Things i think i should know 6-8 Flashcards
(97 cards)
1
Q
Define infertile
A
• A couple who has regular unprotected intercourse for a period of 12 months without a pregnancy is considered to be infertile.
2
Q
What is primary and secondary subfertility?
A
- Primary subfertility means that a pregnancy has never been achieved before.
- Secondary subfertility implies a previous pregnancy, though it may have ended in miscarriage or ectopic loss
3
Q
What are the main risks of OHSS?
A
- ovarian hyperstimulation syndrome (OHSS)
- ectopic pregnancy
- multiple pregnancies.
4
Q
How is ultrasound used in ART?
A
- track the ovarian response to the ovarian stimulation protocol
- guide the oocyte retrieval
- occasionally to observe the embryo transfer catheter entering the cavity and releasing the transfer medium with the embryo.
- When pregnancy occurs an ultrasound is performed four to six weeks after oocyte retrieval to confirm the pregnancy location and to determine the number of viable embryos.
5
Q
What does The proximal part of the mesonephric duct become?
A
highly convoluted to form the epididymis.
6
Q
What does The remainder of the mesonephric duct form?
A
the ductus deferens and ejaculatory duct
7
Q
A lateral outgrowth from the caudal end of each mesonephric duct gives rise to?
A
the seminal vesicle, a gland that produces a secretion that nourishes the sperm
8
Q
What glands are derived from the uerthra?
A
- Other glands important in the male genital system are derived from the urethra
- prostate arises from the prostatic part of the urethra
- bulbourethral glands develop from paired outgrowths from the spongy part of the urethra.
- secretions of these glands contribute to the semen.
9
Q
What is the function of the gubernaculum?
A
- The gubernaculum forms a path through the anterior abdominal wall for the processus vaginalis to follow during formation of the inguinal canal.
- The gubernaculum anchors the testis to the scrotum and guides its descent into the scrotum.
10
Q
When are both testes usually present in the scrotum?
A
32 weeks
11
Q
What can occur if there is a persistant processus vaginalis?
A
hydrocele
congenital hernia
12
Q
What is associated with congenital hernias?
A
• undescended testes.
• ectopic testes
in females with androgen insensitivity syndrome
13
Q
What is cryptorchidism?
A
undescended testes
14
Q
What happens if testes remain outside the scrotum?
A
- If both testes remain within or just outside the abdominal cavity, they fail to mature and sterility is common.
- If uncorrected, these men have a significantly higher risk of developing germ cell tumors
15
Q
What is the most common site of undescended testes?
A
Inguinal canal
16
Q
What is an ectopic testis?
A
• After traversing the inguinal canal, the testes may deviate from its usual path of descent and lodge in various abnormal locations
o Interstitial (external to aponeurosis of external oblique muscle)
o In the proximal part of the medial thigh
o Dorsal to the penis
o On the opposite side (crossed ectopia)
17
Q
Where is the fluid of a hydrocele contained?
A
Between the layers of the tunica vaginalis
18
Q
What may cause a hydrocele?
A
inflammation of the tunica vaginalis and injury/inflammation of the epididymis.
19
Q
What does the spermatic cord consist of?
A
• contains all the elements entering or leaving the scrotum
o vas deferens
o the testicular, deferential and cremasteric arteries
o the pampiniform plexus of veins
o the lymphatic vessels
o nerves
o the ligament of Cloquet (vestige of the processus vaginalis)
20
Q
How can spectral Doppler be used in assessing the testis?
A
• suspected epididymitis
o spectral Doppler of the cremasteric or deferential arteries showing increased blood flow as compared to the contralateral side
o often the only ultrasound evidence of mild or partially treated epididymitis.
• ultrasound sign of impending infarction
o reduced or reverse flow in diastole in the spectral trace of an intratesticular artery compared to the contralateral side.
• Any varicose veins of the pampiniform plexus can also be assessed.
21
Q
Whats another name for the epididymal head?
A
globus major
22
Q
What are the common congenital abnormalities of the male reproductive system?
A
- cryptorchidism or ‘undescended testes’
- ectopic testes
- congenital inguinal hernia
- hydrocele
23
Q
What is agenesis of the vas deferens associated with?
A
• Agenesis of the vas deferens is commonly associated with renal agenesis
24
Q
What does a Persistence of the middle portion of the processus vaginalis create?
A
encysted hydrocele
25
What does Persistence of the upper portion of the processus vaginalis result in?
inguinal hernia
26
What is the typical appearance of an epidermoid cyst?
Whorled
27
Where are intratesticular cysts often found?
• Often located next to mediastinum testis
28
What causes tubular ectasia of the rete testes?
* Obstruction of efferent tubules or epididymis
* Inflammation, trauma or surgery (vasectomy) causation
* May be congenital
29
How do epidermoid cysts appear?
* well-defined, round to ovoid, avascular masses and may be multiple or bilateral.
* characteristic whorled or laminated appearance
* may not be pathognomonic because it is rarely seen with teratoma
* Another typical appearance of an epidermoid cyst is a well-defined hypoechoic mass with an echogenic capsule that may be calcified
* may be central calcification, giving a “bull’s eye” or target appearance
* may also have the nonspecific appearance of a hypoechoic mass with or without calcifications and may resemble germ cell tumors
* Avascularity is clue to the diagnosis
* appearance is characteristic, it is not pathognomonic, and histologic confirmation should be obtained
30
Comment on abscesses in the testes
* usually a complication of epdidymo-orchitis
* may also result from undiagnosed torsion, infarct, trauma and gangrenous or infected or tumour pyogenic orchitis
* sonography demonstrates an irregularly marginated, hypoechoic or mixed echogenic intratesticular mass
* no diagnostic sonographic features but can often be distinguished from tumors on the basis of clinical symptoms and short-term interval change.
31
What does a testes infarction look like?
depends on the age of infarction
• typical segmental infarct is seen as a focal, wedge-shaped or round hypoechoic mass, with approximately 80% occurring in the upper pole
• focal hypoechoic mass may not be distinguishable from a neoplasm on the basis of its gray-scale sonographic appearance
• should have reduced or absent blood flow
• early sonographic appearance may be difficult to distinguish from a testicular neoplasm, but infarcts decrease substantially in size, whereas tumors characteristically enlarge with time
32
When might you see an adrenal rest?
in setting of congenital adrenal hyperplasia (CAH) or cushing syndrome
33
What are some associations of microlithiasis?
cryptorchidism, Klinefelter syndrome, Down syndrome, pulmonary alveolar microlithiasis, AIDS, neurofibromatosis, previous radiotherapy, and subfertility
34
How do epidydimal cysts present?
painless testicular swelling
| palpable lump
35
How are epidydimal cysts formed?
result from blockage of epididymal ductules with proximal dilation.
36
How do epididymal cysts appear on ultrasound?
anechoic
well circumscribed lesion
no or fine echoes
sometimes with loculations and septations.
Rarely, spermatoceles will be hyperechoic
37
What are sperm granulomas?
found within the epididymis and vas deferens after vasectomy.
• This inflammatory reaction can be confused with epididymitis and antibiotic treatment will have no effect
• common sites are around the cut ends of the vas and the junction between the epididymal tail and the vas.
• firm nodules that can be quite painful
• can be small or large
• can vary in size over time
• Inflammatory hyperaemia may be seen around them
• variety of appearances on ultrasound.
38
What is most common cause of acute scrotal pain in postpubertal men?
Epididymitis. peak incidence 40-50yrs
39
How di patients with epididymitis present?
* patients present with the insidious onset of pain which increases over 1 or 2 days.
* Fever, dysuria, and urethral discharge may also be present
40
How does acute epididymitis appear on ultrasound?
* enlargement of the epididymis,
* echogenicity usually decreased
* echotexture is often coarse and heterogeneous
* likely secondary to edema, hemorrhage, or both.
* Color flow Doppler increased blood flow in the epididymis or testis, or both, compared with the asymptomatic side
* Reactive hydrocele formation is common
* associated scrotal wall thickening may be seen
41
What is epididymo orchitis?
* Direct extension of epididymal inflammation to the testis
* occurs in up to 20% of patients with acute epididymitis
* Isolated orchitis may also occur
42
What does orchitis look like on ultrasound?
• Testicular involvement may be focal or diffuse.
• focal orchitis produces a hypoechoic area adjacent to an enlarged portion of the epididymis.
• Color Doppler shows increased flow in the hypoechoic area of the testis
intratesticular abscess and pyocele may form if left untreated
in comparison, one testis may appear large and hypoechoic
43
Is the striated appearance indicative of orchitis?
• striated appearance of the testis is nonspecific and may also be seen after ischemia from torsion or during a hernia repair
44
Why can colour Doppler define an abscess more clearly?
The lack of vascularity within
45
What are hematoceles?
associated with trauma
| often isoechoic to the testis in the acute phase
46
what are varicoceles?
dilated (greater than 2-3mm)
tortuous
elongated veins of the pampiniform plexus
occur in approximately 15% of the male population
40% of men seeking fertility treatment
47
What is the classic clinical presentation of varicocele?
painless scrotal swelling
bag of worms
sometimes aching
48
What is a primary varicocele?
occurs on the left
20% bilateral
due to absent or valvular incompetent testicular vein
49
What is a secondary varicocele?
caused by increased pressure in the testicular vein due to
extrinsic compression (abdominal or retroperitoneal mass),
obstruction (renal vein thrombus),
splenorenal shunting and,
rarely, nutcracker syndrome
50
What is nutcracker syndrome?
It occurs when arteries, most often the abdomen's aorta and superior mesenteric artery, squeeze the left renal (kidney) vein.
51
How do varicoceles appear on ultrasound?
increased flow and distension upon Valsalva.
the appearance of secondary varicoceles will not be affected as such.
Grey scale images will show multiple, serpiginous anechoic structures
if large, slow blood flow can be identified on b-mode imaging that may not be detectable using colour Doppler.
Thrombus and phleboliths may form within the varicocele causing acute pain
52
What are the four differentials for the acute scrotum?
* Torsion
* Trauma
* Tumor
* “testiculitis” (epididymo-orchitis).
53
What does acute scrotum mean?
clinical conditions characterised by the sudden onset of pain, swelling and reddening of the scrotum.
54
What should ultrasound aim for in the setting of trauma?
to distinguish between testicular rupture, fracture or haematoma
• Surgery is required within 72 hours to save a ruptured testis
• Conversely, a fractured testis or haematoma does not require surgery if the tunica albuginea has not been interrupted
55
How does trauma appear on ultrasound?
* break in the tunica albuginea
* testicular contour irregularity
* hematoma
* poorly defined borders of the testicle
* testicular and scrotal wall thickening
56
How does a testicular fracture appear on ultrasound?
irregular linear hypoechoic band and a smooth well defined testicular outline. (It is important not to mistake the prominent vessel for a cleft created by a contusion)
57
How does a testicular rupture appear on ultrasound?
disruption of the smooth walls of the tunica albuginea and a resultant haematocele
58
Why is it important to assess blood flow in testicular rupture?
a partial testicular salvage may be possible.
59
What can the presence of hematoceles tell you about trauma?
* large hematocele is present, a testicular rupture should be suspected
* small hematocele is present, there is little risk of rupture and surgical exploration should not be considered.
60
How do intratesticular hematomas appear?
* appear as hyperechoic collections within the testicle
* become complex and/or cystic over time
* characteristically avascular
* If there is flow within a suspected hematoma, the possibility of an actively haemorrhaging hematoma or a neoplasm should be suspected.
61
What are complications of epididymoorchitis?
```
o Orchitis
o testicular infarct
o scrotal abscess
o chronic epididymitis
o testicular atrophy
o infertility
```
62
How does acute epididymitis appear on ultrasound?
epididymis will become enlarged and hypoechoic
associated haemorrhage and microabscess formation may be seen resulting in the appearances becoming more complex and heterogeneous.
o Scrotal wall thickening and secondary hydrocele formation are common.
o Further spread of the infection can result in pyocele and abscess formation
63
How does a pyocele appear on ultrasound?
multiple septations and low level echoes within the fluid surrounding the testis
64
How does chronic epididymitis appear?
o epididymis is usually enlarged and hyperechoic.
o Focal areas of fibrosis can be quite painful and these feel nodular to palpation.
o This palpation is an essential part of the testicular ultrasound.
o A hard bulky tail of the epididymis is a strong marker for chronic scarring post epididymitis
65
Why is colour Doppler important in the setting of epididymitis?
• Unless there is development of a sperm granuloma, the resultant focal hyperaemia in the distended epididymis may be the only diagnostic ultrasound feature.
66
What is orchitis?
* inflammation of the testis.
* Isolated orchitis is uncommon
* usually the result of a virus, for example, mumps.
* may be the initial manifestation of the virus.
* Atrophy of the affected testis can be a sequelae of severe inflammation.
* Orchitis usually occurs secondary to epididymitis
* can also be seen following trauma
* Approximately 33% of cases of epididymitis progress to involve the testicle, either diffusely or focally
67
What is the ultrasound appearance of orchitis?
* Grey scale findings are non specific
* testis may become enlarged and hypoechoic
* may demonstrate diffuse increase in vascularity
* Indirect signs of inflammation can be seen such as a reactive hydrocele or a pyocele with associated scrotal wall thickening
68
What is bell clapper deformity?
Where the tunica vaginalis connects high on the spermatic cord allowing torsion
69
How do the testes appear initially in torsion?
Normal apart from colour flow
70
What is a spectral sign of early torsion?
reverse flow end diastolic flow
71
With time how does the testes appear during torsion?
increasingly more heterogeneous
72
What is the b mode appearance of torsion after 24 hrs?
the testis will become hypoechoic on ultrasound
• After 24 hours, vascular congestion, haemorrhage and infarction will cause the testis to become quite heterogeneous
• epididymis will also increase in size and be hypoechoic
• the adjacent scrotal wall will also be thickened
• reactive hydrocele can also be present
• The spermatic cord will also increase in size and become hyperechoic.
73
How is colour used in torsion assessment?
```
essential
optimised
do both sides
use spectral
ensure intratesticular artery
```
74
Why is torsion assessment hard in peads?
low flow
small size
movement
75
What suggests torsion detorsion?
• Sudden onset of pain with high physical activity then diminishment of pain with the ultrasound appearances of epididymitis and/or orchitis, is highly suggestive of torsion/detorsion.
76
Comment on scrotal malignancy
Malignancy in the scrotum, but outside the testis, is very rare
• majority of extratesticular tumours of the scrotum are benign and originate in the spermatic cord
• Lipomas are the most frequent benign lesions
• sarcomas the most frequent malignant ones.
• Rhabdomyosarcoma affects infants, young boys and adolescents
77
What are the benign entities that should be considered when differentiating a potential malginancy?
granulomas, focal orchitis, infarcts and haematomas.
78
How should you extend the exam if a mass is found?
paraaortic nodes for disseminated disease
79
B mode appearance of testicular malignancy
* Most testicular tumours are hypoechoic
* can also display areas of mixed echogenicity due to calcification, haemorrhage, necrosis and fatty change
* borders can be either smooth or irregular
* larger tumours destroying the entire testicular parenchyma.
* a solitary hypoechoic lesion would be typical of a seminoma, the most common intratesticular tumour
80
What are the most common testicular tumours?
* 95 percent of testicular tumours arise from germ cells, and almost all of these are malignant
* Seminomas are the most common form of germ cell tumours and occur predominantly in the third and fourth decade.
* Non seminomatous germ cell tumours include embryonal cell carcinomas, teratomas and choriocarcinomas
81
What is seminoma associated with?
• associated with cryptorchid testes and atrophic testes
82
Whats the demographic for non seminatomas germ cell tumours (NSGCT)
younger people
| 2 3 decade
83
What are the second most common type of testicular tumour?
Stromal cell tumours
84
How might a man with a stromal cell tumour present?
have gynecomastia because of androgen secretion
85
What colour appearance is indicative of a leydig cell tumour?
Lots of peripheral vasculairty
86
In the setting of malignancy why is it important to include a comparison shot?
In rare settings, malignancy will distribute diffusely through the testis, producing a homogeneous echotexture which only is evident when compared to the other side.
87
How can colour doppler help in assessing tumours?
* can help distinguish haematomas and testicular infarcts from tumours
* has a limited role in assessing malignant from benign tumours
* because of the overlap in appearances
* If the vessels are arranged in a more irregular pattern than normal, there would be a higher suspicion for malignancy.
88
How can mets be diagnosed in the testes?
* hypoechoic mass
* may be single or multiple
* can be diagnosed with the help of the clinical history.
* Primary sites include lung, kidneys, prostate, bladder, stomach, colon and melanoma.
* Most are clinically silent and are found at autopsy
89
WHat is the most common testicular met?
Lymphoma
• most common testicular tumor in men older than 60 years, where it can account for up to 50% of intratesticular masses
• Leukemia is the second most common metastatic testicular neoplasm
90
How can tumour markers help in assessing tumours?
* α-fetoprotein
* human chorionic gonadotropin
* less so, lactate dehydrogenase.
* α-Fetoprotein is produced by the fetal liver, gastrointestinal tract, and yolk sac and is elevated in yolk sac tumors or mixed germ cell tumors containing yolk sac elements.
* Human chorionic gonadotropin is a glycoprotein produced by syncytiotrophoblasts of the developing placenta. It is elevated in tumors containing syncytiotrophoblasts, including choriocarcinoma and seminoma.
* Lactate dehydrogenase, although not specific, correlates with bulk of disease and is used in staging
91
What are the four zones of the prostate?
o the peripheral zone
o the central zone
o the transition zone
o the periurethral zone
92
Where in the prostate does BPH originate?
* BPH originates exclusively from the inner gland
* 95 percent arises in the transition zone
* only five percent from the periurethral glands or tissue.
93
What is the normal size f the prostate?
• normal values from 20-33 cc
94
How does BPH obstruct the bladder?
• produces bladder outlet obstruction by two mechanisms
o first by changes to the smooth muscle tone in the bladder neck and prostatic capsule
o the other is actual mechanical obstruction caused by enlargement of the periurethral area of the gland.
o The latter results from an increase in muscle tension causing an increase in resistance to urinary outflow.
95
What zone does prostate cancer usually arise in?
• Seventy percent of the adenocarcinomas arise in the true glandular tissue in the peripheral zone
96
Why is PSa important in assessing lesions?
When assessing lesions, the PSA value needs to be taken into account. The larger the lesion and the higher the PSA, the more likely it is that a malignancy is the cause.
97
How useful is colour in detecting prostate cancer?
Approximately 85 percent of prostate cancers will be hyperaemic
