The urethra and male genital tract
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  • Large posterior urethral diverticulum in an 8-year-old male child presenting with recurrent urinary tract infection. An oblique VCUG image reveals a large wide-neck diverticulum (*) arising from the prostatic urethra
  • Anterior urethral diverticulum in a 5-year-old male child. An oblique VCUG image reveals a large diverticulum arising from the ventral surface of the penile urethra. Note the prominent anterior as well as posterior lips (arrows). The diverticulum caused external compression of the penile urethra, leading to a poor urinary stream
  • A 50-year-old male patient with a history of schizoid disorder and alcohol abuse who consulted for urethral suppuration and a mass at the base of the penis that increased in size while urinating.Retrograde voiding urethrography showing contrast filling in a sac-like cavity in the bulbar urethra and a urethral stenosis distal to the diverticulum.
  • Retrograde voiding cystography where one of the cavities is filled but shows a filling defect, corresponding to an intradiverticular calculus.
  • A, Voiding phase of voiding cystourethrography (VCUG) shows contrast material filling urinary diverticulum (arrowheads) that encircles urethral lumen (arrow). Filling started on right lateral aspect of urethra and extended to fill remaining diverticulum.
    B, Voiding phase of VCUG after diverticulum resection shows normal appearance of urethra (arrow).
  • C, Transverse contrast-enhanced CT scan shows fluidfilled diverticular sac (asterisk) in enlarged urethra. Mucosal and submucosal component of urethra is displaced to left (arrow). transverse (E) fast spin-echo T2-weighted MR images confirm diagnosis of highsignal intensity, fluid-filled diverticulum (asterisk) with fluid–debris level (white arrow, E). Note displaced urethra (black arrow) and anterior septation (arrowhead, E).
  • Transverse contrast enhanced CT scan of pelvis shows multiple dependent calculi (arrowheads) within fluid-filled urethral diverticulum (asterisk) that displaces urethra (arrow) to the right.
  • Urethral diverticula in a 36-year-old woman. Axial (a) and sagittal (b) T2-weighted images of the pelvis show diverticular sacs (arrows) as multiple cystic lesions surrounding the urethra (U).
  • Prostatic urethrorectal fistula in a patient who sustained both a urethral disruption and a rectal injury in an automobile accident. Voiding cystourethrogram demonstrates a distal prostatic urethrorectal fistula (white arrow); the urethral stricture (black arrow) is just distal to the fistula. R rectum.
  • Voiding cystourethrographic image showing the fistula (arrow).
  •  Urethrovaginal fistula in a 74-year-old woman with a history of delivery trauma. Sagittal T2-weighted image shows a fistulous communication (arrows) between the urethra (U) and vagina (V).
  • Male pseudohermaphroditism (46,XY DSD) in a teenage phenotypic girl who presented with amenorrhea and prominent labioscrotal folds that caused some degree of genital ambiguity. (a) US image of the pelvis does not depict the uterus or ovaries. (b, c) Color Doppler US images show right (b) and left (c) testes (arrows) in the inguinal canals. In this case, partial androgen insensitivity syndrome (Reifenstein syndrome) caused the genital ambiguity.
  • Ovotesticular DSD (true hermaphroditism) in a child with ambiguous external genitalia. (a) US image of the pelvis shows a normal uterus (arrows). (b, c) US images show gonadal tissue in the right inguinal canal (arrows and cursors in b) and left iliac fossa (arrows in c) having the appearance of testes. No follicles were seen in either gonad. (d) Genitogram shows a normal vagina (arrowheads) with reflux of contrast material into the cervix (large arrow). The configuration of the urethra (small arrow) indicates an unusual female type or severe hypospadias. Biopsy of the right and left gonads showed immature testicular tissue and an ovotestis, respectively. Cytogenetic analysis revealed a genotype of 46,XY in both gonads.
  • Ambiguous genitalia in a newborn with congenital adrenal hyperplasia. (a) Longitudinal US scan shows a normal uterus (arrow). (b) Lateral image from genitography shows urethrovaginal confluence (solid arrow) and partial opacification of the uterine cavity (open arrow). B bladder, V vagina.
  • Ambiguous genitalia in a newborn with true hermaphroditism. (a) Longitudinal US scan of the inguinal region shows a testicular echostructure (between cursors). (b) Longitudinal US scan of the pelvis shows a uterus (arrow).
  • A, Midline transverse sonogram of the scrotum through the median raphe reveals no testis in the scrotal sac. B and C, Sagittal sonograms show both testes to be located in the inguinal canals and diminutive. Testicular volume measured 2–3 mL each (normal range, 18–20 mL).
  • A and B, Sagittal sonograms of both testes show that the left testis (B) is smaller than the right (A) and markedly heterogeneous.
  • A, Sonogram shows relatively well-marginated, hypoechoic, ovoid mass measuring approximately 3 cm with increased through transmission in lower right abdominal quadrant. B, Contrast-enhanced CT scan shows enhancing nodular mass with target appearance in medial wall of cecum. Mass (arrow) is surrounded by omental fat.
  • A, T2-weighted coronal MR image shows left hyperintense testis at left side of groin (arrow ). Atrophic right intraabdominal testis (arrowhead) is next to bladder (B). B, Source image from gadolinium-infusion MR angiography shows linear pampiniform venous plexus and rim enhancement around left testis at left groin region (thin arrows). Note rim enhancement at right intraabdominal testis (arrowhead ), which is partially obscured by contrast-enhanced right external iliac vessels (thick arrow).
  • A, T2-weighted coronal MR image shows normal hyperintense testis in left scrotum (arrow ). Right testis could not be found.
    B, Source image from gadolinium-infusion MR angiography shows right (arrow ) and left (arrowhead ) pampiniform venous plexus draining from scrotum. B. Blind-ended right pampiniform venous plexus descended from groin region to right
    scrotum (thin arrow).
  • Congenital hydrocele in a neonate. Ultrasound. The epididymal appendix (asterisk), body of epididymis (open arrow) and mediastinum testis (white arrow) are clearly demonstrated.
  • Appendix epididymis. Longitudinal US image shows an appendix epididymis (arrow) projecting from the normal triangular epididymal head (arrowhead). Visualization is aided by the presence of a hydrocele. T testis. Appendix testis. Longitudinal US image shows a small soft tissue remnant projecting from the superior aspect of the testis (arrow). There is also a moderate-sized hydrocele.
  • Longitudinal (A) and transverse (B) US views of organizing scrotal haematoma following trauma. The adjacent testis is compressed but otherwise normal. A septated hydrocele may present a similar appearance.
  • Coronal T2-weighted MR image of the scrotum shows a high-signal-intensity testis within each hemiscrotum. A low-signal-intensity capsule, the tunica albuginea, surrounds each testis. The epididymis (long arrow) is low signal intensity compared with the testis. Also note the small left-sided hydrocele (*), spermatic cord (arrowhead), and varicocele (short arrow).
  • Hematocele. (a) Longitudinal US scan shows a complex, heterogeneous fluid collection
    distorting the left testis (T).
  • Scrotal abscess with Fournier gangrene. (a) Transverse US image shows a large, complex, heterogeneous fluid collection. It is exerting marked mass effect with displacement and distortion of the testis (arrow).
  • Epididymal cyst. Longitudinal US image shows a large cyst within the head of the epididymis (arrow). The cyst cannot be distinguished sonographically from a spermatocele. T testis.
  • Clinically proved epididymitis in an 11-year-old boy. (a) Longitudinal US scan of the right hemiscrotum
    shows an enlarged hypoechoic epididymal head (E), reactive hydrocele (h), and thickening of the scrotal wall (*).
    m mediastinum. (b) Color and pulsed-wave Doppler image shows increased vascularity in the epididymal head
    with a low-flow, low-resistance waveform pattern.
  • Acute epididymitis in a 9-year-old boy with scrotal pain and redness. Longitudinal US scan shows that the epididymal head and body (arrows) are enlarged and hypoechoic relative to the normal testis (T). Wall thickening (*) and reactive hydrocele (h) are also seen. Power Doppler imaging showed increased perfusion of the epididymis.
  • The inflamed epididymis is enlarged and hypoechoic (arrows).
  • Note the increased vascularity within the inflamed epididymis and a small reactive hydrocele.
  • B-mode ultrasound images reveal a swollen and edematous epididymis. The entire structure including the head, body and tail of the epididymis appear to be involved. Color doppler images confirm the presence of inflammation by the increased vascularity
  • Left varicocele in a 15-year-old boy. (a) Longitudinal US scan of the left hemiscrotum shows multiple anechoic structures (arrows) in the supratesticular region and extending behind the upper pole of the testis (T). (b) Color Doppler image shows that the anechoic structures
    are vascular. (c) Pulsed-wave Doppler image shows a venous waveform with increased flow during the Valsalva maneuver (arrow).
  • Varicocele. (a) Longitudinal US image of the left testis shows multiple, serpiginous, hypoechoic spaces around the testis (T). (b, c) Color Doppler images obtained just above the testis at rest (b) and during the Valsalva maneuver (c) show flow. Note the marked enlargement and increased flow with the Valsalva maneuver.
  • (c) CT image obtained at the inguinal level shows dilatation of the vessels in the right spermatic cord (arrow).
  •   Varicocele in a 45-year-old man. (a) Axial contrast-enhanced reformatted CT image through the inguinal regions shows a right-sided varicocele (arrow) simulating an inguinal hernia. (b) Coronal thick-section MPR image delineates the course of the varicocele (arrows) to the level of a renal cell carcinoma (arrowheads) arising from the right kidney.
  • Left testicular venogram. This image shows a left testicular varicocele before embolization. Note: radiographs of varicoceles should be avoided to restrict radiation exposure.

Transcript

  • 1. Contents Structural Lesions of the Urethral Wall Congenital Scrotal Disorders Extra testicular Scrotal Disorders
  • 2. Urethral Diverticulum Urethral diverticulum may be defined as a localized out pouching of tissue from the urethra into the potential space surrounding the urethra. The cause is uncertain. Symptoms are variable, the most common being frequency, urgency, and dysuria. Congenital or Acquired Female > Male
  • 3. Urethral Fistulas Urethral fistulas develop if there is failure of closure after urethral rupture or laceration. They may be caused by; - Rectal or Gynecological surgery. -Obstetric injury. -Radiotherapy. -Inflammatory lesions. -Strictures or Carcinomas.
  • 4.  Urethrorectal, urethroperineal, urethrovaginal, urethrovesical and urethrocutaneous. IMAGING  Cystourethroscopy  VCUG  Retrograde urethrography  MRI  CT scan
  • 5. 1 month old girl
  • 6. Ambiguous Genitalia And Intersex (Disorders of Sex Development) Atypical appearance of the external genitalia making sex determination difficult Occur when Genetic sex, Gonadal sex, or Genital sex of an individual are discordant. Complex situation with a wide variety of phenotypes.
  • 7. Types 1.True Hermaphrodite (ovotesticular DSD) 2.Pseudohermaphrodite a. Male Pseudo hermaphrodite (46 XY with two testes) b. Female Pseudo hermaphrodite (46 XX with two ovaries) 3.Gonadal Dysgenesis a. Pure (bilateral streak gonads) b. Mixed(testis and a streak gonad)
  • 8. Teenage girl presented with primary amenorrhea and prominent labioscrotal folds
  • 9. A child with ambiguous genitalia
  • 10. Ambiguous genitalia in a newborn with congenital adrenal hyperplasia
  • 11. A newborn with Ambiguous genitalia
  • 12. Undescended Testes (Cryptorchidism) Cryptorchidism is defined as failure of the testis to descend from its intra-abdominal location into the scrotum. Preterm infants 28-32 wks Unilateral or bilateral 20-48 times more likely to undergo malignant degeneration
  • 13. Cryptorchid: testis neither resides nor can be manipulated into the scrotum Ectopic: aberrant course Retractile: can be manipulated into scrotum where it remains without tension Gliding: can be manipulated into upper scrotum but retracts when released
  • 14. Imaging Ultrasound CT scan MRI Angiography
  • 15. 34 years old male with infertility
  • 16. 28-year-old man with history of left cryptorchidism after orchiopexy at age 6 years.
  • 17. 34 years old male with severe pain in the RIF along with fever and chills.
  • 18. 1 year old boy with non palpable testes
  • 19. 9 year old boy…
  • 20. Hydrocele A hydrocele is filling of serous fluid between the visceral and parietal layers of tunica vaginalis. Congenital or Acquired. Is most often idiopathic. Can be secondary to infection or lymphatic blockage by tumor.
  • 21. Chronic infective hydrocele (especially tuberculous) may be associated with considerable calcification of the tunica. Hydrocele may demonstrate internal echoes.
  • 22. Hematocele It is an accumulation of blood distending the tunica vaginalis. Acute or Chronic Is most often caused by trauma. Is occasionally due to tumor.
  • 23. Complex appearance with echogenic debris and septations.
  • 24. Pyocele A scrotal abscess, or pyocele, is most often a complication of epididymo-orchitis, which has crossed the mesothelial lining of the tunica vaginalis. On US scans, an abscess appears as a complex, heterogeneous fluid collection. Gas may be present, causing bright specular reflectors and shadowing
  • 25. Spermatocele The most common scrotal mass is spermatocele. Cystic lesions in the head of epididymis. Filled with spermatozoa containing fluid. Low level echoes can be seen in some cases. Septations --- with large spermatoceles.
  • 26. Epididymal Cysts Epididymal cysts form in the head as well as in the body and tail of the epididymis. Are anechoic. Contains serous fluid. Indistinguishable from spermatoceles.
  • 27. Epididymitis Inflammation of the epididymis, usually due to ascending infection with gram negative bacilli or Chlamydia. Young adult males, late middle age and elderly.
  • 28. Imaging of epididymitis The preferred imaging examination is ultrasonography. Enlarged (>17 mm) epididymis . Hypoechoic, hyperechoic, or heterogeneous echotexture. Increased blood flow. Associated reactive hydrocele . Scrotal wall thickening.
  • 29. Patient with severe pain in the scrotum.
  • 30. Varicocele Varicoceles are dilated peritesticular veins that form as the result of incompetent valves in the spermatic veins. Extremely common(8-16% of male population) 15-25 years of age. 85% Left sided 15% Bilateral. If only right sided-Malignancy should be suspected. If presenting in old age(>40 yrs) for the first time- Malignancy should be suspected. Pain ,discomfort and Infertility.
  • 31. Gray scale sonography depicts Varicoceles as numerous, dilated(>2mm), tortuous, tubular channels in the peritesticular tissues. Located lateral, posterior and/or superior to the testis. Visible flow may be seen within larger varicoceles on conventional ultrasound, but it is usually too slow to be detected with color Doppler imaging. Their prominence is increased in the upright position and with valsalva maneuver, and this is detectable on color Doppler imaging.