Testicular Physical Exam, Fluid Collections, and Inflammation PDF

The Scrotum The Physical Exam, Fluid Collections and Inflammation Dalhousie School of Health Sciences DMUT 2050 Topic 9 Physical and Lab Tests Male Pelvic Physical Exam Miscellaneous Male Pelvis Physica...

The Scrotum The Physical Exam, Fluid Collections and Inflammation Dalhousie School of Health Sciences DMUT 2050 Topic 9 Physical and Lab Tests Male Pelvic Physical Exam Miscellaneous Male Pelvis Physical Exam ⚫ Palpate for 2 testes in the scrotal sac ⚫ Absence may indicate undescended testicle ⚫ Palpate for any additional masses/lumps/swellings ⚫ Hernias, neoplasms, hydroceles, varicoceles ⚫ Assess for evidence of transillumination ⚫ Hydrocele ⚫ Digital Rectal Exam ⚫ Prostate assessment Infertility ⚫ Failure to achieve pregnancy after 1 year of regular, unprotected intercourse ⚫ May be a male factor or ⚫ combined male/female factors or ⚫ May be female factor ⚫ First investigation is semen analysis ⚫ Sperm counts ⚫ Azoospermia (low or no sperm) may be evaluated by TRUS ⚫ Look for ejaculatory duct obstruction, undescended testicles, varicoceles Hematospermia ⚫ Blood in the seminal fluid ⚫ Red = acute bleeding ⚫ Dark brown = old blood ⚫ Usually results from prostatitis ⚫ Also common after prostate biopsy ⚫ Often resolves spontaneously ⚫ Persistent hematospermia should be investigated ⚫ Bladder or prostate neoplasms ⚫ Infection ⚫ Calculi Testicular Prostheses ⚫ Artificial device that replaces missing testicle ⚫ Saline or silicone Causes of testicular loss include: ⚫ Malignancy ⚫ Torsion ⚫ Orchitis ⚫ Trauma ⚫ Undescended testicle ⚫ Psychological and/or cosmetic reasons Fluid Collections Hydroceles Hematoceles Pyoceles Varicoceles Hydroceles ⚫ Most common cause of painless scrotal swelling ⚫ Serous fluid collection ⚫ Located between 2 layers of tunica vaginalis ⚫ Visceral and parietal ⚫ Confined to anterolateral portions of scrotum ⚫ Tunica vaginalis is not present posterior to testicle ⚫ “Bare area” ⚫ Small amount of fluid is normal ⚫ Larger amounts indicate pathology Hydroceles Clinical Manifestations ⚫ Diffuse enlargement of the scrotal sac ⚫ “Swelling” ⚫ May show “trans-illumination” on clinical exam Transillumination in a newborn male infant with hydrocele Hydroceles ⚫ May be congenital or acquired ⚫ Congenital ⚫ Acquired ⚫ Incomplete closure of processus vaginalis ⚫ Trauma (25-50%) ⚫ Causes a persistent communication ⚫ Neoplasms (10%) between scrotal sac and peritoneum ⚫ Epididymitis ⚫ Usually closes by ~18 months old ⚫ Epididymo-orchitis ⚫ Torsion ⚫ Idiopathic ⚫ Excessive fluid production Congenital Hydroceles Incomplete closure Complete closure Diagram shows the normal embryologic development of the processus vaginalis, which arises as an out-pouching of the parietal peritoneum during the 3rd month of gestation. After the testis descends into the scrotum (between months 7 and 9), the processus vaginalis is obliterated. Congenital hydroceles occur due to incomplete obliteration of processus vaginalis. (Radiographics (2009). 29, 2017-2032.) Hydroceles Sonographic Appearance ⚫ Anechoic fluid collection in scrotal sac ⚫ Surrounds anterolateral aspects of testicle ⚫ No fluid collects posterior to testicle Acquired ⚫ “Bare area” ⚫ May see: ⚫ Medium-low level echoes ⚫ Mobile ⚫ Septations Congenital Hydroceles Sonographic Appearance Parietal layer of tun. vaginalis “Bare area” Visceral layer no tun. of tun. vaginalis vaginalis continuous  no fluid with tun. albuginea Hydroceles Sonographic Appearance Complex hydrocele (no symptoms of infection or trauma)….use of curved transducer was required to capture extent of collection Hematoceles and Pyoceles ⚫ Hematoceles ⚫ Pyoceles ⚫ Collection of blood ⚫ Collection of pus ⚫ Same location as hydroceles ⚫ Same location as hydroceles ⚫ Caused by: ⚫ Caused by: ⚫ Trauma ⚫ Rupture of abscess ⚫ Surgery ⚫ Infection within hydrocele ⚫ Diabetes ⚫ Infection within scrotum ⚫ Neoplasms ⚫ Torsion ⚫ Atherosclerotic disease Hematoceles and Pyoceles Sonographic Appearance ⚫ Anechoic fluid collections ⚫ Usually see: ⚫ Medium-low level echoes ⚫ Mobile ⚫ Septations and loculations ⚫ Both may change appearance with time ⚫ As collections resolve ⚫ May see (chronically) ⚫ Scrotal skin thickening ⚫ Calcifications Hematoceles and Pyoceles -Depends on age of collection -May see: -loculations -septations -mobile debris Varicoceles ⚫ Collection of abnormally dilated veins ⚫ Pampiniform plexus ⚫ Veins become tortuous and elongated ⚫ Located posterior to the testicle ⚫ Adjacent to epididymis and vas deferens ⚫ 2 Types ⚫ Primary (idiopathic) ⚫ Secondary Idiopathic Varicoceles ⚫ Caused by incompetent valves in spermatic vein ⚫ Retrograde passage of blood into pampiniform plexus of veins ⚫ Usually detected in males 15-25 y.o. ⚫ May cause infertility ⚫ Most common cause of correctable male infertility (up to 40% of patients with infertility) ⚫ 98% are left sided, often bilateral ⚫ Due to LT testicular drainage into LRV before IVC ⚫ Will distend with upright position or valsalva, and decompress with patient supine Secondary Varicoceles ⚫ Caused by increased pressure on spermatic vein or tributaries ⚫ Marked hydronephrosis ⚫ Hepatomegaly ⚫ Abdominal neoplasms ⚫ Retroperitoneal mass ⚫ Nutcracker syndrome ⚫ SMA compresses LRV ⚫ Will not change with upright position or valsalva ⚫ Search for neoplasms in patients with: ⚫ Right sided varicocele ⚫ Non-decompressible varicoceles ⚫ New varicoceles in patients > 40 y.o. Varicoceles Sonographic Appearance ⚫ Multiple, serpentine, anechoic structures ⚫ >2mm in diameter ⚫ Increases with Valsalva maneuver ⚫ Usually located outside of testicle ⚫ May occasionally see dilated intratesticular veins as well ⚫ Will demonstrate flow on color Doppler ⚫ May require “slow-flow” settings ⚫ May see moving RBCs within lumen on gray-scale ⚫ Veins should be compressible and may be visualized into spermatic cord ⚫ May demonstrate thrombus Varicoceles Sonographic Appearance Varicoceles Sonographic Appearance Veins distend with Valsalva Note low-level echoes of moving RBCs Varicoceles Sonographic Appearance Varicocele extending into testicle Varicoceles Sonographic Appearance Varicocele with non-compressibility – shows acute thrombus Inflammation and Infection Epididymitis Orchitis Scrotal Abscess Sperm Granuloma Fibrous Pseudotumor Inflammatory Processes Epididymitis ⚫ Inflammation of the epididymis ⚫ Most common cause of acute scrotal pain in post-pubertal men ⚫ Accounts for 75% of all acute inflammatory processes of the scrotum ⚫ Peak incidence ⚫ 40-50 y.o. males ⚫ Clinical Symptoms ⚫ Increasing pain ⚫ Fever ⚫ Dysuria ⚫ Urethral discharge Recurrent bouts may present as a chronically painful scrotum termed “chronic epididymitis  Epididymitis Causes ⚫ Ascending spread of lower urinary tract ⚫ Causative agents: infection ⚫ E. coli ⚫ Most common ⚫ Pseudomonas ⚫ Spread of distant infection ⚫ Klebsiella ⚫ Hematogeneous ⚫ Gonorrhea ⚫ Trauma ⚫ Chlamydia ⚫ Surgery ⚫ Tuberculosis ⚫ Mumps ⚫ Urine reflux into ejaculatory ducts ⚫ Syphillis ⚫ Idiopathic Epididymitis Sonographic Appearance ⚫ Thickened and enlarged epididymis ⚫ Often begins in tail region ⚫ Spreads to include entire epididymis ⚫ Decreased echogenicity of epididymis ⚫ Coarse, heterogeneous echotexture ⚫ Reactive hydrocele or pyocele formation ⚫ Reactive scrotal skin edema and thickening ⚫ Increased color Doppler flow compared to unaffected side Epididymitis Sonographic Appearance Enlarged, heterogeneous Enlarged, epididymis head, epididymal head body and tail with reactive Hydrocele and skin thickening Epididymitis Sonographic Appearance Increased vascularity (hyperemia) on color Doppler Epididymo-orchitis ⚫ Direct extension of inflammation to include both the testicle and epididymis ⚫ Occurs in up to 20% of epididymitis cases Inflammatory Processes Orchitis ⚫ Isolated inflammation of the testicle ⚫ Without epididymal involvement ⚫ Increased blood flow is confined to testicle ⚫ May be focal or diffuse ⚫ Focal ⚫ Focal hypoechoic area with increased vascularity ⚫ Diffuse ⚫ Entire testicle is enlarged and hypoechoic ⚫ Causes venous infarction ⚫ DDx ▪ Testicular torsion ▪ No flow indicates torsion, increased flow indicates diffuse orchitis Orchitis Enlarged hypoechoic testicle Increased vascularity Epididymitis, Orchitis and Epididymo- orchitis ⚫ Complications ⚫ Abscess formation ⚫ Pyocele formation ⚫ Chronic changes ⚫ Swelling of epididymis ⚫ Fibrotic septal accentuation of testicle ⚫ Focal areas of infarction and scarring ⚫ Small, atrophic testicle Epididymitis, Orchitis and Epididymo- orchitis Orchitis with pyocele formation Epididymitis with abscess formation Epididymitis, Orchitis Chronic Changes Unaffected testicle Affected testicle Small, atrophic, with fibrous septal accentuation Inflammatary Processes Scrotal Abscesses ⚫ Intratesticular or extratesticular ⚫ Complication of: ⚫ Causes of epididymo-orchitis ⚫ Epididymitis ⚫ Influenza ⚫ Epididymo-orchitis ⚫ Mumps ⚫ Undiagnosed torsion ⚫ Appendicitis ⚫ Gangrenous or infected ⚫ Smallpox neoplasm ⚫ Scarlet fever ⚫ Surgery ⚫ Typhoid ⚫ Trauma ⚫ Sinusitis ⚫ Osteomyelitis Scrotal Abscesses Sonographic Appearance ⚫ Fluid-filled mass ⚫ Complications ⚫ Intratesticular or extratesticular ⚫ May rupture ⚫ Hypoechoic – complex ⚫ Causing pyocele ⚫ May see: ⚫ Cause fistula to the skin ⚫ Internal debris ⚫ Fluid-fluid or fluid-debris levels ⚫ Gas ⚫ Echogenic foci with ringdown artifact ⚫ Posterior acoustic enhancement As with any other abscess, clinical symptoms are important Scrotal Abscesses Sonographic Appearance Complex-hypoechoic collection Epididymitis with abscess formation with posterior acoustic enhancement Showing gas Scrotal Abscesses Sonographic Appearance Ruptured abscess Inflammatory Processes Sperm Granuloma ⚫ Granulomatous inflammation ⚫ Reaction of extravasated sperm into soft tissues surrounding epididymis ⚫ Most often found in post-vasectomy patients ⚫ May be related to previous epididymal infection or trauma ⚫ May be asymptomatic or painful ⚫ Sonographic Appearance ⚫ Solid, hypoechoic or heterogeneous mass ⚫ Usually within epididymis ⚫ May contain calcification Sperm Granuloma Hypoechoic mass in the epididymis in a patient with a history of Tuberculosis and previous epididymitis Inflammatory Processes Fibrous Pseudotumor ⚫ Rare ⚫ Non-neoplastic paratesticular “mass” ⚫ Mimics a neoplasm ⚫ Reactive thickening of epididymis or tunica vaginalis from chronic inflammation ⚫ History of surgery, trauma, infection or inflammation ⚫ Sonographic Appearance ⚫ Hypoechoic, hyperechoic or heterogeneous lesions ⚫ Extratesticular ⚫ May be single or multiple Fibrous Pseudotumor Solitary fibrous pseudotumor Multiple fibrous pseudotumors References ⚫ Garriga, L., Serrano, A. Marin, A., Medrano, S. Roson, N. & Pruna, X. (2009). US of the tunica vaginalis testis: Anatomic relationships and pathologic conditions [Electronic version], Radiographics, 29, 2017-2032. ⚫ Kim, W. Rosen, M. A., Langer, J. E., Banner, M. P., Siegelman, E. S. & Amchandani, P. (2007). US- MR imaging correlation in pathologic conditions of the scrotum [Electronic version], Radiographics, 27, 1239-1253. ⚫ Kocakoc, E., Bhatt, S., and Dogra, V. (2007). Ultrasound evaluation of testicular neoplasms [Electronic version], Ultrasound Clinics, 2:1, 27-44. ⚫ Loya, A. G., Said, J. W. & Grant, E. G. (2004). Epidermoid cyst of the testis: Radiologic-pathologic correlation [Electronic version], Radiographics, 24, S243-S246. ⚫ Mittelstaedt, C. A. (Ed.). (1992). General ultrasound. New York, NY: Churchill Livingstone Inc. ⚫ Moran, D. T. (2001). Serum acid phosphatase test. Retrieved from http://www.medicineonline.com/articles/S/2/Serum-Acid-Phosphatase-Test/Acid-Phosphatase- Test.html ⚫ Rumack, C. M., Wilson, S. R., Charboneau, M. D. & Levine, D. (Eds.). (2011). Diagnostic ultrasound (4th ed.). Philadelphia, PA: Elsevier Inc.