Diagnostic Ultrasound - Abdomen and Pelvis
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Diagnostic Ultrasound - Abdomen and Pelvis

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09.07.2019 Views

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

Scrotal Trauma Diagnoses: Scrotum (Left) Grayscale ultrasound of the testis after a Lacrosse ball injury demonstrates a disrupted tunica albuginea , heterogeneous testicular parenchyma , and a contour abnormality st, consistent with testicular rupture. (Right) Corresponding color Doppler ultrasound in the same patient shows the extruded testicular parenchyma to be avascular, suggestive of nonviable portions. (Left) Transverse grayscale ultrasound of bilateral testes shows a normal right testis and a heterogeneous left testis with disrupted tunica albuginea ſt consistent with testicular rupture. (Right) Color Doppler ultrasound of the scrotal cavity in the same patient with testicular rupture demonstrates a complex extratesticular fluid collection, consistent with an associated hematocele. (Left) Transverse grayscale ultrasound of the testis after blunt trauma shows a welldefined echogenic lesion ſt in the parenchyma. (Right) Corresponding color Doppler ultrasound in the same patient confirms that the lesion is avascular ſt, suggestive of an acute intratesticular hematoma. The patient was sequentially followed until resolution. In cases of focal intratesticular hematomas, follow-up to resolution is recommended to exclude underlying neoplasm. 712

Scrotal Trauma<br />

Diagnoses: Scrotum<br />

(Left) Grayscale ultrasound of<br />

the testis after a Lacrosse ball<br />

injury demonstrates a<br />

disrupted tunica albuginea ,<br />

heterogeneous testicular<br />

parenchyma , <strong>and</strong> a contour<br />

abnormality st, consistent<br />

with testicular rupture. (Right)<br />

Corresponding color Doppler<br />

ultrasound in the same patient<br />

shows the extruded testicular<br />

parenchyma to be<br />

avascular, suggestive of<br />

nonviable portions.<br />

(Left) Transverse grayscale<br />

ultrasound of bilateral testes<br />

shows a normal right testis <br />

<strong>and</strong> a heterogeneous left<br />

testis with disrupted tunica<br />

albuginea ſt consistent with<br />

testicular rupture. (Right)<br />

Color Doppler ultrasound of<br />

the scrotal cavity in the same<br />

patient with testicular rupture<br />

demonstrates a complex<br />

extratesticular fluid collection,<br />

consistent with an associated<br />

hematocele.<br />

(Left) Transverse grayscale<br />

ultrasound of the testis after<br />

blunt trauma shows a welldefined<br />

echogenic lesion ſt in<br />

the parenchyma. (Right)<br />

Corresponding color Doppler<br />

ultrasound in the same patient<br />

confirms that the lesion is<br />

avascular ſt, suggestive of an<br />

acute intratesticular<br />

hematoma. The patient was<br />

sequentially followed until<br />

resolution. In cases of focal<br />

intratesticular hematomas,<br />

follow-up to resolution is<br />

recommended to exclude<br />

underlying neoplasm.<br />

712

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