a granulomatous inflammation caused by extravasated sperm into surrounding tissues, primarily in post-vasectomy patients.
• It may be related to previous epididymal infections or trauma, and may or may not be painful.
• Sonographic presentation is usually a solid hypoechoic or heterogeneous mass within the epididymis, and may show calcification.

Inflammatory Processes: Fibrous Pseudotumor

• Fibrous pseudotumor is a rare, non-neoplastic paratesticular mass that mimics a neoplasm. It often arises from reactive thickening of the epididymis or tunica vaginalis due to chronic inflammation.
• It commonly follows a history of surgical, traumatic, infectious, or inflammatory episodes.
• Sonographic appearances vary to include hypoechoic, hyperechoic, or heterogeneous lesions that appear extra or intratesticular, and may be single or multiple.