TESTES, SCROTUM and PROSTATE

The Scrotum, Testis, Epididymis I. Introduction/ General Information A. Scrotum 1. Medial pendant pouch of loose skin & superficial fascia (Grays) 2. Raphe (Gr. seam or suture):
Superficial division between compartments

3. Left side lower than right

Introduction, continued

4. Dartos muscle (lies in fascia)

a. Temperature sensitive response hot = relax cold = contract b. Right & left compartments c. Testis, epididymis, tunica vaginalis in each

Scrotum, Testes, Epididymis, cont

B. Testis 1. Suspended in scrotum by spermatic cord 2. 4 - 5 cm long 3. Weigh 10.5 - 14 grams 3. Oval

Anatomy of the Male Pelvis

Testis, continued

4. Descend from abdominal cavity prior to birth

a. As they descend they collect various coverings

b. Layers of abdominal wall

Scrotum, Testis, Epididymis, continued

C. Epididymis
1. Highly coiled tube 2. 15 - 16 feet long 3. Located on posterior & superior margins of testes 4. Elongated, flattened structures

Epididymis, continued

5. Partially covered by visceral layer of the tunica vaginalis 6. Structurally divided into a head, body, and tail 7. Tail is continuous with vas deferens 8. Head receives efferent ductules from testes

Testicular Anatomy

Testicular Anatomy, cont

D.

Appendages
1. Appendix of the testis
a. Lies beneath head of Epididymis
b. Remnant of the Mullerian duct (gives rise to uterine tubes, uterus in female) c. May be referred to as Hydatid of Morgagni

Testicular Anatomy, cont

Appendix of Testis

Appendix of Testis

Appendages, continued

2.

Appendix of the Epididymis

a. Attached to head of Epididymis b. Detatched, modified efferent duct c. Remnant of mesonephric duct (primitive Epididymis, vas deferens)

Appendages, continued
Appendix of Epididymis

Appendix of Epididymis

II. Detailed Anatomy A. Superficial inguinal rings

(of inguinal canal) 1. Triangular openings in abdominal muscle 2. Superior & lateral to pubic tubercles 3. House contents of spermatic cord

Anatomy of the Spermatic Cord

Deep inguinal ring

Superficial inguinal ring

Detailed Anatomy, continued

B. Scrotum 1. Layers, beginning superficially

a. Superficial fascia 1. skin & tunica dartos b. Colles fascia 1. membranous layer of superficial fascia 2. continuous over penis & scrotum

Scrotum, continued

c. External spermatic fascia: derived

from

1. transversus abdominis 2. internal oblique muscle d. Cremasteric fascia: derived from 1. transversus abdominis 2. internal oblique muscle e. Internal spermatic fascia: derived from transversalis muscle

Detailed Anatomy, Layers of the Scrotum, continued

Superficial (Dartos) Fascia Colles Fascia External Spermatic Fascia Cremasteric Fascia Internal Spermatic Fascia Parietal Layer, Tunica Vaginalis Visceral Layer, Tunica Vaginalis Tunica Albuginea Skin

Scrotum, continued

f. Layers of peritoneum have serous fluid between to allow mobility 1. Parietal layer of tunica vaginalis a. Lines scrotal sacs 2. Visceral layer of tunica vaginalis a. covers testis b. part of epididymis

Scrotum, detailed anatomy, continued

2. Testis (superficial to deep)

a. b. c. d. Visceral layer of tunica vaginalis Tunica albuginea (capsule of testis) Seminiferous tubules Mediastinum testis (aka: hilum of testis)
- Efferent Ductules - Rete testis (network of tubules)

Testicular Anatomy (Netter, Plate 371)

Efferent Ductules Rete Testis Seminiferous Tubules Mediastinum Testis Tunica Albuginea

Detailed Anatomy, continued

C. Spermatic Cord 1. Coverings from abdominal wall 2. Each spermatic cord contains:
a. Ductus (vas) deferens b. Deferential artery & vein c. Sympathetic nervous system fibers

Spermatic Cord, detailed anatomy, continued

d. Spermatic/testicular artery & vein e. Pampiniform plexus (network of veins) f. Lymph vessels g. Vaginal ligament
1. Obliterated diverticulum 2. From Processus vaginalis (later)

Anatomy of the Spermatic Cord

III. Vessels & Nerves

A. Arteries
1. Testicular (internal spermatic) artery
a. Branches directly from abdominal aorta

b. Inferior to renal artery

c. Passes deep to peritoneum

Arteries, continued

d. Travels through inguinal canal to reach testis e. Testicular migration follows this path
Testicular Artery

Arteries, continued

2. Cremasteric artery
a. Branch of Testicular Artery

b. Supplies Ureter & Cremaster muscle

Arteries, continued

3. Perineal artery
a. Branch of internal pudendal artery

b. Gives rise to posterior scrotal artery

c. Supplies perineum & external genitalia

Arteries, continued

4. Superior Vesical artery

a. From fetal hypogastric artery b. Gives rise to deferential artery c. Anastomosis with testicular artery d. Supplies upper portion of urinary bladder

Arteries of the Male Reproductive Tract

Fetal hypogastric artery

Superior vesical artery

Arteries of the Reproductive Tract

Vessels & Nerves, cont

B. Veins
1. Pampiniform plexus (major venous drainage)
a. Approximately a dozen b. form a network c. Become larger, converge approaching inguinal canal.

Veins, continued

2. Testicular vein
a. From convergence of pampiniform plexus veins b Enters IVC on right c. Enters renal vein on left

Vessels & nerves, continued

C. Testicular Lymphatics 1. Follow arteries, veins 2. End in lumbar nodes 3. From scrotum, penis, prepuce:
terminate in superficial inguinal nodes

4. From testis, spermatic cord:

drain into external iliac & lumbar nodes

Vessels & Nerves, continued

D. Nerves 1. Ilioinguinal nerve (L-1)

a. Into inguinal canal b. Through superficial inguinal ring c. Supplies skin of upper scrotum & medial thigh d. via anterior scrotal nerve

Nerves, continued

2. Genitofemoral nerve
a. Genital branch supplies cremaster muscle b. Receives branch of iliohypogastric nerve c. Femoral branch supplies medial portion of thigh d. Cremasteric reflex (scratch
medial thigh, causes scrotum to contract)

IV. Embryology/Descent of Testis

A. Development
1. Scrotal swellings appear at ~ 7 weeks in lower abdominal wall 2. Processus Vaginalis:
a. evagination of peritoneum b. push into scrotal swellings

3. Layers of abdominal muscle, fascia 4. Give rise to inguinal canal

Embryonic Development, continued

4. Testes develop on posterior abdominal wall

a. on urogenital ridge b. near kidneys

5. Gubernaculum testis: ligament that

connects testis & epididymis to inside of scrotum

Embryonic Development
Testis Formation of Processus Vaginalis

Gubernaculum

Development, continued

6. As scrotum grows it pulls testes, epididymis, and gubernaculum posterior and inferior 7. Testis are retroperitoneal
a. travel inferiorly
b. exit through inguinal canal c. into scrotum

Descent of Testes

Descent begins at ~3 months Adult Configuration

Development, continued

8. Gubernaculum testis becomes scrotal ligament 9. Testis pulls spermatic cord along 10. Processus vaginalis pinches off
a. forms tunica vaginalis b. Visceral: covers testis & epididymis c. Parietal: folds back, leaves hilus uncovered

Descent of Testes

Copyright 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Descent of Testes, cont.

B. Descent (by way of inguinal canal) 1. Inguinal ligament

a. Formed from exterior oblique aponeurosis b. Extends from anterior superior iliac spine to pubic tubercle c. Forms base of inguinal canal d. Some fibers bend laterally & posteriorly to form pectineal ligament e. Attached to bone

Descent, continued

2. Deep inguinal ring (deep to anterior

superior iliac spine)

3. External spermatic fascia: derived

from what muscle??

4. Cremasteric fascia: formed from

what muscle??

Spermatic and Cremasteric Fasciae

Descent, continued

5. Superficial inguinal ring

a. Subcutaneous opening of inguinal canal b. Surrounds contents & coverings of spermatic cord c. Located superior to inguinal ligament & lateral to pubic tubercle

Anatomy of the Spermatic Cord

Deep inguinal ring

Superficial inguinal ring

Descent, continued

6. Testes develop in lumbar region between peritoneum & fascia of transversalis muscle
a. Begin descent at ~ 3rd month b. Have descended from posterior abdominal wall to deep inguinal ring at ~ 7th month

Descent, continued

c. Testes are preceded by Processus Vaginalis (aka: peritoneal diverticulum) d. Collect fascia, muscles: these give rise to layers covering testes e. Reach superficial inguinal ring by ~8th month f. Testes are usually in scrotum by birth

Embryonic Development
Testis Formation of Processus Vaginalis

Gubernaculum

Descent of Testes

Fused Processus Vaginalis

Descent begins at ~3 months Adult Configuration

V. Anomalies/Diseases

Hernias 1. Indirect (oblique) inguinal hernia

a. Results when processus vaginalis fails to close at birth b. May allow for loops of small bowel, greater omentum to enter processus vaginalis & scrotum c. causing bowel obstruction

Hernias, continued

2. Peritoneal cyst
a. Results from persistent connection between peritoneal cavity & tunica vaginalis
(due to partial closure of tunica vaginalis)

b. A cyst forms in the connection space c. May not be noticeable at birth; later, accumulation of fluid may form a Hydrocoele

Normal vs. Abnormal Scrotum

Note: Hydrocele

Testicular torsion Normal Testis

Testicular Microlithiasis, Hydrocele

Hernias, continued

3. Femoral hernia:
a. Opening in fascia covering femoral canal b. May allow small bowel to slide through, causing obstruction

Hernias, continued

4. Direct inguinal hernia

a. Arises from weakness in abdominal wall near rectus abdominis muscle b. Area is a common site of herniation c. Loops of small bowel may pass through opening

Hernias, continued

5. Congenital inguinal hernia

a. Result from failure of Processus Vaginalis to close prior to birth b. Allows head of Epididymis to remain in deep inguinal ring

Anomalies of the Processus Vaginalis

Normal

Partially Patent

Completely Patent

Deep and Superficial Rings in Infancy

Herniation

Anomalies/Diseases, continued

B. Varicocoele 1. Expansion of pampiniform plexus 2. Usually seen on left (why??) 3. Can be palpated
a. feels like a bag of worms

Pampiniform Plexus

Anomalies/Diseases, continued

C.

Cryptorchidism (occurs in 4% live births in U.S.)

1. Failure of testis to descend by birth 2. Unilateral = less potent; Bilateral = sterile 3. Abdomen: sterile 4. Inguinal canal may contain testes 5. More often affected by malignancy (20x) 6. Often descend in the first year of life

Anomalies/Diseases, continued

D. Ectopic testis (out of place) 1. Migrated from normal course 2. Found in thigh or perineum E. Hematocoele: 1. accumulation of blood 2. in tunica vaginalis from trauma

Anomalies/Diseases, continued

G.

Lymph Edema
1. 2. 3. 4. 5. Due to abdominal venous compression Abdominal aortic aneurysm (AAA) Intra-abdominal tumor Cirrhosis with ascites Filariasis
a. From filarial worms in drinking water b. Can cause elephantiasis

Anomalies/Diseases, continued

H. Testicular tumor
1. Generally have unknown etiology 2. Most arise from primordial germ cells 3. Usual symptom: scrotal mass of increasing size 4. May be associated with pain 5. Any firm mass or cystic mass in scrotum should be checked

Testicular Tumor: Doppler U/S

Testicular Tumor, continued

6. Biopsy is primary diagnostic tool

a. Chest x-ray, IVP b. To check for direct/indirect metastasis

7. Treatment
a. Surgical excision if tumor is benign b. Castration with chemotherapy & radiation if malignant

Endodermal Sinus and Yolk Sac Tumor

Doppler U/S

Tumor of Testis

PROSTATE GLAND

I. Introduction/General Information A. Attached inferiorly to urinary bladder by ligaments B. Posterior to pubic symphysis C. Surrounds superior portion of urethra D. Anterior to rectum (palpation, ultrasound) E. Conical shape

Introduction, Prostate Gland, continued

F. Walnut sized
1. 4 cm trans x 2 cm A/P x 3 cm Sup/Inf

G. Lightly encapsulated
1. Fibrous connective tissue 2. Smooth muscle 3. Capsule extends into lobes

II. Prostate Gland: Detailed Anatomy

A. Largest male accessory gland

B. Located in subperitoneal compartment

(between pelvic diaphragm & peritoneum)
Prostate Gland, Mid-sagittal Section

Prostate Gland: Detailed Anatomy

C. Enclosed in fascial sheath

(aka: prostatic sheath)

1. Inferiorly, sheath is continuous with superior fascia of urogenital diaphragm

2. Posteriorly, sheath forms part of retrovesical septum

Prostate Gland: Detailed Anatomy

D. Double Capsule 1. Fibrous portion contacts gland 2. External capsule formed by pelvic fascia 3. Venous plexus lies between

Male Reproductive System, Posterior View

Detailed Anatomy, contined

E. Conical shape with base (sup), apex (inf), four surfaces 1. Surfaces: posterior, anterior, right &
left inferolateral

2. Base (aka: vesicular surface): superior

a. Attached to neck of urinary bladder b. Prostatic urethra enters middle of base close to anterior surface

Prostate Anatomy

Prostatic Urethra

Detailed Anatomy, contined

3. Apex: inferior
a. Rests on superior fascia of urogenital diaphragm muscle
b. Associated with sphincter urethrae

c. Contacts medial margins of levator ani muscles

Detailed Anatomy, contined

4. Posterior surface: triangular, flat 5. Anterior surface: narrow, convex 6. Inferiorolateral surfaces
a. Meet with anterior surface b. Rest on levator ani fascia above urogenital diaphragm

Detailed Anatomy, contined

F. Lobes of the Prostate

1. Divisions are arbitrary, indistinct

2. Usually divided into

a. two lateral lobes

b. one median lobe

c. anterior and posterior lobes

Lobes of the Prostate, continued

3. Median lobe
a. Lies posterior and superior to prostatic utricle and ejaculatory ducts b. May project into urinary bladder c. Utricle lies within lobe
1. Vestigial remains of uterine homolog 2. Sometimes called uterus masculinis

Lobes of the Prostate, continued

4. Lateral lobes
a. Comprise the greatest mass of the gland b. Contain most secretory tissue

c. Are continuous posteriorly

5. Glandular tissue with varying amounts of fibrous tissue

Lobes of the Prostate, continued

Prostate Gland in situ

Detailed Anatomy, continued

G. Blood & lymph

1. Arteries derived from:
a. Internal pudendal artery
b. Inferior vesical artery c. Middle rectal artery

Blood & Lymph, continued

2. Veins
a. Form venous plexus b. Drain into internal iliac veins c. Communicate with vesical & vertebral venous plexuses

Blood & Lymph, continued

3. Lymphatics
a. Most terminate in internal iliac & sacral nodes (unable to palpate) b. From posterior: to external iliac nodes (unable to palpate)

Detailed Anatomy, contined

H. Glandular tissue

1. 30 - 50 different glandular elements

a. Serous glands

b. 20 - 30 ducts empty into prostatic urethra

2. Most are posterior & lateral to urethra

Blood & Lymph, continued

3. Prostatic secretions a. Thin, milky, alkaline (looks like

skim milk)

b. Discharged at ejaculation

c. Make up ~ 1/3 of semen

Detailed Anatomy, continued

I. Prostate size changes

1. 2. 3. 4. 5. Small at birth Enlarges at puberty Maximum at about 13 Progressive enlargement after 40 Sometimes: undergoes atrophy

III. Pathology
A. Benign prostatic hypertrophy (BPH):
1. Affects ~90% of men >50

BPH, continued

2. Common cause of urethral obstruction: causes a. Nocturia b. Dysuria c. Urgency d. Back-pressure effects e. Complete obstruction can occur

Pathology, continued

B. Prostate cancer
1. Most common cancer in males

Pathology, continued

2. Metastasizes via blood (hematogenous) or lymph (lymphogenous) 3. Common sites: vertebrae, pelvis
a. Via venous plexus surrounding prostate b. Bone or direct metastasis most common

Prostate Cancer: Routes of Metastasis

Pathology, continued

C. Prostatitis (accompanied by cystitis)

1. Inflammation of gland 2. Gland enlarges, becomes tender 3. Causes: gonorrhea? Other UTIs? STDs? 4. May require antibiotics, massage 5. Symptoms: chills, painful urination, back pain

Pathology, continued

A. Prostatic concretions (aka:

amylacea [starch bodies])

corpora

1. 2. 3. 4.

Small spherical or ellipsoid bodies Number increases with age May become calcified as male ages May simulate carcinoma

Digital Rectal Exam

Pathology, continued

E. Rarely, prostatic abscesses develop

1. Frequently caused by gonorrhea 2. May rupture through to rectum, bladder, perineum 3. Other causes:
a. Urethritis b. Epididymitis