1. Lecture 1 superficial structures SCROTUM
Holdorf
Lecture 1 superficial structures SCROTUM

2. SCROTUM
Testicular abscess
Scrotal calcifications
Normal anatomy
Testicular infarct
Malignant testicular tumors
Hydrocele
Varicocele
Seminoma
Scrotal hernia
Pre-pubertal testicular tumors
Extratesticular tumors
Spermatoceles (Epididymal cysts)
Teratomas
Laboratory values
The acute scrotum
Choriocarcinoma
Epididymitis
Mixed germ cell tumors
Testicular torsion
Testicular Metastases
Cryptorchidism
Testicular cysts
Epidermoid cysts

3. SCROTUM OUTLINE Normal Anatomy
The normal testis has a homogeneous medium-level echo texture.
The testicle is surrounded by a fibrous capsule, the tunica albuginea. Multiple septations (septula) arise from the tunica albuginea to form the mediastinum testis, which is sonographically seen as an echogenic linear band extending longitudinally within the testis.
The septula forms wedge-shaped compartments that contain the seminiferous tubules. The seminiferous tubules converge to form the tubuli recti. The tubuli recti enter the mediastinum testis forming a network of channels called the rete testis. The efferent ductules carry the seminal fluid from the rete testes to the epididymis.

4. Normal Scrotal Cartoon

5. Normal Scrotal Ultrasound e epididymis head, T tail of epididymus, Arrows- tunica albuginea

6. Normal Scrotal Ultrasound mediastinum

7. Mediastinum testis

8. The epididymis is composed of a head, body, and tail
The epididymis is composed of a head, body, and tail. Its position is parallel to the testicle. The head of the epididymis (globus major) is located adjacent to the superior pole of the testis, and is the largest part of the epididymis. This is where the efferent ductules converge to form a single convoluted duct (ductus epididymis). The tail of the epididymis (globus minor) forms an acute angle and courses cephlad as the vas deferens (also known as the ductus deferens), which carries sperm from the epididymis in anticipation of ejaculation.

9. Epididymis cartoon

10. Epididymis Ultrasound

11. Sonographically, the epididymis is normally isoechogenic, or slightly hyperechoic than the testis.
The appendix testis, a remnant of the Mullerian duct, is a small ovoid structure located beneath the head of the epididymis.
The appendix epididymis, representing a detached efferent duct, is a small stalk projecting off the epididymis.
The dartos is a layer of muscle fibers, lying beneath the scrotal skin and dividing the scrotum into two chambers. The division of the two scrotal chambers is called the scrotal raphe.

12. The Tunica Vaginalis is a saccular extension of the peritoneum into the scrotal chambers. The inner or visceral layer of the tunica Vaginalis covers the testis and epididymis. The outer or parietal layer of the tunica Vaginalis, lines the scrotal chamber.

13. Tunica vaginalis Cartoon

14. Testicular blood flow is supplied by the:
Deferential artery
Cremasteric (external spermatic) artery
Testicular artery

15. The testicular artery divides into capsular and centripetal (intratesticular) branches. The centripetal arteries course along the septula converging on the mediastinum testis.
 The spermatic Cord consist of
Vas deferens
Cremasteric, deferential, testicular arteries
Pampiniform plexus of veins
Lymphatics
Nerves

16. Spermatic Cord cartoon

17. Spermatic cord ultrasound

18. Scrotum Part II Abnormal
GERM CELLS:
A germ cell is any biological cell that gives rise to the gametes of an organism that reproduces sexually.
A germ cell tumor is a neoplasm derived from germ cells.

19. Malignant Testicular tumors
Most Extratesticular masses are benign, but the majority of intratesticular lesions are malignant.
Most malignant testicular neoplasms are hypoechoic compared to the normal testicular parenchyma. All intratesticular masses should be considered potentially malignant until proven otherwise.
Testicular neoplasms are the most common tumor in men 15 to 35 years of age.
Germ cell tumors account for 95% of testicular tumors and include:
Seminomas
Teratomas
Choriocarcinomas
Mixed tumors

20. Seminoma
Most common germ cell tumor in adults. Seminomas are radiosensitive and chemosensitive, resulting in the most favorable prognosis of all testicular tumors.
There is an increased risk of developing a Seminoma in an undescended testis and the Contralateral normally located testis, even after orchiopexy (the surgery to move the undescended testicle into the scrotum).
Seminoma spreads initially to draining lymph nodes in the retroperitoneum. When an intratesticular mass is discovered, the paraaortic region should be evaluated for lymph nodes.

21. Seminoma

22. Seminoma

23. Teratoma

24. Undescended testicle cartoon

25. Undescended testicle ultrasound

26. Prepubertal testicular tumors
The most common prepubertal testicular tumor is the yolk sac tumor (endoermal sinus tumor). This is a germ cell tumor. Increased level of alpha-fetoprotein is seen with yolk sac tumors.
The leydig cell tumor is the most common Gonadal stromal (non-germ cell) tumor in children and adults. They occur most frequently in boys aged 4-5 years of age. They are usually benign and produce testosterone leading to precocious puberty.

27. Yolk Sac tumor(endodermal sinus tumor)

28. Leydig Cell tumor

29. Consists of different germinal layers
Teratomas
Consists of different germinal layers
endoderm: One of the three primary germ cell layers in the very early embryo
mesoderm: Same as above
ectoderm: Same as above

30. Teratoma

31. Teratomas are the second most common testicular tumor in children, and are usually benign.
Teratomas in adults are usually malignant. They sonographically appear as well-defined masses containing cystic and solid components. Dense echogenic foci are common, representing calcifications, immature bone and fibrosis.

32. Laboratory Values
The following laboratory values are associated with certain testicular tumors:
Beta-human chorionic Gonadotropin
Choriocarcinoma
Embryonal carcinoma
Alpha-fetoprotein
Yolk sac tumors

33. Choriocarcinoma
Choriocarcinoma represents the most lethal and least common form of germ cell tumors.
Unlike other testicular cancers that metastasize via the lymphatic system, Choriocarcinoma metastasized by hematogenous routes, thus patients present with distal metastases.
Distal metastases (lug, liver, brain) may be the initial presentation. The primary testicular tumor may be small or non-palpable.
Associated with an increase in Beta-Human chorionic Gonadotropin

34. Choriocarcinoma

35. Mixed Germ cell tumors
These tumors contain different germ cell elements in various combinations.
They are the second most common testicular malignancy after seminoma.
The combination of teratoma and embryonal cell carcinoma is the most common mixed germ cell tumor. It has been called a teratocarcinoma in the past.

36. Mixed germ cell tumors

37. Testicular Metastases.
Leukemia and lymphoma are the most common malignancies to affect the testis secondarily.

38. Testicular Metastases

39. Testicular Cysts
There are two types of benign cysts:
Cysts of the tunica albuginea
Intratesticular cysts
Intratesticular cysts are normally located near the mediastinum testis and probably originate from the rete testis.

40. Intratesticular Cyst

41. Tunica Albuginea

42. Cyst of the Tunica Albuginea

43. Epidermoid cysts
The epidermoid cyst is a benign tumor of germ cell origin. These lesions are well – circumscribed solid tumors lying beneath the tunica albuginea.
The cyst is filled with cheesy-white keratin, which is a fibrous protein. Sonographically, epidermoid cysts are well-defined, solid, hypoechoic masses with an echogenic capsule or onion ring pattern formed by multiple layers of keratin.
Keratin is the essential element of hair and nails.

44. Epidermoid Cyst

45. Testicular abscess
Abscesses are usually a complication of epididymo-orchitis.
Sonographically, abscesses present with an enlarged testicle containing a predominantly fluid-filled mass with hypoechoic or mixed echogenic areas.

46. Testicular Abscess

47. Scrotal Calcifications
Calcifications (scrotal pearls) may be located within the testicle or between the layers of the tunica vaginalis.

48. Scrotal Calcifications

49. Testicular microlithiasis are frequently seen sonographically
Testicular microlithiasis are frequently seen sonographically. Microlithiasis has not been proven to define a benign or malignant testicular condition.

50. Testicular Microlithiasis

51. Testicular infarct
Testicular infarction commonly results from torsion or trauma.
The Sonographic appearance depends on the age of the infarction. Initially, the infarction produces a focal or diffuse hypoechoic testicle.
With time, the testicle decreases in size and develops areas of increased echogenicity representing fibrosis or calcifications.

52. Testicular infarct - Acute stage

53. Hydrocele
A hydrocele is serious fluid that accumulates within the tunica vaginalis or between the layers of the tunica vaginalis (visceral and parietal layers)
Hydroceles may be congenital or acquired. They may be idiopathic or the result of trauma, torsion, neoplasms, epidymitis or orchitis.
Low-level echoes from fibrin or cholesterol crystals may be visualized within the hydrocele.

54. Hydrocele adult

55. Hydrocele - fetus

56. A hematocele is seen when blood fills the scrotal chamber associated with trauma.

57. Hematocele

58. Varicocele
A varicocele is a dilation of the pampiniform venous plexus (a bunch of veins located in the spermatic cord) of the testicular veins which drain the testicle.
90% of the varicoceles are on the left side. Varicoceles are the most common correctable causes of male infertility.
Incompetent spermatic venous valves lead to increased hydrostatic pressure in the venous system which dilates and leads to varicoceles.
The left testicular vein drains into the left renal vein. The pressure in the left renal vein is higher than the IVC which explains the greater incidence of left varicoceles.
Varicoceles should distend when a patient is standing, with Valsalva, or with abdominal compression.
Due to the slow blood flow, varicoceles may become thrombosed.

59. Varicocele

60. varicocele

61. Scrotal Hernia
This results from bowel protruding through the inguinal canal into the tunica vaginalis or the scrotum.
The presence of peristalsis confirms the diagnosis. Small inguinal hernias can be visualized by using the Valsalva maneuver.

62. Scrotal Hernia

63. Scrotal hernia – one month old

64. Extratesticular tumors
Extratesticular tumors usually involve the epididymis. The most common extratesticular tumor is the andenomatoid tumor.

65. Extratesticular Tumor-Hematocele

66. Spermatoceles
Epididymal Cysts
Spermatoceles are cystic masses of the epididymis that result from dilation of the epididymal tubules.
Spermatoceles are more common than epididymal cysts. Epdidyjmal cysts are composed of clear fluid whereas spermatoceles are filled with thick milky fluid containing spermatoazoa. Both lesions result from prior episodes of epididymitis.
Sonographically both lesions MAY appear identical: anechoic, well-defined masses with no or few internal echoes. But usually, Spermatoceles, which usually occur at the epididymal head, will appear dense with echoes.

67. Spermatocele

68. Epididymal Cyst

69. The acute scrotum
The two most common causes of acute scrotal pain are:
Epididymitis/orchitis
Torsion of the spermatic cord

70. Sonographically, epididymitis is associated with
Acute epididymitis is the most common condition that causes acute scrotal pain
Acute epididymitis is usually caused by sexually transmitted diseases in men under 35 years of age and urinary tract infections in men older than 35.
Patients present with acute scrotal pain which may be associated with fever and pyruia.
Sonographically, epididymitis is associated with
Enlarged hypoechoic epididymis
Hypoechoic testicle
Increased blood flow (hyperemia)
Reactive hydrocele
Scrotal wall thickening
The infection may extend into the testicle causing orchitis. Sonographically, orchitis is seen as an enlarged and hypoechoic testicle with increased blood flow.

71. Epididymitis

72. Testicular torsion
Typically, the testicle is attached to the tunica vaginalis. Without this attachment, the testicle can rotate freely on the spermatic cord (bell clapper deformity). This congenital anomaly, which can be found in as many as 12% of males, allows the testicle to twist, causing testicular torsion.
Testicular torsion leads to venous occlusion and arterial ischemia causing infarction of the testicle. Torsion more often involves the left testicle.
After hours, the testicular salvage rate markedly decreases, and it is near 0% at 12 hours.
Testicular torsion is observed in males younger than 3o years of age, with most aged The patient typically presents with a sudden onset of severe unilateral scrotal pain.

73. Testicular torsion is a clinical diagnosis
Testicular torsion is a clinical diagnosis. Imaging studies usually are not necessary and waste valuable time. Sonographically, with testicular ischemia, the testicle becomes enlarged, inhomogeneous and hypoechoic compared to the contra lateral testicle.
The degree of torsion may vary between 180 – 540 degrees. Blood flow within the testicle would theoretically exclude the diagnosis of acute torsion, although the presence of flow does not exclude partial torsion.
Manual de-torsion is often performed in the emergency room. Testicles commonly rotate toward the mid-line. Manual detorsion involves rotating the painful testicle outward like opening a book.

74. Testicular torsion

75. Complete testicular torsion >12 hours

76. Testicular torsion Cartoon

77. Cryptorchidism
Cryptorchidism, literally means hidden testicle. and generally refers to an Undescended testicle.
Testicles are usually descended at birth, although spontaneous descent may occur in the first year. Orchioplexy is the treatment of choice and is usually performed on patients aged 2-10 years.
Infertility and cancer are complications of cryptorchidism. Patients with cryptorchidism have an increased risk of developing a malignancy in both the Undescended testis and the contralateral testis.

78. The most common location of the cryptorchid testis is in the inguinal canal or prescrotal positions. Less than 10% of Undescended testis are located in the abdomen.
Anorchia or congenital absence is rare and accounts for only 4% of patients who present with cryptorchidism.

79. Ct and MRI are typically used to image an abdominal testis
Ct and MRI are typically used to image an abdominal testis. although imaging posterior to a filled bladder may aid in the abdominal evaluation by ultrasound
NOTE: looks like an enlarged lymph node when seen.

80. Cryptochidism

81. Cryptochidism