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Anatomy of the Scrotum

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DOI: 10.1007/174_2011_170

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Book Title
Series Title 174
Chapter Title Anatomy of the Scrotum
Copyright Year 2011
Copyright HolderName Springer-Verlag Berlin Heidelberg
Corresponding Author Family Name Trombetta
Particle
Given Name Carlo
Suffix
Division Department of Urology
Organization University of Trieste
Address Ospedale di Cattinara, Strada di Fiume 447, 34124, Trieste, Italy
Email trombcar@units.it

Author Family Name Liguori

Particle
Given Name Giovanni
Suffix
Division Department of Urology
Organization University of Trieste
Address Ospedale di Cattinara, Strada di Fiume 447, 34124, Trieste, Italy
Email
Author Family Name Ollandini
Particle
Given Name Gian Giacomo
Suffix
Division Department of Urology
Organization University of Trieste
Address Ospedale di Cattinara, Strada di Fiume 447, 34124, Trieste, Italy
Email
Author Family Name Napoli
Particle
Given Name Renata
Suffix
Division Department of Urology
Organization University of Trieste
Address Ospedale di Cattinara, Strada di Fiume 447, 34124, Trieste, Italy
Email
Author Family Name Mazzon
Particle
Given Name Giorgio
 Suffix
Division Department of Urology
Organization University of Trieste
Address Ospedale di Cattinara, Strada di Fiume 447, 34124, Trieste, Italy
Email
Author Family Name Petrovic
Particle
Given Name Miloš
Suffix
Division Department of Urology
Organization University of Trieste
Address Ospedale di Cattinara, Strada di Fiume 447, 34124, Trieste, Italy
Email

Abstract An adequate knowledge of normal anatomy of the scrotum and its content is mandatory to identify the
structures during imaging evaluation, and to understand their modifications when pathologies occur. In this
chapter anatomy of the scrotal wall, testis, and cord will be described with particular emphasis to the structures
that are clinically relevant and can be better recognized at ultrasound and other imaging modalities.
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1
Anatomy of the Scrotum
3
2
4 Giovanni Liguori, Gian Giacomo Ollandini, Renata Napoli, Giorgio
5 Mazzon, Miloš Petrovic and Carlo Trombetta
Author Proof

F
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PR
6 Contents Abstract 55
56
An adequate knowledge of normal anatomy of the 57
8
7 1 Introduction.............................................................. scrotum and its content is mandatory to identify 58

10
9 2 Scrotal Wall.............................................................. the structures during imaging evaluation, and to 59
12
11 2.1 Skin ............................................................................ understand their modifications when pathologies 60

D
14
13 2.2 Dartos ......................................................................... occur. In this chapter anatomy of the scrotal wall, 61
16
15 2.3 External Spermatic and Cremasteric Fascia.............
18
testis, and cord will be described with particular 62
17 2.4 Internal Spermatic Fascia..........................................
emphasis to the structures that are clinically
TE
63
20
19 3 Testis.......................................................................... relevant and can be better recognized at ultrasound 64
22
21 4 Tunica Vaginalis ...................................................... and other imaging modalities. 65

24
23 5 Tunica Albuginea.....................................................
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26 6 Structure of the Testis ............................................ 66

25 1 Introduction 67
28
27 7 Epididymis ................................................................
30
29 8 Appendages...............................................................
Among the male reproductive system, the scrotum, a 68
32
31 8.1 Appendix Testis and Epididymis .............................. thin external sac of skin, contains the two testes, the 69
34
33 8.2 Other Appendages ..................................................... epididymes and part of the spermatic cord. The
RR

70

36
35 9 Vascular Supply ....................................................... scrotum is a cutaneous pouch divided in its surface 71
into two lateral portions. It is derived from the 72
38
37 10 Spermatic Cord........................................................
labioscrotal folds, which under the influence of tes- 73
40
39 11 Lymphatic Drainage................................................ tosterone, swell and fuse to form twin scrotal sacs. 74
CO

42
41 12 Innervation ............................................................... The point of fusion is the median raphe, which 75

44
43 13 Congenital Anomalies..............................................
extends from the anus along the perineum to the 76
46
45 13.1 Scrotal Transposition................................................. ventral surface of the penis (Larsen 1993). Usually the 77
48
47 13.2 Funicular Anomalies ................................................. two parts of the scrotum are not fully symmetrical: the 78
50
49 13.3 Number Abnormalities of the Testis ........................ left side hangs lower than the right, due to a greater 79
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52
51 13.4 Position Abnormalities of the Testis ........................
length of left spermatic cord. 80
54
53 References..........................................................................

81
2 Scrotal Wall 82

G. Liguori
G. G. Ollandini
R. Napoli
G. Mazzon
The scrotal wall (Fig. 1) is composed of the following 83
M. Petrovic
C. Trombetta (&) structures, listed from the superficial to the deep 84
Department of Urology, University of Trieste, Ospedale di
Cattinara, Strada di Fiume 447, Trieste 34124, Italy layers: rugated skin, superficial fascia, dartos tunica, 85

e-mail: trombcar@units.it external spermatic fascia, cremasteric fascia, and 86

Medical Radiology. Diagnostic Imaging, DOI: 10.1007/174_2011_170, Ó Springer-Verlag Berlin Heidelberg 2011 1
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2 G. Liguori et al.

further. The tunica dartos acts to regulate the tem- 114

perature of the testicles, which promotes spermato- 115
genesis. It does this by expanding or contracting to 116
wrinkle the scrotal skin. The dartos is closely united 117
to the skin externally, but connected with the subja- 118
Author Proof

cent parts by delicate areolar tissue, upon which it 119

glides with the greatest facility. 120

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2.3 External Spermatic and Cremasteric 121
Fascia 122
Fig. 1 Layers of the scrotal wall. a Side view. b Transversal
view. 1 skin, 2 dartos, 3 external spermatic fascia or cremas- Prolonged downward around the surface of the cord 123
teric fascia, 4 cremaster muscle, 5 internal spermatic fascia or
tunica vaginalis communis, 6 epididymis, 7 testis, 8 visceral
and testis, the external spermatic fascia is a thin 124

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and parietal layers of the tunica vaginalis 9 vas deferens membrane, derived from the aponeurosis of the 125
external oblique muscle. It is separated from the 126
87 internal spermatic fascia. It varies from 2 to 8 mm in dartos by loose areolar tissue. The cremaster muscle 127
88 thickness (Leung et al. 1984). The system of different consists of scattered bundles of muscular fibers con- 128
89 membranes inside the scrotum avoids testes from nected together into a continuous covering by inter- 129

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90 being injured due to blows or squeezes and acts as a mediate areolar tissue. It is a thin layer of skeletal 130
91 covering and a protection to the testes: the testes lies muscle found in the inguinal canal and scrotum 131
92 suspended and loose in its cavity and are surrounded between the external and internal layers of spermatic 132
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93 by several different layers in order to allow them a fascia, surrounding the testis and spermatic cord. The 133
94 better mobility. cremaster muscle is a paired structure, there being one 134
on each side of the body. 135
Anatomically, the lateral cremaster muscle origi- 136
EC

95 2.1 Skin nates from the internal oblique muscle, just superior 137
to the inguinal canal, and the middle of the inguinal 138
96 The skin of the scrotum is a brownish layer, usually ligament. The medial cremaster muscle, which 139
97 thrown into folds or rugæ, which contains roots of sometimes is absent, originates from the pubic 140
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98 scattered, crisp hairs that cover the scrotum surface. It tubercle and sometimes the lateral pubic crest. Both 141
99 is very elastic and capable of great distension, and on insert into the tunica vaginalis underneath the testis. 142
100 account of the looseness and amount of subcutaneous
101 tissue, the scrotum becomes greatly enlarged in cases
102 of edema, to which this part is especially liable as a 2.4 Internal Spermatic Fascia 143
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103 result of its dependent position.

The infundibuliform fascia (tunica vaginalis communis) 144
is a thin layer, which loosely invests the cord; it is a 145
104 2.2 Dartos continuation downward of the transversalis fascia. 146
UN

105 The tunica dartos is a fat-free thin layer of smooth

147
106 muscular fibers: it is a continuation of Scarpa’s fascia 3 Testis 148
107 which is a membranous layer of the subcutaneous
108 tissue in the abdominal wall. The dartos divides the The testes, or testicles, are two glandular organs, 149
109 scrotum into two cavities, each containing one testis, which secrete the semen, and are suspended in the 150
110 through an inward septum that extends between the scrotum by the spermatic cords. Usually, the left testis 151
111 raphe and the under surface of the penis. In older hangs lower than its fellow. They normally, complete 152
112 males, the dartos muscle loses its tone, and tends to their descent into the scrotum from their point of 153
113 cause the scrotum to be smoother and to hang down origin on the back wall of the abdomen in the seventh 154
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Anatomy of the Scrotum 3

155 month after conception. At an early period of fetal life while the lower one remains as a shut sac, covering the 202
156 the testes are contained in the abdominal cavity, surface of the testis. The tunica vaginalis is divided into 203
157 behind the peritoneum. Before birth they descend into two parts: the visceral and the parietal lamina. The 204
158 the inguinal canal with the spermatic cord, and then visceral lamina (lamina visceralis) covers the greater 205
159 into the scrotum, becoming invested in their course by part of the testis and epididymis. It reflects on to the 206
Author Proof

160 coverings derived from the serous, muscular, and internal surface of the scrotum from the posterior bor- 207
161 fibrous layers of the abdominal walls, as well as by der of the gland. The parietal lamina (lamina parietalis) 208

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162 the scrotum. is larger than the visceral lamina, extending upward in 209
163 Testicular size depends on age and stage of sexual front and on the medial side of the cord and reaching 210

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164 development. At birth, the testes measure approxi- below the testis. The visceral and parietal laminæ set a 211
165 mately 1.5 cm in length and 1 cm in width. Before the virtual cavity inside the tunica vaginalis. Several 212
166 age of 12 years testicular volume is around 1–2 cm3. pathological processes can involve this space, pre- 213
167 Clinically, a male individual is considered to have dominantly in the form of fluid collections. Hydroceles 214
168 reached puberty once the testis achieves volume of occur when serous fluid accumulates between the 215

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169 4 cm3. On average, testes of adults are 3.8 cm long, parietal and visceral layers of the tunica vaginalis. 216
170 3 cm wide, and 2.5 cm deep and have a volume of A small amount of fluid is normal and has been noted at 217
171 30 ml. The weight varies from 10.5 to 14 g (Leung sonography in up to 86% of asymptomatic men (Leung 218
172 et al. 1984). Testes are oval and have an oblique posi- et al. 1984). When the tunica vaginalis does not become 219
173 tion in the scrotum: the upper extremity is directed obliterated and still communicates with the perito- 220

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174 forward and a little lateralward; the lower, backward neum, an oblique inguinal hernia usually appears. 221
175 and a little medialward; the anterior convex border
176 looks forward and downward, the posterior or straight
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222
177 border, to which the cord is attached, backward and 5 Tunica Albuginea 223
178 upward. Prepubertal testes are of low to medium ech-
179 ogenicity, whereas pubertal and postpubertal testes are The tunica albuginea is an inextensible, fibrous layer 224
180 of medium homogeneous echogenicity, reflecting the that covers the testis composed of bundles of collag- 225
EC

181 development of germ cell elements and tubular matu- enous and smooth muscle elements which interlace in 226
182 ration (Siegel 1997). every direction. It is covered by the tunica vaginalis, 227
183 Each testis is enclosed in a fibrous inextensible sac, except along the posterior border of the testis where 228
184 the tunica albuginea. This sac is lined internally by the the spermatic vessels enter the gland and at the epi- 229
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185 tunica vasculosa, which contains a network of blood didymis. At ultrasound, the tunica albuginea can be 230
186 vessels, held together by areolar tissue. The anterior seen as a thin echogenic line around the testis. 231
187 border, lateral surfaces, and both extremities of the The mediastinum testis (corpus highmori) is an 232
188 testis are convex, free, smooth, and invested by the invagination of the tunica albuginea, from which 233
189 visceral layer of the tunica vaginalis. The posterior multiple septa (trabeculae) arise dividing the testis 234
CO

190 border of the testis, to which the cord is attached, into multiple (250–400) lobules (Fig. 2a). The medi- 235
191 receives only a partial investment from that membrane astinum extends from the upper to near the lower 236
192 and is covered by the epididymis on the lateral edge. extremity of the gland, and supports the vessels and 237
ducts of the testis in their passage to and from the 238
parenchima of the gland. At ultrasound, it is identified 239
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193
194 4 Tunica Vaginalis as an echogenic band of variable thickness and length 240
extending in a caudocranial direction. 241
195 The tunica vaginalis (tunica vaginalis propria testis) is a
196 pouch of serous membrane that invests the testis, cov-
242
197 ered by a layer of endothelial cells in the inner surface. 6 Structure of the Testis 243
198 It derives from the saccus vaginalis of the peritoneum,
199 which in the fetus preceded the descent of the testis The lobules are cone-shaped spaces that become nar- 244
200 from the abdomen into the scrotum. After its descent, rower as they converge to the mediastinum and con- 245
201 the upper portion of the pouch becomes obliterated, tains one to three convoluted seminiferous tubules 246
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4 G. Liguori et al.

convoluted, and form a sort of conical masses, called 280

the coni vasculosi, which together constitute the head 281
of the epididymis. These multiple ducti converge 282
within the body and tail of the epididym into a single 283
larger duct (Hirsh 1995). 284
Author Proof

F
285
7 Epididymis 286

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Sperm cells produced in the testes are transported to the 287
epididymes, where they mature and are stored. Each 288
Fig. 2 Anatomy of the testis and epididymis. a Longitudunal epididymis has three regions (Fig. 2), called, respec- 289
anatomical section. b Inner structure of the spermatic route. tively, the head (globus major), body, and tail (globus 290
1 tunica albuginea, 2 lobules, 3 mediastinum testis, 4 seminif-
erous tubules, 5, rete testis, 6 head of the epididymis, 7 body of minor). The head is intimately connected with the 291

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the epididymis, 8 tail of the epididymis, 9 vas deferens upper end of the testis by means of the efferent ductules 292
of the gland; the tail is connected with the lower end by 293
247 (Fig. 2b). These are supported by loose connective cellular tissue, and a reflection of the tunica vaginalis. 294
248 tissue which contains somewhere groups of ‘‘interstitial The body is attached to the posterior side of the testis 295
249 cells’’ (Leydig cells) responsible for testosterone pro- and extends the length of the gland. The lateral surface, 296

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250 duction. The total number of tubules is estimated at head and tail of the epididymis are free and covered by 297
251 840, and the average length of each is 70–80 cm. Their the serous membrane; the body is also completely 298
252 diameter range from 0.12 to 0.3 mm. Within the invested by it, excepting along its posterior border; 299
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253 tubules spermatocytes and the supporting Sertoli cells while between the body and the testis is a pouch, named 300
254 give rise to sperm. The development of the spermato- the sinus of the epididymis (digital fossa). The smallest 301
255 zoa begins around the inner extremities of the sup- region is the tail, which begins at the point of separation 302
256 porting cells. The nuclear portion of the spermatid, of the epididymis from the testis. Sperm cells mature 303
EC

257 which is partly imbedded in the supporting cell, is primarily in the head and body of the epididymis and 304
258 differentiated in the head of the spermatozoön, while are stored in the tail (Bostwick 1997). The epididymis is 305
259 part of the cell protoplasm forms the middle piece and best evaluated in a longitudinal view when the epi- 306
260 the tail is produced by an outgrowth from the double didymal head (globus major) can be seen as a pyramidal 307
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261 centriole of the cell. Ultimately the heads are liberated structure 5–12 mm in maximum length lying atop the 308
262 and the spermatozoa are set free (Gray 1918). In the superior pole of the testis. The head of the epididymis is 309
263 apices of the lobules, the tubules become less convo- usually isoechoic to the testis, and its echotexture may 310
264 luted, assume a nearly straight course, and unite toge- be coarser than that of the testis (Bree and Hoang 1996; 311
265 ther to form about twenty to thirty larger ducts, of about Dambro et al. 1998). The narrow body of the epididy- 312
CO

266 0.5 mm. in diameter, called tubuli recti. They enter the mis (2–4 mm in diameter), when normal, is usually 313
267 fibrous tissue of the mediastinum, and pass upward and indistinguishable from the surrounding peritesticular 314
268 backward, forming a close network of anastomosing tissue. The tail of the epididymis (globus minor) is 315
269 tubes, called rete testis (Fig. 2b). The normal rete testis approximately 2–5 mm in diameter and can be seen as a 316
270 can be identified at high-frequency US in 18% of curved structure at the inferior pole of the testis, where 317
UN

271 patients as a hypoechoic area with a striated configu- it becomes the proximal portion of the ductus deferens. 318
272 ration adjacent to the mediastinum testis (as opposed to
273 the tubular ectasia of the rete testis when it is seen as
319
274 fluid-filled dilated tubular structures) (Thomas and 8 Appendages 320
275 Dewbury 1993).
276 The rete testis terminates at the upper end of the Testicular and epididymal appendages were once 321
277 mediastinum perforating the tunica albuginea with the considered anatomic anomalies, however, some 322
278 ductuli efferentes (from 10 to 15). Their course is studies report that these structures are present in the 323
279 firstly straight, then the ducts become enlarged, majority of normal individuals. Such appendages are 324
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Anatomy of the Scrotum 5

325 easily seen at scrotal ultrasound. When they are too the epididymis. The paradidymis, also called parepi- 352
326 long or pedunculated, appendages can twist around didymis, is a small body, sometimes attached to the 353
327 their own axis, causing very painful symptoms, sim- front of the lower part of the spermatic cord, above 354
328 ulating torsion of the spermatic cord (Favorito et al. the head of the epididymis, composed of the remnants 355
329 2004). There are also reports on tumors originated of tubules of the mesonephros (Murnaghan 1959). 356
Author Proof

330 from these structures. Four testicular appendages have

331 been described: the appendix testis, the appendix

F
357
332 epididymis, the vas aberrans, and the paradidymis 9 Vascular Supply 358
333 (Fig. 3). These are remnants of embryonic ducts

OO
334 (Trainer 1992). The right and left spermatic arteries, branches of the 359
abdominal aorta, arise just distal to the renal arteries 360
and provide the primary vascular supply to the testes 361
335 8.1 Appendix Testis and Epididymis (Fig. 4). They enter the spermatic cord at the deep 362
inguinal ring and divide into two main branches: 363

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336 The appendix testis (hydatid of morgagni) is a testicular and epididymal artery. Testicular artery 364
337 müllerian duct remnant and consists of fibrous tissue continues along the posterior surface of the testis, 365
338 and blood vessels within an envelope of columnar penetrating the tunica albuginea and building a 366
339 epithelium (Bucci et al. 2002). It is attached to the vascular terminal system, made of capsular and in- 367
340 upper pole of the testis in the groove between tratesticular arteries, within the tunica vasculosa. 368

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341 the testis and the epididymis. In postmortem studies, Centripetal branches arising from the capsular 369
342 the appendix testis has been identified in 92% of arteries carry blood toward the mediastinum, where 370
343 testes unilaterally and in 69% bilaterally. The they divide to form the recurrent branches that carry 371
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344 appendix epididymis is attached to the head of the blood away from the mediastinum into the testis. 372
345 epididymis and has been encountered unilaterally in A transmediastinal arterial division of testicular 373
346 34% and bilaterally in 12% of testes in postmortem artery is evident in approximately 50% of normal 374
347 series (Rolnick et al. 1968). testes; it courses through the mediastinum to supply 375
EC

the capsular arteries and is usually accompanied by a 376

large vein (Middleton and Bell 1993). The deferen- 377
348 8.2 Other Appendages tial artery, a branch of the superior vesicle artery, 378
and the cremasteric artery, a branch of the inferior 379
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349 The vas aberrans is a blind tube that is occasionally epigastric artery, supply the epididymis, vas 380
350 present parallel to the first part of the vas deferens and
351 that may communicate with the vas deferens or with
Fig. 4 Vascularization of the
testis and epididymis.
1 internal iliac vessels,
CO

Fig. 3 Anatomical location 2 deferential vessels,

of appendages. Epididimal 3 inferior epigastrc vessels,
appendage (curved arrow), 4 external spermatic vessels,
testicular appendage (arrow 5 pampiniform plexus,
head), paraepididymis 6 internal spermatic vessels,
(arrow), superior and inferior 7 internal spermatic fascia,
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vas aberrans (*) 8 cremasteric muscle,

9 deferential vessels
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6 G. Liguori et al.

381 deferens, and peritesticular tissue (Siegel 1994). The anastomoses building a supplementary circulation 430
382 number and locations of anastomoses vary between system. Whereas the contribution of deferential and 431
383 the testicular artery and its branches and between the cremasteric veins to the total amount of blood 432
384 artery to the vas deferens and the cremasteric artery. drainage is low, both in healthy and varicocele-suf- 433
385 Branches of the pudendal artery supply the scrotal fering men, on the contrary, the external pudendal 434
Author Proof

386 wall. vein plays an important role, especially after the 435
387 Venous anatomy of the scrotum is very complex treatment of varicocele (ligation or sclerotization of 436

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388 (Dogra et al. 2003). The subcutaneous veins are the internal spermatic veins). 437
389 divided into anterior and posterior scrotal veins. The The deferential vein ascends with the deferential 438

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390 former drain into the external pudendal veins, drained artery and duct within the spermatic cord and drains 439
391 themselves into the major saphenous or directly into into the vesicoprosthatic plexus. Therefore, it is 440
392 the femoral vein. The latter drain into the internal connected to the internal iliac vein: its preservation 441
393 pudendal vessels through the deep dorsal vein of the after varicocele correction prevents testicular 442
394 penis. The deep venous system originates as a plexus, congestion. 443

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395 anatomically schematized into anterior and posterior The cremasteric vein, (or external spermatic veins) 444
396 pampiniform plexuses. This plexus runs with a pattern runs into the posterior section of the deep venous 445
397 of a decreasing number of constituents into the sper- system of the testis outside the funicle, and drains 446
398 matic funicle forming three main groups—anterior blood into the inferior epigastric or into the big 447
399 group: including the spermatic vein, intermediate saphenous vein to the external iliac vein. 448

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400 group: including the ductus deferens vein (a layer of Soon after originating from the pampiniformis 449
401 the internal spermatic fascia separate it from the plexus, the external pudendal vein runs on the side, to 450
402 anterior group); posterior group: including the crem- reach the big saphenous vein or the femoral vein 451
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403 asteric veins. directly draining blood into the external iliac vein. 452
404 The anterior pampiniform plexus drains the blood The scrotal veins, a superficial venous system of 453
405 coming from the testicle and the head of the epidid- the scrotum, drain into the external pudendal vein too, 454
406 ymis. It is composed of 3–9 veins greatly connected but they also communicate with the internal pudendal 455
EC

407 with the deferential and cremasteric veins in a large vein, reaching the internal iliac through the superficial 456
408 amount of anastomoses. The normal size of these veins of the perineum. 457
409 veins ranges from 0.5 to 1.5 mm in diameter, with the
410 main draining vein being as large as 2 mm in
458
10 Spermatic Cord
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411 diameter. 459

412 Beyond the internal inguinal orifice, the spermatic
413 vein turns back into the retroperitoneum; here this The vas deferens, testicular artery, cremasteric artery, 460
414 vein can be single, double, or even multiple. On the deferential artery, pampiniform plexuses, genitofem- 461
415 left side, the spermatic vein connects with the left oral nerve, and lymphatic vessels compose the sper- 462
CO

416 renal vein, whereas on the right side it drains matic cord, which begin at the deep inguinal ring and 463
417 directly into the vena cava. It is a propulsive-type descends vertically into the scrotum. The spermatic 464
418 vein, as mostly happens below the diaphragm. Most cord or funicle is an organ of cylindrical shape sur- 465
419 of these veins that drain blood against gravity, rounded by adipose tissue and enveloped within three 466
420 contain semilunar valves, forming membranous fasciae: the external spermatic fascia, an extension of 467
UN

421 pouches, in order not to allow blood reflow. It is the oblique muscle’s aponevrosis; the cremasteric 468
422 highly discussed in the scientific literature whether fascia and muscle, that is a continuation of the 469
423 semilunar valves are present within the spermatic internal oblique muscle and its fascia; the internal 470
424 vein or not. There is no clear evidence of a role of spermatic fascia, extending from the transversalis 471
425 the semilunar valves on varicocele’s pathogenesis fascia. The spermatic cord should be evaluated in 472
426 (Wishahi 1992). every scrotal ultrasound examination. It lies just 473
427 The deferential, cremasteric, and external puden- below the skin but can sometimes be difficult to dis- 474
428 dal vein originate from the posterior pampiniform criminate it from surrounding soft tissue (Woodward 475
429 plexus and are highly connected with several et al. 2003). 476
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Anatomy of the Scrotum 7

at birth is rather frequent, being present in 94% of 517

477
478 11 Lymphatic Drainage infants. The complete or partial persistence of a patent 518
peritoneal-vaginal duct may lead to three different 519
479 Lymph vessels are made of 4–8 collector ducts, that run diseases: hydrocele, cord cyst, and inguinal hernia. 520
480 aside to the spermatic vessels, and reach abdomino- The accumulation of peritoneal fluid through the 521
Author Proof

481 aortic lymph nodes along aortic biforcation, until renal peritoneal-vaginal duct leads to formation of a con- 522
482 vessels. There is also a supplementary lymphatic genital hydrocele. This event is particularly frequent 523

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483 pathway reaching the external iliac lymph nodes. at birth, but spontaneous closure of the duct during 524
the first year of life leads to spontaneous resolution in 525

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484
485 12 Innervation most of cases (Garriga et al. 2009). If there is the 526
overlap of inflammatory phenomena, the differential 527

486 The skin and dartos of the scrotum are largely sup- diagnosis with other causes of acute scrotum can be 528

487 plied posteriorly by the posterior scrotal nerves and particularly difficult. The persistence of a hydrocele 529

by branches of the pudendal nerve which supply the after two years of life expresses a condition that has 530

PR
488
489 sensory innervation to the external genitalia. The no chance of spontaneous resolution. 531

490 perineal branches of the posterior femoral cutaneous A partial obliteration of the peritoneal-vaginal duct 532

491 nerves expand laterally toward the scrotum. Its ante- can lead to the formation of a cyst of the spermatic 533

492 rior and upper part is supplied by the ilioinguinal and cord that may be present at every level, from the 534

493 genitofemoral nerves, the ilioinguinal nerve originat- scrotum to the inguinal canal. The ultrasound diag- 535

D
494 ing from the lumbar plexus and descending through nosis is usually easy, but particular attention should 536

495 the superficial inguinal ring to form the anterior be given to the differential diagnosis of congenital 537
hernia, a disease which is often associated. 538
TE
496 scrotal nerves. The genitofemoral nerve supplies both
497 the skin and the cremasteric muscle (Yachia 2007).

498 13.3 Number Abnormalities of the Testis 539

499 13 Congenital Anomalies
EC

Absence of one (monorchidism) or both (anorchi- 540

500 Several scrotal congenital abnormalities may be rec- dism) testes is a rare occurrence, reported in a vari- 541
501 ognized. Among them, abnormalities of the position able percentage from 3.3 to 5.2% of patients operated 542
502 of the scrotum, funicular abnormalities, as well as on for cryptorchidism. The absence is unilateral in 543
503 variation in the number and position of the testes
RR

80% of cases (Messina et al. 2000). 544

504 should be considered. Before concluding for an absent testis, a careful 545
instrumental evaluation is mandatory to eventually 546
505 13.1 Scrotal Transposition identify the missed testis elsewhere (testicular 547
ectopy). 548
CO

506 The abnormal descent of the scrotum leads to scrotal Poliorchidism is very rare compared to monor- 549
507 transposition: in these cases the penis is lying side- chidism or anorchidism. It is represented by the 550
508 ways or behind the scrotum, or in the middle of it. presence of a supernumerary testis, generated by an 551
509 The complete transposition of the scrotum, which abnormal transverse division on embryonic gonad. 552
510 represents the true ectopy is rare and is usually The supernumerary gonad can be normal sized and 553
UN

511 associated with other severe malformations, such as may or may not be connected with the seminal ducts. 554
512 perineal hypospadias, absence of the urinary tract, In adults it can actively contribute to normal sper- 555
513 polycystic kidneys, and imperforated anus. matogenesis (Smart 1972), but often, although histo- 556
logically normal, their spermatogenesis is abnormal. 557
Poliorchidism is very often associated with other 558
514 13.2 Funicular Anomalies anomalies, such as hydrocele, hernia (30% of cases) 559
or cryptorchidism (50% of cases). The supernumerary 560
515 The closure of the peritoneal-vaginal duct is a late testes are intrascrotal in approximately 75% of cases, 561
516 event during embryonic development and its patency presenting as painless scrotal masses. Of the 562
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Chapter No.: 170 Date: 26-2-2011 Page: 8/8

8 G. Liguori et al.

563 remaining cases, 20% of the testes are inguinal and Dogra VS, Gottlieb RH, Oka M et al (2003) Sonography of the 604

564 5% retroperitoneal (Bostwick 1997). scrotum. Radiology 227:18–36 605

Favorito LA, Cavalcante AG, Babinski MA (2004) Study 606
on the incidence of testicular and epididymal appen- 607
dages in patients with cryptorchidism. Int Braz J Urol 608
565 13.4 Position Abnormalities of the Testis 30:49–52 609
Garriga V, Serrano A, Marin A et al (2009) US of the tunica 610
Author Proof

vaginalis testis: anatomic relationships and pathologic 611

566 Testicular ectopy is defined as the presence of the

F
conditions. Radiographics 29:2017–2032 612
567 testicle outside the normal route of descent. Gray H (1918) Anatomy of the human body. Lea & Febiger, 613
568 Depending on the position, five ectopic sites can be Philadelphia 614

OO
569 generally recognized: superficial inguinal above the Hirsh AV (1995) The anatomical preparations of the human 615
testis and epididymis in the Glasgow Hunterian Anatomical 616
570 band of external oblique muscle, perineal, femoral or Collection. Hum Reprod Update 1:515–521 617
571 crural, contralateral (in which both testes are in the Larsen W (1993) Human embriology. Churchill Livingstone, 618
572 same inguinal channel), pelvic. New York 619
573 The undescended testis results in a pathological Leung ML, Gooding GA, Williams RD (1984) High-resolution 620

PR
sonography of scrotal contents in asymptomatic subjects. 621
574 condition widely known, and called cryptorchidism. AJR Am J Roentgenol 143:161–164 622
575 Cryptorchidism is an extremely common disease with Messina M, Ferrucci E, Zingaro P et al (2000) Epididymal 623
576 an incidence of 3.4% in normal newborns and 30.3% anomalies in cryptorchidism and in peritoneal-vaginal duct 624
577 in preterm ones. The undescended testis may be persistence. A multicentric study. Minerva Urologica e 625
Nefrologica 52:189–193 626
578 positioned anywhere along the normal path of des- Middleton WD, Bell MW (1993) Analysis of intratesticular 627

D
579 cent. The most common location is in the inguinal arterial anatomy with emphasis on transmediastinal arteries. 628
580 canal (72%), followed by prescrotal (20%) and Radiology 189:157–160 629
581 abdominal (8%) locations (Nguyen et al. 1999). The Murnaghan GF (1959) The appendages of the testis and 630
TE
epididymis: a short review with case reports. Br J Urol 631
582 undescended testis is generally smaller and less 31:190–195 632
583 echogenic than the normal testis. Nguyen HT, Coakley F, Hricak H (1999) Cryptorchidism: 633
584 The major complications of cryptorchidism are strategies in detection. Eur Radiol 9:336–343 634
585 malignant degeneration, infertility, torsion, and bowel Rolnick D, Kawanoue S, Szanto P et al (1968) Anatomical 635
EC

incidence of testicular appendages. J Urol 100:755–756 636

586 incarceration because of an associated indirect Siegel BA (ed) (1994) Diagnostic ultrasonography test and 637
587 inguinal hernia. Orchiopexy of a cryptorchid testis is syllabus (second series). American College of Radiology, 638
588 usually performed in patients between 1 and 10 years Reston, pp 148–149 639
589 of age; orchiectomy is considered for postpubertal Siegel MJ (1997) The acute scrotum. Radiol Clin North Am 640
35:959–976 641
RR

590 patients (Dogra et al. 2003). Smart RH (1972) Polyorchism with normal spermatogenesis. 642
J Urol 107:278 643
Thomas RD, Dewbury KC (1993) Ultrasound appearances of 644
591 the rete testis. Clin Radiol 47:121–124 645
592 References
Trainer TD (1992) Testis and the excretory duct system. In: 646
Sternberg SS (ed) Histology for pathologists. Raven, New 647
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593 Bostwick DG (1997) Spermatic cord and testicular adnexa. In: York, pp 744–746 648
594 Bostwick DG, Eble JN (eds) Urologic surgical pathology. Wishahi MM (1992) Anatomy of the spermatic venous plexus 649
595 Mosby, St Louis, pp 647–674 (pampiniform plexus) in men with and without varicocele: 650
596 Bree RL, Hoang DT (1996) Scrotal ultrasound. Radiol Clin intraoperative venographic study. J Urol 147:1285–1289 651
597 North Am 34:1183–1205 Woodward PJ, Schwab CM, Sesterhenn IA (2003) From the 652
598 Bucci S, Liguori G, Buttazzi L et al (2002) Bilateral testicular archives of the AFIP: extratesticular scrotal masses: radi- 653
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599 carcinoma in patient with the persistent mullerian duct ologic-pathologic correlation. Radiographics 23:215–240 654
600 syndrome. J Urol 167:1790 Yachia D (2007) Surgical anatomy of the penis and scrotum. In: 655
601 Dambro TJ, Stewart RR, Barbara CA (1998) The scrotum. In: Yachia D (ed) Text atlas of penile surgery. Healthcare 656
602 Rumack CM, Wilson SR, Charboneau JW (eds) Diagnostic Informa, London, pp 1–8 657
603 ultrasound, 2nd edn. Mosby, St Louis, pp 791–821
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