Scrotum Pathology PDF

Cryptorchidis m Sonographic Findings: Undescended...

Cryptorchidis m Sonographic Findings: Undescended testicle is smaller and less echogenic than normal testis Usually oval with homogeneous texture Mediastinum rarely seen Undescended left testicle with normal right testicle. The undescended testis is smaller and hypoechoic compared with the normal right testis. Testicular Ectopia Very rare condition Ectopic testicle cannot be manipulated into correct path of descent Most common site for ectopic testicle to rest is superficial inguinal pouch Other sites include: Perineum Femoral canal Suprapubic area Penis Diaphragm Other scrotal compartment  Rare condition Anorchi Unilateral anorchia a (monorchidism) found in 4% of patients with nonpalpable testis More common on left side; definitive diagnosis depends on surgical diagnosis Causes: Intrauterine testicular torsion or other forms of decreased vascular supply to testicle in utero Polyorchidis m (Testicular Duplication) Very rare disorder; more common on left side (75%) Bilateral in 5% of cases Associated with: Malignancy Cryptorchidism Inguinal hernia Torsion Supernumerary testicle is usually small  Torsion Appendages Fluid Collections Trauma Scrotal Varicocele Inflammation Pathology Epididymitis Orchitis Epididymo-orchitis Microlithiasis Masses  Arterial blood supply to testicle is interrupted Torsion secondary to twisting of spermatic cord Commonly due to Bell clapper deformity Tunica vaginalis completely surrounds testis, epididymis, distal spermatic cord, allowing them to move and rotate freely within scrotum. Bilateral More common in adolescence (12-18 years)  Torsion Compromises blood flow to testis, epididymis, and intrascrotal portion of spermatic cord Venous flow affected first with occluded veins, causing swelling of scrotal structures on affected side If torsion continues, arterial flow obstructed and testicular ischemia follows 360-degree torsion affects all vessels  Torsion is a surgical emergency! Surgery within 6 hours of onset of pain, 80% to 100% of testes can be saved Between 6-12 hours salvage rate is 70% After 12 hours only 20% will be saved After 24 hours, typically not salvageable Torsion Clinical S&S: Acute onset pain (often during sleep) Possible lower abdomen or inguinal pain Swollen testis/scrotum Nausea & vomiting Malposition of testicle Torsion Sonographic Appearance: Enlargement of spermatic cord, epididymis and testicle Absent or diminished intratesticular flow Heterogenous, hypoechoic testicle Hydrocele Thick scrotal wall  Normal finding, may not be seen in absence of fluid Embryologic remnants Small pieces of tissue originating from: Testicle – between head of epi and superior pole of testicle Appendag Epididymis – at head of epi Appendages can become torsed es Most common cause of acute scrotal pain in prepubertal boys “Blue-dot sign” After torsion, appendix becomes mobile and calcified – scrotal pearl Appendices  Potential space exists between visceral and Fluid parietal layers of tunica Collection vaginalis This space is where a s hydrocele, pyocele, or hematocele may develop.  Hydrocele Collection of serous fluid Most common cause of painless scrotal swelling. May be idiopathic, but commonly associated with epididymo-orchitis and torsion  Pyocele Collection of pus. Occur with untreated infection or when an abscess ruptures into space between layers of tunica vaginalis Hematocele Collection of blood Secondary to trauma Sonographic appearance: Varies with age of injury Acute hematocele - Echogenic with numerous, highly visible echoes that can be seen to float or move in real time Over time, hematoceles show low-level echoes and develop fluid-fluid levels or septations  Scrotal trauma presents challenge because scrotum often painful and swollen. Acute Trauma may be result of MVA, Scrotum athletic injury, direct blow to scrotum, or straddle injury. Testicular rupture is possible  Testicular Rupture/Fracture Sonographic findings associated with scrotal rupture:  Focal alteration of testicular parenchymal pattern  Interruption of tunica albuginea  Blood flow disruption across surface of testis  Irregular testicular contour  Scrotal wall thickening  Hematocele If surgery performed within 72 hours following injury, up to 90% of testes can be saved, but only 45% can be saved after 72 hours. Hematoma Hematomas associated with trauma may be large and cause displacement of the associated testis. Hematomas appear as heterogeneous areas within scrotum. Become more complex with time, developing cystic components. Hematomas may involve testis or epididymis, or they can be contained within scrotal wall.  An abnormal dilation of Varicoce veins of pampiniform le plexus Most common cause of correctible male infertility More common on left Etiology - Primary vs secondary  Primary: Incompetent venous valves of spermatic vein or pampiniform plexus Usually on left Varicoce Nutcracker syndrome Left renal vein entrapment le between SMA and aorta Secondary: Increased pressure in spermatic vein Hydronephrosis, hepatomegaly/cirrhosis, retroperitoneal/abdominal mass Varicocele Sonographic Clinical S&S: appearance: Typically painless Numerous anechoic Palpable extratesticular tortuous tubes of mass varying sizes outside of “bag of worms” testicle Possible infertility Tubes may contain echoes that move real-time imaging Distended veins that fill with color Increased flow and diameter in response to Valsalva maneuver Varicoceles measure > 2 mm in diameter Varicocele Scrotal Inflammation Inflammation can occur in various structures within the scrotum Epididymis Testicle Epididymis & testicle Clinical S&S: Acute testicular pain Leukocytosis Fever Dysuria Urethral discharge Scrotal wall edema Possible STD Epididymitis Inflammation of the epididymis Most common cause of acute testicular pain in adults Most common cause in younger men is STDs Sonographic Findings: Epididymitis appears enlarged, hypoechoic Focal or diffuse Hyperemic flow confirmed with color Doppler  Epididymitis Normal epididymis shows little flow with color Doppler. Amount of color flow signal should be compared between sides. Affected side shows significantly more flow than asymptomatic epididymis. Important to use same color Doppler settings when comparing amount of flow between sides Scrotal Inflammation Orchitis Sonographic Inflammation of the testicle appearance: Usually occurs secondary to Signs of epididymitis epididymitis Hypoechoic testicle Hyperemia Epididymo-orchitis Epididymis and testis Infection of epididymis and when both involved testis. Most commonly results from Thickened scrotal wall spread of lower urinary Reactive hydrocele tract infection via spermatic cord. Possible pyocele Epididymo- orchitis Epididymo-orchitis Pyocele may be present in severe cases Pyocele occurs when pus fills space between layers of tunica vaginalis. Usually contains internal septations, loculations, debris.  Testicular infarction may occur in severe cases of orchitis. Swollen testis confined within rigid tunica albuginea. Epididymo Excessive swelling can cause obstruction to testicular blood supply. -orchitis Color Doppler: Decreased or absent flow compared with contralateral testis. Decreased flow, spectral Doppler waveforms—high resistance with little or no diastolic flow.  Numerous echogenic foci with no acoustic shadowing throughout Microlithias the testis is Microcalcifications are < 3 mm Usually bilateral condition Associated with increased risk of testicular malignancy; exact nature unknown. Associated with: Cryptorchidism, Klinefelter’s syndrome, infertility, varicoceles, testicular atrophy, and male pseudohermaphroditism MICROLITHIASI S   Most scrotal cysts are extratesticular, found in tunica albuginea or epididymis. Extratesticu Include spermatoceles, lar Masses epididymal cysts, tunica albuginea cysts General asymptomatic, but may be palpable SPERMATOCELES Cystic dilatations of efferent ductules of epididymis: Most often located in epididymal head  Contain proteinaceous fluid and nonviable sperm  May be seen more often following vasectomy EPIDIDYMAL CYSTS Small, clear cysts containing serous fluid located within the epididymis TUNICA ALBUGINEA CYST Located anywhere along the periphery of the testicle Within the albuginea  Scrotal Hernia (inguinal) Occur when bowel, omentum, or other structures herniate into scrotum Clinical diagnosis usually sufficient; sonography helpful in cases of equivocal findings. Bowel most commonly herniated structure, followed by omentum.  Cystic dilatation of the rete testis Tubula Rete testis is located at hilum r of testis where mediastinum Ectasi resides Uncommon, benign condition a Associated with: Spermatocele, epididymal/testicular cyst or other epididymal obstruction on same side as dilated tubules TUBULAR ECTASIA Intratesticular Cyst Cysts more common in men over 40 years of age Associated with extratesticular spermatoceles Located near mediastinum Single or multiple and of variable size Sperm Granuloma Occur as chronic inflammatory reaction to extravasation of spermatozoa. Most frequently seen in patients with history of vasectomy May be located anywhere within epididymis or vas deferens Adrenal Rests Ectopic adrenal tissue within the testicle Migration of adrenal tissue during fetal development Clinical S&S: Congenital adrenal hyperplasia Elevated adrenocorticotropic hormone (ACTH) Cushing syndrome Sonographic appearance: Bilateral, round hypoechoic intratesticular masses (commonly near mediastinum) Testicular Carcinoma Testicular cancer is uncommon Categorized as germ cell and non–germ cell tumors One of most curable forms of cancer Occurs most frequently between ages of 20 and 34 Symptoms: Painless lump, testicular enlargement, or vague discomfort in scrotum Extratesticular masses: Usually benign Intratesticular masses: More likely to be malignant; considered malignant until proven otherwise  Associated with elevated level of human chorionic gonadotropin and alpha-fetoprotein GERM CELL Approximately 95% of all testicular tumors are of germ cell TUMORS type and highly malignant Types Seminoma of GCT: Teratoma Embryonal cell carcinoma Yolk sac tumor Choriocarcinoma SEMINOMA Most common malignancy of testicles Most common in ages 30– 50 Clinical S&S: Painless scrotal mass Hardening of testicle Elevated hCG Sonographic appearance: Solid, hypoechoic intratesticular mass Heterogenous if large  TERATOMA Benign, with a malignant potential Clinical S&S: May be palpable Elevated AFP & hCG (when malignant) Sonographic appearance: Heterogenous mass with calcifications May contain bone, teeth, cartilage, hair, etc. EMBRYONAL CELL CARCINOMA More aggressive than seminomas Clinical S&S: May be palpable Elevated AFP & hCG Sonographic appearance: Heterogenous mass with cystic components May contain areas of increased echogenicity resulting from calcification, hemorrhage, or fibrosis YOLK SAC TUMOR Rare; favorable prognosis Clinical S&S: May be palpable Elevated AFP only Sonographic appearance: Heterogenous mass with areas of hemorrhage and calcifications CHORIOCARCINOMA Rare; aggressive Clinical S&S: May be palpable Elevated hCg Sonographic appearance: Varied sonographic appearance because of mixed cell types Heterogenous mass with areas of hemorrhage, necrosis, and calcifications Irregular borders NON- Typically in younger boys GERM Sex cord- Leydig cell tumor CELL stromal tumors Sertoli cell tumor TUMORS Granulosa cell tumor Lymphoma Leukemia Metastases LEYDIG CELL TUMOR Uncommon Clinical S&S: Increased levels of testosterone Virilization Sonographic appearance: Small, hypoechoic Possible cystic areas  SERTOLI CELL TUMOR Extremely rare Clinical S&S: Produces estrogen Gynecomastia Sonographic appearance: Hypoechoic Hypervascular GRANULOSA CELL TUMOR Rare Associated with chromosomal abnormalities Clinical S&S: Sonographic appearance: Hypoechoic Hypervascular  Malignant lymphoma: 1% to 7% of all testicular tumors; Lympho most common bilateral ma and secondary testicular neoplasm affecting men > 60 Leukemia years. Leukemia involvement of testicle is next most common secondary testicular neoplasm; most often found in children. Testicle may become enlarged; tumor bilateral or unilateral. Lymphoma & Leukemia  Rare, normally occurring later in life Primary tumor may originate from prostate or kidneys Less common sites include lung, pancreas, bladder, colon, thyroid, or melanoma Metastasis Metastasis to testicle is bilateral, with multiple lesions found Sonographic Findings: Hyperechoic Solid hypoechoic mass Mixture of both