Urology Quiz 1

Question 1
Label the following layers of the scrotum and contents of the spermatic cord.

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Hover over the icon for the answer:
A (red & blue): Testicular artery and Pampiniform plexus, B (green): Internal spermatic fascia, C (purple): Parietal and visceral layers of tunica vaginalis. Note: the internal spermatic fascia is the layer the tunica vaginalis should adhere to in normal development. In boys and men who have partial, weak or failed adherence of the tunica to this layer, the whole testis is predisposed to rotation (extravaginal torsion) within the scrotum.

Question 2
The following diagram shows a congenital deformity of the tunica vaginalis. What is this deformity called and why does this predispose patients to testicular torsion?

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Answer:
Bell clapper deformity: because the testis is sitting almost horizontally within an extensive tunica vaginalis sac, it has very extensive freedom of movement. This means it can easily rotate around the axis of the spermatic cord and cause torsion of the blood vessels. Torsion can even extend to 720 degrees.

The following image relating to question 3-4 is a longitudinal ultrasound of a healthy testis.

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Question 3
Label parts A, B and C.

Answer:
A: Testis, B: Head of epididymis, C: Appendix or appendage of epididymis

Question 4
Why is structure C important in the differential of an acute scrotum?

Answer:
The appendix or appendage of the epididymis can twist spontaneously and cause appendiceal torsion. The appendix is a vestigial remnant of the mesonephric (Wolffian) duct and present in about 23% of males. It will present as an acute scrotum and is an important differential. Like testicular torsion, it is a surgical emergency, as inflammation and necrosis can lead to loss of testicular and reproductive viability.

Question 5
On the left is a Doppler Ultrasound of a normal testis and on the right is one of torsional testis. List three features you might see in the torsional ultrasound. Note: ultrasound is rarely useful in diagnosis or treatment of torsion. It is a clinical diagnosis.

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Answer:
1. Loss of blood flow (as indicated by lack of Doppler patterns). 2. Free fluid, or fluid filled spaces (hydrocoeles), caused by venous congestion. 3. Loss of uniform echogenicity (several dark and light patches) caused by ischaemia and necrosing tissue. 4. Swollen, engorged epididymis (mottled structure to the left of testes). The epididymis should be much less wide than the upper pole of the testis in a longitudinal ultrasound.