1. TESTES, SCROTUM and PROSTATE

2. The Scrotum, Testis, Epididymis
Introduction/ General Information
A. Scrotum
1. “Medial pendant pouch of loose skin & superficial fascia” (Gray’s)
2. Raphe (Gr. “seam” or “suture”): Superficial division between compartments
3. Left side lower than right

3. 4. Dartos muscle (lies in fascia) a. Temperature sensitive response
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

4. Scrotum, Testes, Epididymis, con’t…
B. Testis
1. Suspended in scrotum by spermatic cord
cm long
3. Weigh grams
3. Oval

5. Anatomy of the Male Pelvis

6. 4. Descend from abdominal cavity prior to birth
Testis, continued …
4. Descend from abdominal cavity prior to birth
a. As they descend they collect various coverings
b. Layers of abdominal wall

7. 3. Located on posterior & superior margins of testes
Scrotum, Testis, Epididymis, continued …
Epididymis
1. Highly coiled tube
feet long
3. Located on posterior & superior margins of testes
4. Elongated, flattened structures

8. 5. Partially covered by visceral layer of the tunica vaginalis
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

9. Testicular Anatomy

10. Appendages 1. Appendix of the testis
Testicular Anatomy, con’t…
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”

11. Testicular Anatomy, con’t…
Appendix of Testis
Appendix of Testis

12. 2. Appendix of the Epididymis a. Attached to head of Epididymis
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)

13. Appendages, continued …
Appendix of Epididymis
Appendix of Epididymis

14. A. Superficial inguinal rings (of inguinal canal)
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

15. Anatomy of the Spermatic Cord
Deep inguinal ring
Superficial inguinal ring

16. 1. Layers, beginning superficially a. Superficial fascia
Detailed Anatomy, continued …
B. Scrotum
1. Layers, beginning superficially
a. Superficial fascia
1. skin & tunica dartos
b. Colle’s fascia
1. membranous layer of superficial fascia
2. continuous over penis & scrotum

17. c. External spermatic fascia: derived from
Scrotum, continued …
c. External spermatic fascia: derived from
1. transversus abdominis
2. internal oblique muscle
d. Cremasteric fascia: derived from
2. internal oblique muscle
e. Internal spermatic fascia: derived from transversalis muscle

18. Detailed Anatomy, Layers of the Scrotum, continued …
Superficial (Dartos) Fascia
Colle’s Fascia
External Spermatic Fascia
Cremasteric Fascia
Internal Spermatic Fascia
Parietal Layer, Tunica Vaginalis
Visceral Layer, Tunica Vaginalis
Tunica Albuginea
Skin

19. f. Layers of peritoneum have serous fluid between to allow mobility
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

20. 2. Testis (superficial to deep) a. Visceral layer of tunica vaginalis
Scrotum, detailed anatomy, continued …
2. Testis (superficial to deep)
a. Visceral layer of tunica vaginalis
b. Tunica albuginea (capsule of testis)
c. Seminiferous tubules
d. Mediastinum testis (aka: hilum of testis)
- Efferent Ductules
- Rete testis (network of tubules)

21. Testicular Anatomy (Netter, Plate 371)
Efferent Ductules
Rete Testis
Seminiferous Tubules
Mediastinum Testis
Tunica Albuginea

22. 1. Coverings from abdominal wall 2. Each spermatic cord contains:
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

23. d. Spermatic/testicular artery & vein
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)

24. Anatomy of the Spermatic Cord

25. 1. Testicular (internal spermatic) artery
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

26. d. Travels through inguinal canal to reach testis
Arteries, continued …
d. Travels through inguinal canal to reach testis
e. Testicular migration follows this path
Testicular Artery

27. a. Branch of Testicular Artery
Arteries, continued …
2. Cremasteric artery
a. Branch of Testicular Artery
b. Supplies Ureter & Cremaster muscle

28. a. Branch of internal pudendal artery
Arteries, continued …
3. Perineal artery
a. Branch of internal pudendal artery
b. Gives rise to posterior scrotal artery
c. Supplies perineum & external genitalia

29. 4. Superior Vesical artery a. From fetal hypogastric artery
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

30. Arteries of the Male Reproductive Tract
Fetal hypogastric artery
Superior vesical artery

31. Arteries of the Reproductive Tract

32. 1. Pampiniform plexus (major venous drainage)
Vessels & Nerves, con’t …
B. Veins
1. Pampiniform plexus (major venous drainage)
a. Approximately a dozen
b. form a network
c. Become larger, converge approaching inguinal canal.

33. a. From convergence of pampiniform plexus veins
Veins, continued …
2. Testicular vein
a. From convergence of pampiniform plexus veins
b Enters IVC on right
c. Enters renal vein on left

34. C. Testicular Lymphatics 1. Follow arteries, veins
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

35. 1. Ilioinguinal nerve (L-1) a. Into inguinal canal
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

36. a. Genital branch supplies cremaster muscle
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)

37. IV. Embryology/Descent of Testis A. Development
1. Scrotal swellings appear at ~ 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

38. 4. Testes develop on posterior abdominal wall a. on urogenital ridge
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

39. Formation of Processus Vaginalis
Embryonic Development
Formation of Processus Vaginalis
Testis
Gubernaculum

40. 7. Testis are retroperitoneal a. travel inferiorly
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

41. Descent begins at ~3 months
Descent of Testes
Descent begins at ~3 months
Adult Configuration

42. 8. Gubernaculum testis becomes scrotal ligament
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

43. Descent of Testes
Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

44. B. Descent (by way of inguinal canal) 1. Inguinal ligament
Descent of Testes, con’t….
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

45. 2. Deep inguinal ring (deep to anterior superior iliac spine)
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??

46. Spermatic and Cremasteric Fasciae

47. 5. Superficial inguinal ring a. Subcutaneous opening of inguinal canal
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

48. Anatomy of the Spermatic Cord
Deep inguinal ring
Superficial inguinal ring

49. a. Begin descent at ~ 3rd month
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

50. 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

51. Formation of Processus Vaginalis
Embryonic Development
Formation of Processus Vaginalis
Testis
Gubernaculum

52. Descent of Testes Fused Processus Vaginalis
Descent begins at ~3 months
Adult Configuration

53. 1. Indirect (oblique) inguinal hernia
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

54. 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

55. Normal vs. Abnormal Scrotum
Note:
Hydrocele
Testicular torsion
Normal Testis

56. Testicular Microlithiasis, Hydrocele

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

58. 4. Direct inguinal hernia
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

59. 5. Congenital inguinal hernia
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

60. Anomalies of the Processus Vaginalis
Partially Patent
Normal
Completely Patent
Deep and Superficial Rings in Infancy
Herniation

61. 1. Expansion of pampiniform plexus 2. Usually seen on left (why??)
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”

62. Pampiniform Plexus

63. Cryptorchidism (occurs in 4% live births in U.S.)
Anomalies/Diseases, continued …
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

64. D. Ectopic testis (out of place) 1. Migrated from normal course
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

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

66. H. Testicular tumor 2. Most arise from primordial germ cells
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

67. Testicular Tumor: Doppler U/S

68. 6. Biopsy is primary diagnostic tool a. Chest x-ray, IVP
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

69. Endodermal Sinus and Yolk Sac Tumor
Doppler U/S
Tumor of Testis

70. PROSTATE GLAND

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

72. 1. 4 cm trans x 2 cm A/P x 3 cm Sup/Inf G. Lightly encapsulated
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

73. II. Prostate Gland: Detailed Anatomy
A. Largest male accessory gland
B. Located in subperitoneal compartment (between pelvic diaphragm & peritoneum)
Prostate Gland, Mid-sagittal Section

74. 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

75. 1. Fibrous portion contacts gland
Prostate Gland: Detailed Anatomy
D. Double Capsule
1. Fibrous portion contacts gland
2. External capsule formed by pelvic fascia
3. Venous plexus lies between

76. Male Reproductive System, Posterior View

77. E. Conical shape with base (sup), apex (inf), four surfaces
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

78. Prostate Anatomy
Prostatic Urethra

79. a. Rests on superior fascia of urogenital diaphragm muscle
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

80. 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

81. 1. Divisions are arbitrary, indistinct 2. Usually divided into
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

82. 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”

83. a. Comprise the greatest mass of the gland
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

84. Lobes of the Prostate, continued …
Prostate Gland in situ

85. Detailed Anatomy, continued …
G. Blood & lymph
1. Arteries derived from:
a. Internal pudendal artery
b. Inferior vesical artery
c. Middle rectal artery

86. Blood & Lymph, continued … 2. Veins a. Form venous plexus
b. Drain into internal iliac veins
c. Communicate with vesical & vertebral venous plexuses

87. 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)

88. 1. 30 - 50 different glandular elements a. Serous glands
Detailed Anatomy, contined …
Glandular tissue
different glandular elements
a. Serous glands
b ducts empty into prostatic urethra
2. Most are posterior & lateral to urethra

89. a. Thin, milky, alkaline (looks like skim milk)
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

90. Prostate size changes 1. Small at birth 2. Enlarges at puberty
Detailed Anatomy, continued …
Prostate size changes
1. Small at birth
2. Enlarges at puberty
3. Maximum at about 13
4. Progressive enlargement after 40
5. Sometimes: undergoes atrophy

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

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

93. B. Prostate cancer 1. Most common cancer in males
Pathology, continued …
B. Prostate cancer
1. Most common cancer in males

94. 2. Metastasizes via blood (hematogenous) or lymph (lymphogenous)
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

95. Prostate Cancer: Routes of Metastasis

96. Prostatitis (accompanied by cystitis) 1. Inflammation of gland
Pathology, continued …
Prostatitis (accompanied by cystitis)
1. Inflammation of gland
2. Gland enlarges, becomes tender
3. Causes: gonorrhea? Other UTI’s? STD’s?
4. May require antibiotics, massage
5. Symptoms: chills, painful urination, back pain

97. Prostatic concretions (aka: corpora amylacea [starch bodies])
Pathology, continued …
Prostatic concretions (aka: corpora amylacea [starch bodies])
1. Small spherical or ellipsoid bodies
2. Number increases with age
3. May become calcified as male ages
4. May simulate carcinoma

98. Digital Rectal Exam

99. E. Rarely, prostatic abscesses develop
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