GU

Scrotum
 Appendix testes – Mullerian duct remnant
o Upper pole between testis and epididymis – when it torses it calcifies and
becomes scrotal pearl
 Extratesticular mass that looks just like testes – Polyorchidism
o Abnormal division of ge
o nital ridge
 Large RP lymphadenopathy – have to think of testicular/ovarian pathology
 Adrenal rests – ectopic adrenal tissue in testes – bilateral symmetrical masses with hx
of adrenal insufficiency
o Enlarge with ACTH exposure
 Intratesticular pathology
o Tumor
 Risk factors: cryptorchidism, previous malignancy,
 Burned out germ cell tumor – nonmetabolically active testicular lesion
with mets – primary no longer active
 Painless – some present with mets
 Pain with infarct/hemorrhage/torsion
 Germcell – seminoma/others
 Seminmoa – not aggressive, Older people, Hypoechoic mass –
replaces rest of testicular tissue, squishes parynchema of normal
testes
 Nonseminoma (Embryonal)– more aggressive, younger patients
o Present with adenopathy
o Areas of necrosis/calcification? Not an infarct – think
about tumor
o Teratoma: immature = neural elements – both malignant
mature/immature
o Fat, calcium, scars, cystic/solid components
 Nonseminoma – stromal tumor (Leydig/Sertoli)
 YOUNG MEN
 Mets everywhere with testicular mass – choriocarcinoma
 Cystic more over
 Granulosa cell – cause endometrial hyperplasia
o Excessive estrogen production causes
bleeding/hyperplasia
 Sertoli-leydig – virilization
o Sold mass with intramural cysts
 Lymphoma
 Bilateral, very old patients
 Patients with lymphoma or DLBL
 Follow up other testicle – need ppx orchiectomy
  TESTICULAR METS
 Leukemias and Rhabdo
 Lung and prostate also common
 Mostly silent – “sanctuary for mets”
o Nonneoplastic
 Infarcts: hypoechoic well circumscribed no flow
 Decreases in size over time – unlike tumor
o Leave me alone lesions – do not bx or excise
 Testicular cysts
 Dilated rete testes – epidiymal obsx , always associated with the
mediastinum testes
 If you’re worried about teratoma – bright on T2 – germ cell
neoplasm hypointesnse on T2 – won’t enhance
 Epidermoid – AVASCULAR not a tumor
 Keratinizing squamos fibrous balls
o Partially calcified and avascular
 Tunica cysts – arise from tunica, may calcify
 Can fall off and become scrotal
Adnexal masses
 Functional ovarian cysts – usually asymptomatic pain if ruptured – their should be no
color
o >3cm – if something is less <3 = dominant follicle
o T2 bright unilocular lesions
o Corpus luteal cysts – thick irregular, vascular wall – see it in pregnancy and afer
ovulation
 Can appear solid – intraovarian lesion
 Ring of fire appearance
 Ddx ecotopic – llow resistance flow in wall, this is also intraovarian
(intraovarian ectopics are exceedingly rare)
o Hemorrhagic cysts – fluid/heme levels = subacute, acute is variable in
appearance
 Retracting clot, “reticular, fish net, cob web or lacy”
 No color flow!
 Sometimes bleed enough to require surgery
o >7cm follicular cysts = MR
o 5cm hemorrhagic cysts – 6-12weeks
 Theca lutein and OHHS LOOK THE SAME
o High HCG – trophoblastic/ovarian hyperstim syndrome (drug induced)
o OHS – huge multicystic stx in adnexa with IUP

o OHS with Intrauterine mass = Theca lutein cyst
o OHS with nothing = OHS
 Endometreiosis
 o Peritoneal implants cause the problem
o Likely to see endometrioma – GG homogenous echotexture, with acoustic
enhancement
 High T1, DARK T2
 Chocolate fluid (not simple)
 NO COLOR
 Ddx – endometrioma vs hemorrhagic cyst
o Cysts change very rapidly with time
o Endometrioma with enhancing nodule – clear cell/endometroid ovarian cancer
 Torsion
o Swolling/engorged ovary most sensitive sign
o Presence of color do not exclude diagnosis – if high suspicion if the ovary is
enlarged and tender
o MR/CT findings – Paraovarian cysts can cause torsion – if cyst is moving in time
this can cause symptoms of torsion – OVARY DOESN’T ENHANCE
 T2 bright follicles on MRI with edema – follicles displaced to the side
 Big cyst on top/bottom that twisted
 PCOS – Lots of follicles, enlarged ovary
o Can only see morphology
 Post menopausal
o Cysts in postmenopausal wome and worrisome – but can get little cysts
o 1-7cm f/y, ?cm do an MRI or do surgery
 Adnexa
o Tubal pathology
 Tubular, wasite sign, retort, beads on a string
o Hydrosalpinx – tubular cystic stx – t2 bright
 Can get MRI and look for T2 bright
 “incomplete septum is the bend in the tube”
 PID
o Tuboovarian complex – pyosalpinx – next to ovary – then ovary engulfs abscess
 TOC vs TOA
 Pus spreads throughout peritoneal cavity – Fitz hugh Curtis
 Ovarian vein thrombophlebitis
 Peritoneal inclusion CT
o Loculated peritoneal fluid
o Ovaries secrete fluid that are bound by loculated bands
 Paraovarial/Paratuball – separate from ovaries and separate from tube
o No imaging differences
 Non GYN masses
o Neurofibroma – on enhance avidly
 If lateral to ureter it is no ovarian
 Ovarian dysgerminoma
 o Purely solid locules dividd by speta – T1 darker than muscle, enhance after
contrast
 Ovarian fibromas
o Fibrothecoma – meig syndrome – b/l pleural effusions
Bladder
 Growth through muscle layer is turning point
 Submucosal masses
o “obtuse margins” submucosal
 Transitional cell carcinoma
o High grade – calcs
o Can be multifocal all the way up to the ureter – can have synchronous kidney
lesions
o Staging – MR superior to CT
 Detrusor is T2 dark, tumor is T2 bright
 Squamos cell – worse prognosis
o Angry and invasive – invades adjacent organ more than Transitional
 Adenocarcinoma
o Urachal association – umbilical discharge!
o Foal thickening in bladder that grows all the way up to umbilicus
o Resect everything up to umbilicus
 Mets – looks like linitis plastica – diffuse bladder wall thickening
 Mesenchymal tumors
o Lot of sarcomas, osteosarc, lymphoma
 Leiomyoma – T2 dark, homogenous – looks like a uterine leimyoma
o Leiomyosarc – heterogenous – central necrosis is bad sign – high T2 in the
middle
 Rhabdomyosarcoma – grape like bladder tumor in kids
o Sarcoma botryoides
 Avidly enhancing mass – think neural tissue paraganglioma
 Lymphoma – diffuse lymphoma involves ladder
o Such as mets DLBL involving the liver
 Leukemia –
 Other causes diffuse thickening – neurogenic bladder, cystitis, chemo, radiation
o Shistosoma – thicke bladder with curvilinear calcs
 Can show you in distal urter too
 On radiograph or on US
o Fistual ot bladder
 Diverticular fistula with bladder
 Crohns disease from terminal ileum
o Inflammatory pseudotumor
 Retraction of bladder wall with polypoid tumor = puls in muscle layer
 BPH
o Focal growth in the midline of bladder
 Cervical carcinoma – very agerssive and can see a fistula between bladder and cervix
after tx
