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MIDS 137 > Ch 5b (scrotum pathology) > Flashcards

Ch 5b (scrotum pathology) Flashcards

1
Q

What is tubular ectasia of the rete testis?

A

-A common benign condition
-M/c bilateral + seen in men with vasectomy’s

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2
Q

What is a decrease in testicle size a possible cause of + possible indication of?

A

-Cause of infertility
-Indication of a pituitary or hypothalamus gland abnormality

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3
Q

Hypogonadotropic hypogonadism results from the absence of which hormone?

A

Absence of gonadal-stimulating pituitary hormones causing underdeveloped testicles

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4
Q

What are some causes of testicular atrophy?

A

-cryptorchidism (undescended testicles)
-missed torsion
-postsurgical procedures
-epididymo-orchitis
-trauma

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5
Q

An absence of GnRH affects the size of the testis how?

A

Causes smaller testicles

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6
Q

SF of testicular atrophy?

A

-Small/shrunken
-Heterogeneous
-Increased echogenicity due to fibrosis

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7
Q

Where do the testicles lie in fetuses?

A

In peritoneal cavity near inguinal canal

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8
Q

When do boys testes descend?

A

At birth, sometimes they descend later tho

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9
Q

What is cryptorchidism?

A

Undescended testis:
Unilateral absence of a testis in the scrotum, usually located in abdominal cavity or inguinal canal

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10
Q

Is malignancy higher in an undescended testis?

A

Yes, 48-50x higher than normal descended testis

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11
Q

Why is infertility associated with an undescended testis?

A

B/c sperm are exposed to abnormally high temperatures within the abdomen or inguinal canal

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12
Q

By what age can fertility be preserved when an undescended testis is relocated?

A

Before 2 y/o

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13
Q

Is an undescended testis associated with an increased risk of testicular torsion + inguinal hernia?

A

Yes!

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14
Q

What 4 things are associated with an undescended testis?

A

-malignancy
-infertility
-testicular torsion
-inguinal hernia

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15
Q

80% of undescended testis are located where?

A

Inguinal canal

(20% in intra-abdominal, which is from renal hilum to inguinal canal)

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16
Q

SF of cryptorchidism?

A

-oval/elongated
-well circumscribed
-hypoechoic
-homogeneous soft tissue structure
-smaller than normal descended testis

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17
Q

Testicular torsion represents what % of scrotal disease in postpuberty males?

A

20%

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18
Q

Torsion m/c occurs during what age?

A

Adolescence - b/w 12-18 y/o

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19
Q

What is torsion caused by?

A

Developed weakness of the mesenteric attachment of the spermatic cord to the testis + epi

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20
Q

The weak + faulty development with testicular torsion causes what to happen to the testis?

A

Causes them to fall forward in the scrotum + rotate freely within the tunica vaginalis

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21
Q

Twisting of the spermatic cord with torsion results in what?

A

Venous congestion - prevents venous drainage

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22
Q

What can venous drainage lead to in torsion?

A

-Arterial occlusion
-Scrotal edema
-Hemorrhage
-Infarction

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23
Q

What is the sign for detecting a spermatic cord with torsion?

A

Torsion knot / whirlpool pattern

(shows increased + decreased echogenicity at the external inguinal canal above the testis + epi)

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24
Q

What 2 things must we always use when confirming presence of arterial + venous flow in testis?

A

-Pulsed doppler
-CD

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25
Q

When surgery is performed for torsion within 6 hours after onset of pain, what is the salvage rate?

A

B/w 80-100%

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26
Q

When surgery is performed for torsion after 12 hours after onset of pain, what is the salvage rate?

A

20%

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27
Q

2 types of torsion are?

A

-Intravaginal
-Extravaginal

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28
Q

What is intravaginal torsion?

A

-When testis rotate freely in tunica vaginalis
-M/c type

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29
Q

What is extravaginal torsion?

A

-Only occurs in newborns
-When gubernaculum is not fixed + testis can freely rotate

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30
Q

Which type or torsion is m/c?

A

Intravaginal

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31
Q

Which type of torsion only occurs in newborns?

A

Extravaginal

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32
Q

What are the 4 clinical signs of testicular torsion?

A

-Sudden onset of pain
-Nausea
-Vomiting
-Low grade fever

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33
Q

After how many hours until torsion pain disappears + the testicle is dead?

A

After 24 - 48 hours

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34
Q

What are the 3 phases of torsion?

A

-Acute (within 24 hrs)
-Subacute (1 - 10 days)
-Chronic (over 10 days)

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35
Q

Can the testicle be saved if surgery is done after 24 hours?

A

No, almost never results in successful salvage of the testis

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36
Q

What is a missed torsion?

A

A missed opportunity to save the testicle before it hits the 24 hour mark

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37
Q

What does missed torsion cause?

A

Permanent infertility issues

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38
Q

What do SF in torsion depend on?

A

Duration + degree of spermatic cord rotation

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39
Q

SF of acute torsion?

A

-enlarged testis
-normal or decreased echogenicity
-enlarged epi (with torsic knot/whirlpool pattern)
-scrotal skin thickening
-reactive hydrocele
-lack of blood flow by CD or PD shows ischemia

(occurs within 1-6 hours)

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40
Q

SF of subacute torsion?

A

-enlarged testis, epi + spermatic cord with varying echogenicity
-heterogeneous testis + epi with diffuse or focal hypoechoic changes (represents necrosis, hemorrhagse + infarction)

(occurs within 24hrs - 10 days)

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41
Q

Which stage of torsion is missed torsion territory?

A

Subacute - may not be reversible now

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42
Q

SF of chronic torsion?

A

Testes:
-small + hypoechoic
-heterogeneous + fibrotic in cases of hemorrhage infarction b/c is degenerating

Epi:
-enlarged + echogenic (represents hemorrhage + necrosis)

(occurs after 10 days)

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43
Q

What is torsion-detorsion?

A

-Partial or transient (meaning only lasting for a short time) torsion occurs with spontaneous detorsion of testicular torsion

-Naturally detorts itself

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44
Q

Would torsion-detorsion be hard to image or diagnose?

A

Yes, b/c the affected structures can look normal even though the pathology is present

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45
Q

Characteristics of torsion-detorsion?

A

-Acute + intermittent sharp testicular pain with scrotal swelling
-Long asymptomatic intervals

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46
Q

SF of torsion-detorsion?

A

-Possibly enlarged testis
-Focal infarcts may or may not be present

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47
Q

How could we catch the torsion with someone experiencing torsion-detorsion?

A

Wait until the pt is feeling clinical symptoms until we do an u/s so we can catch it

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48
Q

Which pathology can cause acute scrotal pain that mimic’s testicular torsion?

A

Torsion of the appendix testis or appendix epi

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49
Q

SF of a torsed appendage?

A

Varies:
-large, circular, hyperechoic mass with central hypoechoic area
or
-enlarged, circular, heterogeneous mass adjacent to normal testis + epi

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50
Q

Is it easy to diagnose a torsed appendage?

A

No, it is hard unless we saw the appendix on a previous study

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51
Q

Is testicular rupture common?

A

No, rare

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52
Q

What causes testicular rupture?

A

When the tunica albuginea is torn by trauma

(the layer surrounding the testicle is broken cause of the trauma)

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53
Q

What 2 types of injuries/accidents is testicular rupture associated with?

A

-Athletic injuries
-Industrial/motor vehicle accidents

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54
Q

SF of testicular rupture?

A

-Abnormal contour
-Extrusion of testicle contents into scrotal sac (fluid is draining into scrotum)
-Hematocele b/w tunica vaginalis + parietalis
-Intratesticular hematoma
-Infarction

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55
Q

Which pathology accounts for 75-80% of all acute inflammatory processes in the scrotum?

A

Epididymitis (inflammation of epi)

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56
Q

What age group is m/c affected by epididymitis?

A

Men 20-30 y/o

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57
Q

What can cause epididymitis?

A

Infections:
-STI’s
-chlamydia
-gonorrhoeae
-escherichia coli + proteus mirabilis
-urinary catheters

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58
Q

Which part of the epi is affected with epididymitis?

A

Any part - the entire epi is affected in 50% of cases

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59
Q

What happens if epididymitis is left untreated?

A

-Progresses to involve the spermatic cord + testis
-Results in a spermatic cord abscess or epididymo-orchitis (inflammation of both epi + testicle)

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60
Q

Which pathology accounts for 25% of acute inflammatory processes of the scrotum?

A

Epididymo-orchitis (inflammation of both the epi + testicle)

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61
Q

What happens if acute epididymo-orchitis is left untreated?

A

Progresses to abscess, gangrene, infarct, pyocele, infertility + atrophy

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62
Q

Clinical symptoms of epididymo-orchitis?

A

-fever
-tenderness
-enlarged epi, testis + hemiscrotum

(hemiscrotum = 1 half of scrotum)

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63
Q

Is it common to have an inflamed testicle + a normal epi?

A

No, rare. M/C both are inflamed.

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64
Q

What is orchitis?

A

Inflammation of one or both testicles

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65
Q

SF of epididymo-orchitis?

A

-Hypoechoic due to edema
-Areas of hyperechogenicity
-Secondary to hemorrhage + infection
-Scrotal wall thickening
-Reactive hydrocele
-CD hypervascularity

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66
Q

Common SF’s of acute epididymitis, epididymo-orchitis + orchitis?

A

-Enlargement
-Variable echogenicity of affected structure

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67
Q

What is the hallmark sign that indicates scrotal inflammatory disease?

A

CD hypervascularity of affected structures

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68
Q

SF + result of severe untreated epididymo-orchitis?

A

Scrotal/testicular/epi abscess! Appears as:

-Focal hypoechoic or mixed area
-Irregular walls
-Hypervascular margins
-Scrotal wall thickening
-Reactive hydrocele

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69
Q

What is a reactive hydrocele?

A

Type of non-communicating hydrocele that results from inflammation in scrotum due to trauma, infection or testicular torsion

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70
Q

What is a hydrocele?

A

Abnormal accumulation of serous fluid in potential space b/w visceral + parietal layers of the tunica vaginalis (which surrounds the testis)

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71
Q

What is the m/c cause of painless scrotal swelling?

A

Hydroceles

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72
Q

Difference b/w congenital + acquired hydroceles?

A

Congenital: is fluid communicating b/w abdominal cavity + scrotum

Acquired: is fluid secondary to infection or trauma

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73
Q

What is the classic SF of a hydrocele?

A

Anechoic simple fluid collection surrounding the testis

74
Q

Should we be concerned if we see a hydrocele?

A

If it is small it’s fine, unless it grows to become larger

75
Q

What could chronic hydroceles contain?

A

Calcifications (produces shadowing)

76
Q

What are calcifications in a chronic hydrocele called?

A

Scrotoliths or scrotal pearls

77
Q

SF of scrotoliths?

A

-Multiple or singular
-Fills potential space b/w layers of tunica vaginalis testis

78
Q

How are scrotoliths m/c found?

A

Incidentally

79
Q

What are the 2 m/c epi lesions?

A

-Spermatoceles
-Epi cysts

80
Q

Symptoms of spermatoceles + epi cysts?

A

-Asymptomatic
or
-Painless scrotal masses

81
Q

Size of spermatoceles + epi cysts?

A

Varies, from 0.2 - 9 cm

82
Q

Cause of spermatoceles + epi cysts?

A

Dilatation of epi tubules - whether secondary to vasectomy, scrotal surgery, trauma or epididymitis

83
Q

Which part of epi is m/c location for spermatoceles/epi cysts?

A

Epi head

84
Q

What do spermatoceles contain?

A

-Nonviable spermatozoa
-Cellular debris
-Lymphoceles

85
Q

What do epi cysts contain?

A

Lined wtih epithelium + contain ONLY serous fluid

86
Q

Are spermatoceles + epi cysts hard to distinguish on u/s?

A

Yes, b/c they look almost identical on u/s

87
Q

SF of epi cysts?

A

-Anechoic
-Thin walled
-M/C in head

88
Q

SF of spermatoceles?

A

-Low level echoes
-Thin walled
-Hypoechoic

89
Q

Could spermatoceles + epi cysts contain septations?

A

Yes, they might. Usually unilocular as well.

90
Q

What is tubular ectasia of the rete testis?

A

Dilatation of the efferent ductules

91
Q

What age would we m/c see tubular ectasia of the rete testis?

A

Men over 50 y/o

92
Q

SF of tubular ectasia of the rete testis?

A

-M/C bilateral
-Multiple tiny cystic tubules located within or adjacent to the mediastinum testis

93
Q

Which procedure m/c causes tubular ectasia of the rete testis?

A

Post vasectomy

94
Q

How is a varicocele formed?

A

By dilatation of the pampiniform plexus veins to a width greater than 3 mm

95
Q

Which pathology is the reason why we assess scrotal veins with a valsalva?

A

Varicoceles

96
Q

Where would dilated + tortuous veins be located on the testis?

A

Superior + posterior to the testis

97
Q

What causes dilated + tortuous veins in testicles?

A

From incomplete valves in the testicular vein

98
Q

2 types of varicoceles?

A

-Primary (idiopathic)
-Secondary

99
Q

Lightbulbs for primary varicoceles?

A

-M/C left sided (due to length + pathway of left testicular vein)
-M/C in men aged 15-25

100
Q

Cause of secondary varicoceles?

A

Pressure on testicular vein due to compression

(ex. nutcracker syndrome, RCC, cirrhosis, etc)

101
Q

What pathology is the m/c correctable cause of infertility?

A

Varicoceles

(occurs in 21-39% of men at infertility clinics)

102
Q

Measurement of varicocele?

A

Over 3mm

103
Q

Varicoceles are m/c seen after which procedure?

A

Post vasectomy

104
Q

Are primary or secondary varicoceles m/c?

A

Primary

105
Q

Are varicoceles m/c on right or left testis?

A

Left - b/c has longer path to go

106
Q

Do we perform a valsalva on every scrotum scan?

A

Yes!

107
Q

Generally what causes varicoceles?

A

If valves don’t close properly + flow goes backwards

108
Q

Clinical signs of varicoceles?

A

-Scrotal mass
-Infertility
-Abnormally warm scrotum

109
Q

SF of varicoceles?

A

-Multiple hypoechoic, tortuous, tubular structures
-Measure over 3mm when doing valsalva (must be in supine)

110
Q

What are scrotal hernias?

A

Inguinal hernias that descend into the scrotum

111
Q

What are inguinal hernias?

A

Protrusion of peritoneal contents (bowel or omentum/fat) through the processus vaginalis (canal that connects the peritoneal to tunica vaginalis)

112
Q

Do we need u/s to diagnose a scrotal hernia?

A

No, a clinical exam can diagnose it. Pt will feel bowel slipping down into scrotal sac.

113
Q

Clinical symptoms of scrotal hernias?

A

-Scrotal mass (constant or intermittent)
-Abdominal pain (very painful)
-Blood in stool

(others may have a hard, nonreducible mass that can’t distinguish from a primary scrotal mass)

114
Q

How to treat scrotal hernia?

A

May need to surgically remove the bowel, pay close attention to these pt’s

115
Q

SF of bowel hernia?

A

-Fluid/air filled loops of bowel will peristalse in scrotum or inguinal canal
-Herniated bowel can become strangulated + no longer peristalse, becoming ischemic

(very painful, can lose segment of bowel)

116
Q

SF of omentum/fat hernia?

A

Diffusely echogenic paratesticular mass

117
Q

Can scrotal hematomas be intratesticular + extratesticular?

A

Yes! Extratesticular can involve the scrotal wall, tunica vaginalis + the epi.

118
Q

Cause of scrotal hematomas?

A

Trauma - injury to scrotum

119
Q

Are scrotal hematomas m/c singular or multiple?

A

Singular

120
Q

3 physical symptoms of scrotal hematomas?

A

-Swollen
-Painful
-Can be discolored

121
Q

SF of scrotal hematomas?

A

Varies, but typically has avascular areas with mixed echogenicities

122
Q

What is a hematocele?

A

Accumulation of blood b/w visceral + parietal layers of tunica vaginalis

123
Q

What 4 things can causes a hematocele?

A

-Trauma
-Surgery
-Tumor
-Torsion

124
Q

SF of a hematocele?

A

Complex, heterogeneous collection within tunica vaginalis

(similar to hematoma, except hematoceles have fresher blood appearing more anechoic)

125
Q

What is a pyocele?

A

Pus in the space b/w the parietal + visceral layers of the tunica vaginalis

126
Q

Physical signs of a pyocele?

A

Mimic’s signs of an infection + inflammation, along with hemiscrotal pain + swelling

127
Q

Lightbulb for pyocele?

A

Infection - think fever (pt will be sick)

128
Q

SF of a pyocele?

A

-Thick hemiscrotal wall
-Echogenic fluid with septations
-Can have focal mural calcifications

129
Q

How can we differentiate b/w a pyocele + a hematocele?

A

Must use clinical signs to tell - pyocele the pt will be sick

130
Q

What is granulomatous disease?

A

Disease of testis + epi due to retrograde spread of TB from prostate, seminal vesicles + kidneys OR from hematogenous spread (meaning from the bloodstream)

131
Q

Lightbulb for granulomatous disease?

A

Spread of TB

132
Q

What age m/c gets granulomatous disease?

A

Men aged 20-50

133
Q

What do pt’s present with when having granulomatous disease?

A

Scrotal swelling, often epididymitis or epididymo-orchitis

134
Q

SF of granulomatous disease?

A

-Either diffusely enlarged OR nodular + enlarged
-Hypervascular
-Scrotal wall thickening
-Hydrocele
-Scrotal abscess
-Intrascrotal, extratesticular calcifications

135
Q

Are tunica albuginea cysts common?

A

Nope

136
Q

How do tunica albuginea cysts clinically present?

A

Painless scrotal lump

137
Q

Which decade are tunica albuginea cysts m/c seen?

A

B/w 5-6 decades

138
Q

SF of tunica albuginea cysts?

A

-well circumscribed
-anechoic
-measures 2-5mm
-located along tunica albuginea (shell of testicle)

139
Q

Would a pt know if they have an intratesticular cyst?

A

No, asymptomatic + an incidental finding

140
Q

SF of an intratesticular cysts?

A

-Anechoic
-Smooth walls
-Posterior enhancement
-Measures b/w 2-20mm

141
Q

What is a sperm granuloma?

A

Ball of dead sperm following trauma, vasectomy or infection. Occurs if sperm is floating around.

(sperm may enter surrounding tissues + produce necrosis, resulting in granulomatous formation)

142
Q

Sperm granulomas occur in what % of pt’s post vasectomy?

A

40%

143
Q

SF of a sperm granuloma?

A

-Well defined
-Solid
-Hypoechoic
-Heterogeneous mass
-Located anywhere in ductal system
-M/C in epi tail

144
Q

M/c part of epi where sperm granulomas occur?

A

Epi tail

145
Q

M/c location for benign adenomatoid tumors?

A

Epi tail

146
Q

Are benign adenomatoid tumors common?

A

Represent 30% of extratesticular benign lesions

147
Q

Clinical finding of a benign adenomatoid tumor?

A

Painless mass or incidental finding

148
Q

What age is m/c to find a benign adenomatoid tumor?

A

B/w ages 20-50

149
Q

SF of benign adenomatoid tumors?

A

-Well circumscribed solid mass
-Variable echgenicity

(indistinguishable from other benign tumors)

150
Q

Which pathology is the 2nd m/c primary benign neoplasm of the epi?

A

Leiomyoma / fibroid

151
Q

M/c location for a leiomyoma?

A

Epi tail

152
Q

SF of a leiomyoma?

A

-M/c unilateral
-M/c epi tail
-Well circumscribed
-Homogeneous
-Solid mass with variable echogenicity

(indistinguishable from other benign tumors)

153
Q

Another name for leydig cell tumors?

A

Gonadal stromal tumors

154
Q

M/c neoplasm of the testis?

A

Leydig cell tumors (a non-germ cell neoplasm)

155
Q

Are leydig cell tumors benign or malignant?

A

In the benign group, however up to 15% are malignant

156
Q

M/c age to have a leydig cell tumor?

A

B/w 20-50

157
Q

Clinical signs of leydig cell tumors?

A

-Endocrine imbalance
-Impotence
-Decreased libido
-Gynecomastia

158
Q

SF of benign leydig cell tumors?

A

-Small, less than 1cm
-Well circumscribes masses

(small hypoechoic lesion in slide)

159
Q

SF of malignant leydig cell tumors?

A

-Larger, over 5cm
-Less well defined borders

160
Q

Can u/s determine if a leydig cell tumor is benign or malignant?

A

Nope, need biopsy

161
Q

M/c malignant tumor of epi + spermatic cord?

A

Rhabdomyosarcomas

162
Q

Which age group m/c gets rhabdomyosarcomas?

A

Children + adolescents

163
Q

SF of a rhabdomyosarcoma?

A

-Circumscribed
-Unilateral
-Hypoechoic lesion w/o a capsule
-Measures 1-2cm
-Poorly defined borders

164
Q

Why do cancerous masses have no capsule?

A

B/c they are trying to invade the body. If mass appears large + w/o clear borders, think malignancy.

165
Q

List other malignant neoplasms that have similar appearances?

A

-Leiomyosarcoma
-Liposarcoma
-Fibrosarcoma
-Mesenchymoma

166
Q

What is an epidermoid cyst?

A

Benign teratoma of testicle

(think hair, teeth, skin, nails, etc like the ovaries)

167
Q

Are epidermoid cysts common?

A

Nope, 1-2% of all testicular neoplasms

168
Q

M/c age to get an epidermoid cyst?

A

B/w 20-40

169
Q

Clinical finding of an epidermoid cyst?

A

Painless scrotal mass + asymptomatic

170
Q

SF of epidermoid cysts?

A

-Target/bulls eye/rings of tree appearance
-Sharply circumscribed + encapsulated mass
-Variable echogenicity

171
Q

Another name for testicular microlithiasis (TM)?

A

Intratubular testicular calcification

172
Q

What is testicular microlithiasis?

A

Rare calcifications in tube

173
Q

SF of testicular microlithiasis?

A

-M/c bilateral
-Multiple calcifications (at least 5 foci m/c seen)
-Measure 1-3mm
-Hyperechoic foci w/o shadowing through testis

174
Q

What clinical findings do most pt’s with testicular cancer present with?

A

-Painless unilateral scrotal mass
-Hardness of testis
-Diffuse testicular enlargement

175
Q

Is testicular cancer common?

A

No, only accounts for 1-2% of all malignant neoplasms in men

176
Q

What does testicular carcinoma mimic, making it hard to diagnose?

A

Epididymo-orchitis (b/c cancers can cause inflammation)

177
Q

What 2 pathologies can cause orchitis secondary to obstruction of seminiferous tubules?

A

Seminomas + testicular lymphomas

178
Q

Pt’s with which pathology have a 2.5-8x increased risk for developing testicular cancer?

A

Cryptorchidism (undescended testis)

179
Q

Can u/s distinguish b/w different types of malignancies?

A

Nope, need a biopsy

180
Q

List the names of the different types of testicular cancer?

A

-Seminoma
-Embryonal cell carcinoma
-Choriocarcinoma
-Teratoma
-Yolk sac tumor
-Mixed neoplasms
-Metastases to the testis
-Lymphoma
-Leukemia

181
Q

SF of testicular cancer?

A

Hypoechoic!!!

-If tumor is confined to the tunica albuginea than the testis keeps oval shape
-If tumor invades the testis + epi than it creates an irregular + lumpy contour of the testis

MIDS 137 (14 decks)

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