Diagnostic Ultrasound - Abdomen and Pelvis

Scrotal Trauma
TERMINOLOGY
Definitions
• Rupture of tunica albuginea, extrusion of testicular tissue
into scrotal sac, collection of blood in tunica vaginalis or
scrotal wall
IMAGING
General Features
• Best diagnostic clue
○ Heterogeneous parenchymal echogenicity of testis or
contour abnormality of testis in presence of history of
scrotal trauma
• Morphology
○ Irregularity of testicular contour and focal or diffuse
heterogeneity in testis &/or epididymis
○ Extratesticular hematocele: Most common finding in
scrotum after blunt injury
Ultrasonographic Findings
• Grayscale ultrasound
○ Hematocele: Hemorrhage contained within layers of
tunica vaginalis
○ Testicular rupture
– Disruption of tunica albuginea
– Contour abnormality of testis due to testicular
extrusion
– Heterogeneous testicular echotexture and
echogenicity
○ Testicular fracture
– Discrete linear or irregular fracture plane within testis
(17%)
○ Testicular dislocation
– Unilateral > > bilateral
– Most commonly from high-impact injury against fuel
tank in motorcycle accidents
○ Testicular torsion
– Trauma-induced torsion in 5-8% cases
○ Testicular hematoma
– US appearance depends on time elapsed since trauma
○ Penetrating trauma
– Intra- or extratesticular air in scrotum, missile track
&/or foreign bodies (bullet/pellet)
○ Epididymal injury: Focal epididymal enlargement with
reduced echogenicity & abnormal position in relation to
testis
○ Scrotal wall hematoma: Focal wall thickening or
loculated collection within wall
○ Spermatic cord hematoma: Heterogeneous avascular
mass superior to testis
• Color Doppler
○ Distorted intratesticular vascularity with interruption of
vessels in area of injury due to injury to tunica vasculosa
– Useful to determine viable portions of testis
Imaging Recommendations
• Best imaging tool
○ High-resolution US (9-15 MHz)
DIFFERENTIAL DIAGNOSIS
Testicular Torsion
• ↓ overall vascularity compared to normal testis
Epididymoorchitis
• Acute or chronic pain without history of trauma, enlarged
hypoechoic epididymis with increased vascularity in
epididymis and testis on color Doppler
Testicular Abscess
• Focal ill-defined, thick-walled mass and necrotic center
PATHOLOGY
General Features
• Etiology
○ Sports injuries (> 50%), vehicular and ballistic trauma, and
iatrogenic
○ Blunt trauma impales scrotal contents to symphysis
pubis or pubic rami, pelvic fracture
○ Penetrating trauma includes sharp objects such as
knives, bullets, animal bites, self mutilation; gunshot
injuries most common
○ Iatrogenic injuries from inguinal herniorrhaphy and
orchiectomy
CLINICAL ISSUES
Presentation
• Most common signs/symptoms
○ Acute scrotal hematoma following blunt trauma
Natural History & Prognosis
• Unless repaired within 72 hours, salvage rate only 45%
• Follow-up of conservatively treated testicular hematomas is
essential due to increased risk of infection, which may result
in orchiectomy
Treatment
• Drainage: Large hematocele
• Orchiectomy (total or partial): Nonviable testis in testicular
rupture
• Surgical exploration and drainage: Large intratesticular
hematomas
DIAGNOSTIC CHECKLIST
Image Interpretation Pearls
• Irregularity of testicular contour, heterogeneous
parenchyma and echogenic collection in tunica vaginalis
SELECTED REFERENCES
1. Avery LL et al: Imaging of penile and scrotal emergencies. Radiographics.
33(3):721-40, 2013
2. D'Andrea A et al: US in the assessment of acute scrotum. Crit Ultrasound J. 5
Suppl 1:S8, 2013
3. Bhatt S et al: Role of US in testicular and scrotal trauma. Radiographics.
28(6):1617-29, 2008
4. Deurdulian C et al: US of acute scrotal trauma: optimal technique, imaging
findings, and management. Radiographics. 27(2):357-69, 2007
5. Buckley JC et al: Use of ultrasonography for the diagnosis of testicular
injuries in blunt scrotal trauma. J Urol. 175(1):175-8, 2006
6. Pepe P et al: Does color Doppler sonography improve the clinical
assessment of patients with acute scrotum? Eur J Radiol. 60(1):120-4, 2006
Diagnoses: Scrotum
711