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Scrotal Cysts

GRAND ROUND
by

SAMEH SAIF

on 31 January 2014

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Transcript of Scrotal Cysts

Review Of
Scrotal Cysts
The scrotum: 2 compartments.
Each: testis, epididymis, and spermatic cord.
 The epididymis : head, body and tail.
 The epididymis continue as the vas deferens in the spermatic cord.
 The spermatic cord: the vas deferens, blood vessels, nerves, lymphatics, and connective tissue.
 The testis is invested by three coats from outside inwards:
The tunica vaginalis has a closely applied visceral layer and an outer parietal layer.
The tunica albuginea, a fibrous layer closely invests the testicle.
The tunica vasculosa contains a plexus of blood vessels and delicate loose connective tissue.
Arterial supply:
 The testicular artery: abdominal aorta, provide the primary vascular supply to the testis.
 The deferential artery and the cremasteric artery supply the epididymis, vas deferens, and peritesticular tissue.
Venous and Lymphatic drainage:
The veins within the testis form the pampiniform plexus: drain into the testicular veins.
 The left testicular vein: the left renal vein
The slightly shorter right testicular vein: directly into the inferior vena cava.
 Testicular lymphatic vessels drain to the para-aortic and aortocaval nodes.
 Scrotal US
Ultrasonography (US), with pulsed and color Doppler modes, is the imaging modality of choice for evaluating scrotal lesions.
 With the improvement in the US resolution, more scrotal lesions, particularly intratesticular, are identified. Among them, cystic lesions are detected more frequently.
 The accuracy of sonography approaches 100% in the ability to distinguish intratesticular from extratesticular lesions.
 Technique:
Scrotal US: performed with the highest frequency transducer (i.e. 7.5–10 MHz).
 The patient in the supine or standing positions.
 The room and coupling gel: warm to avoid cremasteric muscle contraction.
 Obtaining a patient history and performing a physical examination are essential parts of a complete examination.
 The scrotum and testes: examined in at least two planes.
 Valsalva maneuver or upright positioning can be used for venous evaluation.
 When a scrotal mass is evaluated, the two most important questions to answer are:
(a) is the mass intratesticular or extratesticular.
(b) is it cystic or solid.
 Extratesticular cysts are more common than intratesticular cysts.
 Middle-aged patients.
 Multiple tubular or oval anechoic structures, located in or around the mediastinum testis, with venous flow on color or pulsed Doppler sonography and a positive response to the Valsalva maneuver.
 The sonographic appearance of ITV is usually sufficiently specific to obviate further investigations.
 The absence of a palpable mass, the absence of a solid component between the cystic spaces, and the color Doppler findings are usually helpful in distinguishing ITV from cystic tumors.
 Results from partial or complete obliteration of the efferent ductules, which causes ectasia and, eventually, cystic transformation of the rete testis.
 Most occur in men older than 55 years, and is frequently bilateral but is often asymmetric.
 It appears as multiple small cystic or tubular anechoic structures that replace and enlarge the mediastinum.
 The geographic shape, lack of mass effect, location of the lesion in or adjacent to the mediastinum testis, presence of epididymal cysts and lack of internal flow are helpful to distinguish this benign condition from a partially cystic tumor.
The most common benign tumor originating in the testis.
Most patients are discovered incidentally in the second to fourth decades of life, although it could be seen in older age.
 Has a characteristic onion ring appearance which is highly suggestive of the diagnosis but not pathognomonic.
In most cases, it has no sound through-transmission on sonography due to cheesy material within.
They can show a variety of atypical appearances. No matter the imaging appearance, epidermoid inclusion cysts should not demonstrate internal flow at Doppler sonography.
Epidermoid cysts may be differentiated from simple and tunica albuginea cysts, which are completely anechoic.
Tumors, granulomatous and chronic inflammatory processes may have a rim or capsule, but they are more likely to have increased vascularity.
 Usually secondary to epididymo-orchitis.
 Other causes include trauma, testicular infarction, and mumps.
 Their US features include shaggy, irregular walls, low-level internal echoes, and occasionally, hypervascular margins.
 Acute haematomas appear hyperechoic at US and may simulate a focal mass.
 After 1–2 weeks, the haematoma undergoes liquefaction and may appear cystic.
 Late intratesticular haematoma is mostly purely cystic.
 Thus the appearance depends on the stage of development and could be confused with neoplastic lesions warranting adequate history taking and close follow up.
 Usually manifests as a hypoechoic mass that is largely avascular.
 US may show a complex cystic lesion with areas of central necrosis resembling a tumor.
 Also can show irregular, shaggy walls with low-level internal echoes and no through transmission resembling an abscess.
 Follow up is usually required.
 Intratesticular cystic lesions include:

1. Tunica albuginea cysts
2. Simple intratesticular cysts
3. Intratesticular spermatocele
4. Intratesticular varicocele
5. Cystic transformation (tubular ectasia) of the rete testis
6. Epidermoid inclusion cyst
7. Intratesticular haematoma
8. Intratesticular infarction
9. Intratesticular abscess
10. Cystic intratesticular tumors
 Typically manifest as small palpable masses.
 The mean age at presentation is 40 years, and can be seen in older age.
 They are peripherally located within the layers of the tunica.
 If larger, they can simulate an intratesticular cyst.
 Detected incidentally.
 Occur in men 40 years of age and older.
 Occur anywhere in the testis but are often near the mediastinum testis.
 Usually not palpable and, even when large, are not firm, while tunica albuginea cysts are very firm, even when small.
 More than 95% of solid intratesticular lesions are malignant; however, benign intratesticular lesions do exist.
 The majority of nonneoplastic intratesticular cystic lesions are benign, and recognition of them can prevent unnecessary surgical exploration.
 Intratesticular spermatocele is attached to the mediastinum in the area of the rete testis.
 These cysts contain spermatozoa and can be septated.
 Tunica albuginea cysts, simple intratesticular cysts and intratesticular spermatocele share the same US appearance which is the typical for a simple cyst; anechoic well defined cyst with acoustic enhancement.
 They rarely show internal echoes or fine septations.
 When any of these is detected, the patient must be assured of its benignity and surgery is usually not needed unless the cyst is huge and symptomatic. In this condition, a testis sparing surgery is usually decided.
 Almost all of the extratesticular cysts are benign and localization of the cyst shortens its differential diagnosis.
 In intratesticular cysts, it is essential to determine if the cyst is purely cystic or associated with solid component:
 Almost all purely cystic intratesticular lesions are benign.
 The intratesticular cyst should be considered malignant if it shows any solid component.
When a scrotal cyst is encountered, it is essential to decide: is it intra or extra testicular?
 Physical examination is sufficient to enable diagnosis in most cases.
 Hernias are either indirect or direct.
 The US appearance of an inguinal hernia depends on its contents:
 Bowel: fluid filled, multiple bright echoes and may show peristalsis.
 Omentum: echogenic mass that is traceable back to the inguinal area.
 Rarely shows liver and urinary bladder.
 Appears as layers of alternating hypoechogenicity and hyperechogenicity, called the onion-ring appearance with thickening of the scrotal wall.
 Causes may be inflammatory or noninflammatory.
 Noninflammatory causes include heart failure, liver failure, renal failure, lymphatic and venous obstruction.
 Inflammatory causes include scrotal wall cellulitis, Fournier gangrene and other inflammatory conditions. They could be complicated by abscess formation.
A. Hydrocele:
 Abnormal collection of serous fluid between the layers of the tunica vaginalis and/or along the spermatic cord.
 The most common cause of painless scrotal swelling.
 May be congenital or acquired.
 Less common types include the localized form (spermatic cord cyst).
 Appears as an anechoic fluid collection surrounding the testis and sometimes extending to the inguinal canal.
 May show low-level echoes.
 B. Hematocele:
Accumulation of blood within the tunica vaginalis.
 May be either acute or chronic.
 Often exerts mass effect, distorting the contour of the testis.
 Acute hematocele is echogenic, whereas an older hematocele appears as a fluid collection with low-level echogenicity, fluid-fluid level, or septations.
C. Pyocele (scrotal abscess):
Appears as a complex, heterogeneous fluid collection with internal septations and loculations on US.
 Gas may be present, causing bright specular reflectors and shadowing.
 Skin thickening and calcifications can be seen in chronic cases.
 Other cystic lesions of the tunica include mesothelioma.
Testicular coats
 Abnormal dilatation of veins in the pampiniform plexus of the spermatic cord.
 Mainly in adolescents and young adults and are more frequent on the left side.
 Varicoceles have been noted in approximately up to 40% of men with infertility.
 At sonography, the dilated veins appear as multiple tortuous, anechoic, tubular structures along the spermatic cord.
 On color and pulsed-wave Doppler images, venous flow is better demonstrated during the Valsalva maneuver and scanning in the upright position.
 Cystic tumor is rare, and when present, cystic tumors do not meet all the criteria of a simple cyst. Usually, an abnormal rind of parenchyma with increased echogenicity surrounds cystic malignant tumors.
 The age of the patient, clinical presentation, and tumor marker status allow diagnosis of a tumor with fair certainty.
 Most testicular malignant tumors are palpable, whereas the majority of intratesticular cysts are not palpable except when they are at the periphery of the testis.
 Include true epididymal cysts or spermatoceles.
 Epididymal cysts may arise throughout the epididymis, while spermatoceles almost always arise in the epididymal head.
 Both appear as well-defined hypoechoic lesions demonstrating posterior acoustic enhancement.
 Spermatoceles often contain low-level echogenic proteinaceous fluid and spermatozoa.
 Other epididymal cysts include sperm granuloma and papillary cystadenoma of the epididymis (seen commonly with von Hippel–Lindau disease).
 Ninety to 95% of testicular tumors are derived from germ cells.
 Other non germ cell testicular tumors include those of gonadal stromal origin, lymphoma, leukemia, and metastases.
 Teratomas are the most frequent to manifest as cystic masses. True cysts with an epithelial lining have a teratoma component; otherwise, tumoral cysts usually represent a dilated rete testis or an area of necrosis.
 As opposed to intratesticular masses, most extratesticular masses are benign.
 Cystic masses are easily diagnosed with ultrasonography and are benign.
 Localizing the abnormality to the epididymis, spermatic cord, tunica vaginalis, paratesticular location or scrotal wall can shorten the differential diagnosis.
Pathology and Imaging of the scrotal cysts
I. Intratesticular Cysts
Testicular tumors
Germ cell tumors
Non Germ cell Tumors
seminomatous
Non seminomatous
Benign
Anatomy
II. Extratesticular Cysts
why do men die younger than women?
why do men die younger than women?
why do men die younger than women?
why do men die younger than women?
Kim et al, Radiographics 2007: US–MR Imaging Correlation in Pathologic Conditions of the Scrotum
Conclusion: MR imaging may add specific value when the location of a scrotal mass is uncertain or when sonography does not allow clear differentiation between a solid mass and an inflammatory or vascular abnormality.
Woodward et al, Extratesticular Scrotal Masses: Radiologic-Pathologic Correlation. Radiographics 2003; 23: 215-240.
References:
Dogra VS, Gottlieb RH, Rubens DJ, Liao L: Benign Intratesticular Cystic Lesions: US Features. Radiographics 2001; 21: S273-S281.
Dogra VS, Gottlieb RH, Oka M, Rubens DJ: Sonography of the Scrotum. Radiology 2003; 227: 18-36.
Kim W, Rosen MA, Langer JE, Banner MP, Siegelman ES, Ramchandani P: US–MR imaging correlation in pathologic conditions of the scrotum. Radiographics 2007; 27: 1239–1253.
Maizlin ZV, Belenky A, Baniel J, Gottlieb P, Sandbank J, Strauss S: Epidermoid Cyst and Teratoma of the Testis: Sonographic and Histologic Similarities. J Ultrasound Med 2005; 24: 1403–1409.
Woodward PJ, Sohaey R, O’Donoghue MJ, Green DE: Tumors and tumorlike lesions of the testis: radiologic-pathologic correlation. RadioGraphics 2002; 22: 189-216.
Woodward PJ, Schwab CM, Sesterhenn IA: Extratesticular Scrotal Masses: Radiologic-Pathologic Correlation. Radiographics 2003; 23: 215-240.
Thank you
Tétreau R. et al, J Ultrasound Med 2007; 26: 1767–1773.
Cassidy et al, Radiographics 2010: MR Imaging of Scrotal Tumors and Pseudotumors
US remains the mainstay of scrotal imaging.
MR imaging can provide additional useful information in approximately 80% of cases where US findings are indeterminate.
Compared with US, MR imaging has a greater ability to characterize certain lesions, such as lipoma and other fat-containing lesions, hematoma, fibrous pseudotumor, and focal testicular infarction.
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