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scrotal pathology


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scrotal __ presents a challenge to the tech because the scrotum is often painful and swollen; may be a result of a motor vehicle accident, athletic injury, direct blow to the scrotum, or a straddle injury; the most important goal of this is to determine i
rupture of the testis is a surgical emergency requiring a prompt dx; if surgery is performed within __ hours after the injury, up to 90% of testes can be saved, but only 45% can be saved after this deadline
72 hours
__ and __ are both complications of trauma; however, neither is specific to trauma
hematocele and hydrocele
contain blood and are also found in advanced cases of epididymitis and orchitis; result from bleeding of the pampiniformis plexus or other extratesticular structure; doesn't confirm rupture
sono appears as focal alteration of the testicular parenchymal pattern, interruption of the tunica albuginea, irregular testicular contour, scrotal wall thickening, and hematocele; associated with abscess, tumor, or other clinical condition. when combine
hematocele/ hydrocele rupture?
hematoceles vary with __.
acute hematocele is __ with numerous highly visible echoes that can be seen to float or move in __. with time it shows low-level echoes and develops __
echogenic, real-time, septations
__ in testicular trauma include identification of blood flow disruption across the surface of the testis which is an indication of rupture and can aid inseparating a normally vascularized testis from one that is disrupted by hematoma
color doppler
may result from trauma and color doppler imaging can be used to identify the associated increased vascularity in the epididymis
tortion may also be associated with __ and color doppler is used to confirm an absence of flow int he testis with torsion.
___ associated with trauma may be large and cause displacement of the testis. appear as heterogeneous within the scrotum. they tend to become more complex with time, developing cystic components; may involve the testis or epididymis, or they can be cont
inflammation of the epididgymis 1st which spread to the testes; is most commonly resulting from the spread of a lower urinary tract infection via the spermatic cord; less common causes include mumps, syphillis, tb, viruses, trauma, or chemical causes; rep
represents teh most common cause of acute scrotal pain in adults
the epididymis is the organ primarily involved with infection, spreading to the testis in about __ to __ % of cases
__ almost always occurs secondary to epididymitis
patients typically present with increasing scrotal pain over 1 to 2 days; the pain may be mild or severe; symptoms may include fever, elevated wbc, and urethral discharge
sono appears as an enlarged, hypoechoic gland; enlargement of epididymis; if secondary hemorrhage has occured, the epididymis may contain focal hyperechoic areas; hyperemic flow is confirmed by color doppler; the normal epididymis shows little flow but th
sono appearance of epididymo-orchitis: if the infection is isolated to the epididymis, the testis appears normal; when orchitis has developed, ultrasound imaging shows and enlarged __; the infection may be focal or diffuse, with the affected areas appeari
testes, heterogenous, homogenous, 20%
sono appearance of epididymo-orchitis con't: __ flow with significantly more visible vessels on color doppler are seen compared with the asymptomatic side; is seen in the epididymis and testis when both are involved, but isolated to the epididymis if the
other sono findings associated include scrotal wall thickening and hydrocele; hydroceles are found around the anterolateral aspect of the testis; they may appear anechoic or contain low-level echoes; complex hydroceles may be associated with severe versio
in severe cases of epididymo-orchitis a __ may be present;occurs when pus fills the space between the layers of the tunica vaginalis; it usually contains internal septations, loculations, and debris; this same appearance can occur after trauma or surgery.
a swollen testis is confined within a rigid __. excessive swelling can cause obstruction tot eh testicular blood supply. color doppler shows decreased or absent flow compared with teh contralateral testis; with decreased flow, doppler has high resistanc
tunica albuginea
a doppler waveform demonstrating reversed diastolic flow is a serious finding indiating threatened testicular __ which can affect the entire testes or be confined to a focal area
with focal infarction, color show __ inonly portions of the testis with an absence of color signals in the affected areas. in diffuse the testis appear __ compared with the surrounding testicular parenchyma depicting a heterogenous pattern
perfusion, hypoechoic
occurs as a result of abnormal mobility of the tests within the scrotump an anomaly termed bell clapper deformity is the most common etiology of this condition which affects the bare area
this anomaly occurs when the tunica vaginalis completely surround the testis, epididymis, and distal spermatic cord, allowing them to move and rotate freely within the scrotum; normally the testis and epididymis are surrounded by the tunica vaginalis, exc
results when teh testis and epididymis twist within the scrotum, cutting off the vascular supply within the spermatic cord; undescended testes are 10 times more likely to be affected than normal; compromised blood flow to the testis, epididymis, intrascro
backup of venous system; venous flow is affected first with the occluded veins, causing swelling of the scrotal structures on the affected side; if it continues, the arterial flow is also obstructed and testicular ischemia follows
torsion of the __ is a surgical emergency; salvage rate of the testis depends on the elapsed time since torsion. if surgery is performed within __ to __ hours of the onset of pain then 80-100% of testes can be saved. between __ and __ hours the salvage
spermatic cord, 5-6 hours, 6-12 hours, 12 hours
most common cause of acute scrotal pain in adolescents; although it is more common in yound adults and adolescents, it can occur at any age with the peak incidence at 14
patient presents with a sudden onset of scrotal pain accompanied by swelling on the affected side; the severe pain causes nausea and vomiting in many patients; patients frequently report previous episodes of scrotal pain
sono appearance depends on how much time has elapsed; in early stages, the scrotum may appear normal. after 4-6 hours the testis become swollen and hypoechoic and very large. the lobes within the testis usually are well identified during this time becau
after 24 hours, the testis become heterogenous because of hemorrhage, infarction, necrosis, and vascular congestion; the epididymal head appears enlarged and has decreased echogenicity or becomes heterogenous; dx by absence of color flow; make sure you de
sono appearance cont: ins ome cases the twisted spermatic cord knot may be seen as a round or oval extratesticular mass that can be traced back to the normal portion; other findings may include scrotal skin thickening and reactive hydrocele; color dopple
appearance depends on how long the testis was torsed and how long it has been since relief, the intratesticular flow may be minimal or hyperemic; extratesticular flow is usually increased
torsion of the __ of the epididymis or testis can also occur and further complicates the clinical picture; the clinical presentation is similar to that of testicular torsion and epididymo-orchitis; ultrasound may show a small, hypoehoic mass located betwe
are benign fluid collections that may be located within the testis or in extratesticular structures; most are extratesticular and are found in the tunica albuginea or epididymis
common; are cystic dilations of the efferent ductules of the epididymis; they are always located in the epididymal head; contain proteinaceous fluid and spermatozoa (sperm); may be see more often after vasectomy
are small, clear cysts containing serous fluid; theycan be found anywhere in the epididymis but mainlyin body and tail; sometimes small cysts are found between the layers of the tuniva vaginalis or between the tunica vaginalis and tunica albuginea
epididymal cyst
are a subcapsular abnormality, whichmay be embryologic, traumtaic, or post-infectious; they occur in the upper lateral aspect of teh testicle and are very firm; most common among men 40-60 years; palpable mass
tunica albuginea cyst
all three are generally asymptomatic, although they may be palpable and cause concern to the patient
spermatocele, epididymal cyst, tunica albuginea cyst
sonographically, ultrasound can't reliably differential between __ and __ other than location. __ may be seen simple cysts or multilocular cystic collections containing internal echoes in head of epididymis. __ appear as simple fluid-filled structures h
*spermatoceles and epididymal cysts *spermatocele *epididymal cysts *tunica albuginea cysts *2-5 mm
abnormal dilation of the veins of the pampiniform plexus (venous system); usually are caused by incompetent venous valves within the spermatic vein; occur more on the left side
primary varicocele
idiopathic but related to left renal vein and left spermatic vein drainage; the spermatic vein empties into the LRV at a steep angle, which may inhibit blood flow return; the lrv can become compressed between the ao and sma
primary varicocele
caused by increased pressure on the spermatic vein usually caused by a retroperitoneal mass; this may be the result of hydronephrosis, ab mass, or liver cirrhosis; an ab malignancy invading the lrv may cause a varicocele with non-compressible veins; usual
secondary varicocele
any non-compressible varicocele in a man greater than 40 should prompt a search for a __
retroperitoneal mass
have a relationship with imparied fertility; they are more common in infertile men; most common correctable cause of male infertility; treatment has been shown to improve sperm countin up to 53% of patients
uncommonly these may extend within the testis near the mediastinum; intratesticular ones have an unknown clinical significance, but it is possible thay they affect male fetility by the same mechanism as the extratesticular kind
varicocele (intratesticular varicocele)
sono appearance: look lateral to testis; shows numerous tortuous tubes of varying sizes within the spermatic cord near the epididymal head; the tubes may contain echoes that move with real-time imaging which represent slow venous flow; measure greater tha
scanning with the patient in upright position enhances the visibility of a __ because the veins become more distended; however, supine scanning with valsalva and color doppler is adequate. with either protocol color and spectral doppler are used to confi
sono appears as straight or serpiginous channels coursing from the mediastinum into the testicular tissue; color and spectral doppler are used to identify these channels as dilated veins; on grayscale imaging, the appearance may mimic that of tubular ect
intratesticular varicocele
occurs when the small bowel or omentum pushes its way through the hole that the testicles pass thourgh to reach the scrotum during a baby's development; patient presetn with a large, painless lump in the scrotum
scrotal hernia
sono appears as peristalsis of bowel may be seen; fluid-filled bowel loops are easily recognizable by ultraosound; air-filled loops or loops containing solid stool are more difficult to recognize; on ultrsound, air appears as bright echoes with a dirty ac
scrotal hernia
closely assoc. with vasectomy; occur as a chronic inflammatory reaction to extravasation of spermatozoa; may be located anywhere within the epididymis or vas deferens. a collection of fluid that leaks from an improperly sealed or tied vas deferens; they u
sperm granuloma
ultrasound imaging is used to determine if the mass is intratesticular or extratesticular; __ masses have a much lower rate of malignancy
patients present with pain and with a clinical history of vasectomy; sono appears as a well-defined, solid mass thay may appear hypoechoic or isoechoic to the epididymis; they are often heterogeneous; calcifications are not commonly present; they may show
sperm granuloma
a potential space exists between the visceral and parietal layers of the tunica vaginalis; normally a small amount of fluid is present in this cavity and should not be confused with the presence of a ___
contains serous fluid and is the most common cause of painless scrotal swelling; may have an unknown cause but are commonly assoc. with epididymo-orchitis and torsion; they also may be found in patients after trauma or a neoplasm; assoc with neoplasms ten
collections of pus; they occur with untreated infection or when an abscess ruptures into the space between the layers of the tunica vaginalis; have fever and elevated wbc; much less common than hydroceles
are assoc. with trauma, surgery, neoplasms, or torsion; they are collections of blood and are much less common than hydroceles
hydroceles, pyoceles, and hematoceles occur in the __ portion. you can only distinguish between pyocele and hematocele by __ because they mimic each other
anterolateral, clinical symptoms
sono appears as anechoic but most often contain some low-level echoes resulting from cellular debris; doesn't contain loculations; ones asso. with infection show more internal echoes and septations
sono appears as internal echoes, thickened septations, and loculations;
pyocele and hematocele
ultrasound depiction of air within the space indicates an abscess, although an abscess may occur without presence of ___
an uncommon, benign condition; it is associated withthe presence of a spermatocele, epididymal or testicular cyst, or other spididymal obstructionon teh same side as the dilated tubules; buildup of sperm; it is more commonly seen in patients 45 years or o
tubular ectasia of the rete testis
sono appears as prominent hypoechoic channels near the echogenic mediastinum testis; color doppler can confirm the avascular nature; may mimic intratesticular varicocele but won't have color on dopper; due to obstruction or trauma
tubular ectasia of the rete testis
are more ocmmon in men over 40 years of age and have an assoc with extratesticular spermatoceles; they are located near the mediastinum; they may be single or multiple and of variable size; are incidental finding on sono and don't require treatment
intratesticular cysts
sono appears anechoic with posterior acoustic enhancement and a smooth border; varies from 2-28 mm; characteristics of simple cyst
intratesticular cyst
be careful because malignancies can have __ components
this is an uncommon condition characterized by tiny calcifications within the testis; calcifications along border of seminiferous tubules; these microcalcifications are smaller than 3 mm; is usually bilateral; has been reported to have an association iwth
been associated with cryporchidism, klinefelter's syndrome, infertility, varicoceles, testicular atrophy, and male pseudohermaphroditism
sono appear as multiple, birght, non-shadowing foci are seen scattered through the testis; may be quite numerous, but are not considered to be abnormal unless more than 5 appear on any single image
seen between layers of tunica vaginalis; extratesticular scrotal calculi that arise from the surface of the tunica vaginalis; may break loose to migrate between teh two layers; may result from an inflammation of the tunica vaginalis or a torsion of the ap
scrotal pearl
calcifications that shadow; seen as a mobile scrotal calcification and reactive hydrocele may be seen
scrotal pearl
two types of testicular tumors
germ-cell and non-germ-cell
testicular cancer is not comm0on, comprising onlyu __% of cancers in men, but it is the most comm0on malignancy in men between the ages of __ and __. fortunately, testicular cancer is one of the most curable forms of cancer; it is more common in __ male
1%, 15-35, white, 20-34
undescended testes are __ to __ times more likely to develop cancer
most patients have no other symptoms except a painless lump, testicular enlargement, or vague discomfort in the scrotum; the primary goal of teh ultrasound exam in testicular tumors is to determine mass location and differentiate between cystic and solid
malignant, benign
intratesticular cysts are benign masses, but care must be taken to ensure a cyst is ___ because some testicular cancers contain cystic components; some benign conditions may mimic malignancy; these include hematome, orchitis (especially when focal), absce
__ can't differentiate between benign or malignant because testicles are so vascular so want to determine characteristics (cystic vs. solid) and intra vs. extratesticular
testicular cancers cause an increase in __ and __ levels
AFP and hCG
tumor of all 3 germ layers; are associated with an elevated level of hcg and afp; approx 95% of all testicular tumors this type and are very malignant
germ-cell tumors
the most common type of germ-cell tumor is __ followed by mixed __ and __
seminoma, mixed embryonal cell tumors, teratocarcinomas
other less common germ cell tumors include 4:
yolk sac, choriocarcinoma, teratomas, combos of these
sono ultrasound is nearly __ % sensitive for detecting tumors
most tumors appear as __, __ masses; ultrasound imaging can't differentiate malignant from benign masses; beither color doppler nor doppler waveforms can reliably distinguish between flow patterns of benign and malignant tumors
focal, hypoechoic
rarest type of germ cell tumor, accounting for less than .5% of malignancy; peak incidence is in the second and third decades; highly malignant and metastasize early by hematogeneous and lymphatic route
patient presents with gynecomastia, elevated hcg levels
sono appears as having a varied sonographic appearance because of mixed cell types; their appearance is determined by the dominant cell type, but they typically have irregular borders, calcification, and focal areas of necrosis
a little aggressive; rare tumor accounting for only 2-3% of germ cell tumors; peak incidence of the latter part of the second and third decade
embryonal cell carcinoma
sono appears heterogeneous and less well circumscribed; they may contain areas of incresed echogenicity resulting from calcification, hemorrhage, or fibrosis; cystic components are found in up to one third of them;
embryonal cell carcinoma
more aggressive than seminoma, often invading the tunica albuginea and distorting the testicular contour; not smooth walls
embryonal cell carcinoma
most common germ cell tumor in infants younger than two year; associated with elevated afp in 95% of infants; 1/3 can have cystic components. sonographically looks like embryonic cell tumor
yolk sac tumor
constitute approx 5-10% of primary testicular neoplasm; 1/3 metastasize, usually by lymphatic route, within 5 years; peak incidence is in infants/early childhood (immature) and then another peak in third decade (mature)
patient presents with elevated afp and hcg; in infants and children, it's the most common testicular tumor and most commonly benign; in adults it's typically malignant
sono it may show dense foci that produce acoustic shadowing; they are normally heterogeneous but have well-defined border
most common single-cell type of testicular tumor in adults; occur in slightly older patient with a peak incidence of fourth and fifth decades; rarely occur before puberty; less aggressive than other testiuclar tumors and responds well to treatment
most common tumor associated with cryptochidism tumor arises in puberty
sono they tend to be homogenous, hypoechoic masses with a smooth border; is uniform and has low level echoes without calcification or cystic components; if large tend to be heterogeneous with foci of necrosis and hemorrhage; usually unilateral and testis
is rare normally occuring later in life >60 yrs; bilateral with multiple lesions found; sono appears as a solid hypoechoic mass, although it has been reported as hyperechoic or a mixture of both
mets may originate to the testis via these 8
prostate and kidneys (most common), lung, pancreas, bladder, colon, thyroid, melanoma
most common secondary tumor of testicles; makes up 1-7% of all testicular tumors and is the most common bilaterly secondary testicular neoplasm affecting men greater than 60 years old 60-70)
non-hodgkins lymphoma
___ involvement of the testicle is the next most common secondary testicular neoplasm most often found in children with 8% of children having this disease having testicular involvement
patients present with weight loss, anorexia, and weakness; the testicle may become enlarged and the tumor may be bilateral or unilateral
sono testes may appear homogenously hypoechoic, or contain multiple focal areas of decreased echogenicity
__ may appear as a focal, well-circumscribed, anechoic mass with through transmision; increased vascularity is seen with color doppler imaging
chronic lymphocyte leukemia
means undescended testes and can't be brought into the scrotum with external manipulation
during fetal growth, the testes first appear in the __ near the kidneys; they descen into the scrotum from the inguinal canal shortly before birthor early in the neonatal period
may be located in the ab, inguinal canl, or other ectopic location such as top area of scrotum; in most cases (80%) they are in inguinal canal and is usually palpable
since the testes don't descend until late in pregnancy, cryptorchidism is more common in ___. is bilateral in __ to __% of cases; surgical treatment of an undescended testicle by freeing it from the structures and implanting it into the scrotum is known
premature babies, 10-25%, orchiopexy
the exposure of the testis to higher temp than when it is located in the scrotum can prohibit spermatogenesis and result in __. also have an increased risk of developing __ which is not reduced by orchiopexy, but it does allow the testis to be more easil
infertility; testicular cancer
__ is also more common with undescended testes
sono the y appear smaller and less echogenic than normal testis; itis usually oval with a homogenous texture; rarely the mediastinum is seen
very rare condition; unlike an undescended testicle, this cannot be manipulated into the correct path of descent
testicular ectopia
the most common site for testicular ectopia is ___
superficial inguinal pouch (other sites are perineum, femoral canal, suprapubic area, penis, diaphragm, and the other scrotal compartment)
a rare condition; causes include intrauterine testicular torsion or other forms of decreased vascular supply to the testicle in utero; bilat. is found in 0.6%-1% of patients with nonpalpable testis; patient have male xy genotype; on physical exam, the scr
found in 4% of patients with a nonpalpable mass; more common on left side, and definitive dx depends on surgical dx
unilateral anorchia (monorchia)
nonfunctioning; is a very rare disorder, with only 80 cases reported; if descend before the real one then you will have cryptorchidism; testicular duplication which is usually found in the scrotum, but also has been found in the inguinal canal or rp; is u
polyorchidism (testicular duplication)

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