DAVID SUTTON PICTURES THE MALE GENITILIA AND URETHRA ONLY FOR STUDY PURPOSE

1. 32
THE MALE GENITILIA
AND URETHRA
DAVID SUTTON

2. DAVID SUTTON PICTURES
DR. Muhammad Bin Zulfiqar
PGR-FCPS III SIMS/SHL

3. • Fig. 32.1 Urethrogram demonstrating short
post inflammatory stricture at the junction of
the bulbar and penile urethra.

4. • Fig. 32.2 Descending urethrogram in a male. The
entire length of the urethra is demonstrated as the
bladder empties. The prostatic urethra is a little
distended in this example due to a short stricture at
the junction of the membranous urethra and the
bulbar urethra following a traumatic urethroscopy.

5. • Fig. 32.3 Multiple short tight anterior urethral
strictures following attempted self-
catheterisation with a knitting needle and
resultant gross urethritis.

6. • Fig. 32.4 Micturating cystogram following extensive
posterior urethral trauma showing gross urethral
disruption at the level of the urogenital diaphragm and
florid extravasation into the perineum.

7. • Fig. 32.5 Ascending urethrogram following a
classical straddle injury showing marked
extravasation of contrast from a partial
anterior urethral tear.

8. • Fig. 32.6 Transverse post-gadolinium TI -
weighted image showing invasion of the
penile bulb and muscles of the right side of
the pelvic floor by urethral carcinoma.

9. • Fig. 32.7 (A) Postmicturition film from an IVU series
showing a urethral calculus and gross detrusor hypertrophy
due to secondary bladder outflow obstruction. (B)
Urethrogram (different patient) showing a filling defect due
to a urethral calculus within the prostatic urethra.

10. • Fig. 32.8 Cystourethrogram showing a
substantial sinus from the posterior aspect of
the urethra following rectal surgery.

11. • Fig. 32.9 Coronal T2 -weighted MR image
showing a sinus from the base of the penile
urethra down into the scrotum.

12. • Fig. 32.10 Sagittal T,-weighted (A) and T.-
weighted (B) MR images in a patient with
Nunan's syndrome showing male external
genitalia and a uterus .

13. • Fig. 32.11 Transverse ultrasound showing an
atrophic undescended testicle (arrows) lying
in the inguinal canal.

14. • Fig. 32.12 Transverse STIR images from MRI
examinations of patients with undescended
testicles (arrow) in the proximal end of the
inguinal canal (A), suprapubic pouch (B) and
pelvis (C).

15. • Fig. 32.13 Ultrasound
demonstration of a
hydrocele seen as an
echofree area partly
surrounding a normal
testicle.

16. • Fig. 32.14 Ultrasound showing an infected,
partly septated echogenic hydrocele.

17. • Fig. 32.15 Ultrasound (A) showing dense
peripheral calcification around the exterior of
a chronic inflammatory hydrocele. This is also
visible on the plain film (B).

18. • Fig. 32.16 Ultrasound showing (A) a classical
echo-free well-defined thin-walled solitary
epididymal cyst and (B) a cluster of simple
cysts.

19. • Fig. 32.17 Ultrasound of infected epididymal
cyst showing debris and fluid level.

20. • Fig. 32.18 Ultrasound of well-defined
spermatocele with slightly echopoor
contents.

21. • Fig. 32.19 Ultrasound of varicocele seen as
echo-free serpiginous structures.

22. • Fig. 32.20 Testicular phlebography and percutaneous embolisation
of varicocele. The testicular vein in this patient has a wide
termination unprotected by a valve and at least one small accessory
connection to the renal vein (A). The catheter is manipulated into
the distal testicular vein (B) to commence deploying the coils (C).

23. • Fig. 32.20 Testicular phlebography and percutaneous
embolisation of varicocele. The testicular vein in this
patient has a wide termination unprotected by a valve and
at least one small accessory connection to the renal vein
(A). The catheter is manipulated into the distal testicular
vein (B) to commence deploying the coils (C).

24. • Fig. 32.21 : Ultrasound showing typical
postvasectomy echopoor epididymus.

25. • Fig. 32.22 Ultrasound of aggressive
epididymitis showing a heterogeneous mass
with areas of reduced and increased
echogenicity adjacent to the lower pole of the
testicle.

26. • Fig. 32.23 Ultrasound of severe orchitis. The
bulk of the testicle shows diffuse reduction in
echogenicity. The heterogeneous area in the
lower pole represents a developing abscess.

27. • Fig. 32.24 Ultrasound of an infarcting testicle.
There are extensive areas of reduced
echogenicity within the substance of the
testicle. The adjacent epididymis is also
markedly diseased and swollen.

28. • Fig. 32.25 Ultrasound showing a classical
highly echogenic scrotolith with marked distal
acoustic shadowing and small hydrocele.

30. • Fig. 32.27 Ultrasound of a small (A) and a
large (B) testicular cyst, both showing an echo-
free area without any significant solid
elements.

31. • Fig. 32.28 Ultrasound of a small echo-free
tunica albuginea cyst.

32. • Fig. 32.29 Ultrasound showing multiple tiny
echo-free areas at the testicular hilum
(dilated rete testis).

33. • Fig. 32.30 Ultrasound of epidermoid cyst seen
as a well-defined echo-poor nodule.

34. • Fig. 32.31 Ultrasound of small testicular
malignancy with hydrocele.

36. • Fig. 32.33 Ultrasound of NSGCT which is
echo-poor but relatively ill defined and
containing at least one area of prominent
calcification.

37. • Fig. 32.34 CT demonstrating para-aortic
metastases from a left testicular malignancy. (A)
At this level a small lymph node deposit is seen
immediately lateral to the aorta and a larger one
is visible anterior to the left psoas muscle. Higher
up (B), just below the level of the renal hila, there
is a large left-sided metastatic mass partly
encasing the aorta.

39. • Fig. 32.36 Transverse T 1 - weighted MR images on
two different patients. (A) In this case there is a
solitary left para-aortic lymph node tumour deposit
from a left-sided testicular primary. (B) In this case
there is a more substantial right-sided deposit from a
NSGCT showing considerable heterogeneity. It has
encased and displaced the inferior vena cava.

40. • Fig. 32.37 Complex deposits of NSGCT in two different
patients seen on MRI. (A) In the first case there are tumour
deposits in the left retrocrural area, close to the left renal
hilum, and a large mass invading into the mesentery. (B) In
this case an undescended testicle is the site of grossly
metastatic NSGCT which is seen throughout the pelvis on
this T 2 - weighted image. It is interesting to note that the
pattern of spread is similar to ovarian cancer because of
the atypical site of the primary.

41. • Fig. 32.38 Post-treatment lymph node masses. (A) CT showing substantial mass
with substantial cystic (low-density) areas. (B) Transverse T,-weighted MR scan
showing a large predominantly cystic lymph node mass with extensive low-signal
areas. These are seen on the transverse STiR squence (C, higher level) as intensely
high-signal areas. Note the tumour has displaced the aorta anteriorly and is
extending into the left renal hilum associated with some renal obstruction, as
demonstrated by the perinephric high signal. (D) CT showing an ill-defined lymph
node mass between the aorta and inferior vena cava (and inseparable from both)
and a second mass to the left of the aorta showing dense areas of calcification.

42. • Fig. 32.38 Post-treatment lymph node masses. (A) CT showing
substantial mass with substantial cystic (low-density) areas. (B)
Transverse T,-weighted MR scan showing a large predominantly cystic
lymph node mass with extensive low-signal areas. These are seen on the
transverse STiR squence (C, higher level) as intensely high-signal areas.
Note the tumour has displaced the aorta anteriorly and is extending into
the left renal hilum associated with some renal obstruction, as
demonstrated by the perinephric high signal. (D) CT showing an ill-defined
lymph node mass between the aorta and inferior vena cava (and
inseparable from both) and a second mass to the left of the aorta showing
dense areas of calcification.

43. • Fig. 32.39 Testicular
ultrasound showing a small
echogenic area with distal
acoustic enhancement. The
patient presented with
widespread abdominal and
mediastinal lymphadenopathy
and pulmonary metastases,
histologically shown to be
teratoma. The testicular lesion
is presumed to be the site of a
burnt-out primary.

44. • Fig. 32.40 Testicular ultrasound showing
virtually complete replacement of normal
testicular tissue by metastatic prostate
cancer. An associated hydrocele is also
demonstrated.

45. • Fig. 32.41 Ultrasound of testicular
microlithiasis showing numerous tiny
maximum calcific foci.

46. • Fig. 32.42 Testicular ultrasound showing
microlithiasis and the development of a
seminoma.

47. • Fig. 32.43 MR scan of extensive penile carcinoma.
Transverse postgadolinium T,-weighted image (A) shows
destruction of the normal anatomy of the glans and shaft
by the irregular enhancing mass of tumour. This is seen on
the transverse STIR sequence (B), which also demonstrates
upstream dilatation of the urethra, a finding generally only
seen with advanced tumours. The coronal post-gadolinium
T1 -weighted image (C) demonstrates the presence of
inguinal lymph nodes. These are not particularly enlarged
but the node on the right (arrow) shows central necrosis
characteristic of squamous cell carcinoma metastasis.

48. • Fig. 32.43 MR scan of extensive penile carcinoma. Transverse
postgadolinium T,-weighted image (A) shows destruction of the
normal anatomy of the glans and shaft by the irregular enhancing
mass of tumour. This is seen on the transverse STIR sequence (B),
which also demonstrates upstream dilatation of the urethra, a
finding generally only seen with advanced tumours. The coronal
post-gadolinium T1 -weighted image (C) demonstrates the presence
of inguinal lymph nodes. These are not particularly enlarged but the
node on the right (arrow) shows central necrosis characteristic of
squamous cell carcinoma metastasis.

49. • Fig. 32.44 Longitudinal ultrasound of a penis
in Peyronie's disease showing a small calcified
echogenic plaque with distal acoustic
shadowing.

50. Fig. 32.45 Acute epididymo-orchitis (two cases). Anterior 99mTc
images obtained 1 min after injection showing diffusely increased
uptake in the right testis of case A and the left testis of case B. Case
A also shows diffusely increased activity along the spermatic cord
on the affected side. A lead marker has been used to indicate the
midline of the scrotum.

51. • Fig. 32.46 Testicular torsion. Anterior view
99mTc pertechnetate study commonest cause of
organic erectile dysfunction. shows an intensely
hyperaemic rim of tissue surrounding a photon-
deficient Haemodynamic evaluation of these
patients aims to detect area which represents the
infarcted left testis (arrows).