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ULTRASONOGRAPHY  
Year : 2012  |  Volume : 22  |  Issue : 4  |  Page : 293-297
Sonography of scrotal trauma


Department of Radiology and Imaging, Teleradiology Solutions Pvt. Ltd., Whitefield, Bangalore, India

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Date of Web Publication7-May-2013
 

   Abstract 

The purpose of this article is to depict the spectrum of scrotal injuries in blunt trauma. Scrotal injuries are not very common and are mostly due to blunt trauma from direct injury, sports injuries or motor vehicle accidents. To minimize complications and ensure testicular salvage, rapid and accurate diagnosis is necessary. High-resolution USG is the investigation of choice, as it is readily available, accurate and has been seen to improve outcomes. An understanding of and familiarity with the sonographic appearance of scrotal injuries on the part of the radiologist/sonographer is therefore of key importance.

Keywords: Blunt testicular trauma; scrotal injuries; sonography

How to cite this article:
Rao MS, Arjun K. Sonography of scrotal trauma. Indian J Radiol Imaging 2012;22:293-7

How to cite this URL:
Rao MS, Arjun K. Sonography of scrotal trauma. Indian J Radiol Imaging [serial online] 2012 [cited 2014 Nov 21];22:293-7. Available from: http://www.ijri.org/text.asp?2012/22/4/293/111482

   Introduction Top


Scrotal trauma accounts for less than 1% of all trauma-related injuries, because of the anatomic location and mobility of the scrotum. [1] Direct trauma to the scrotum, typically during a sporting injury or other similar mechanism is the commonest form of scrotal injury followed by motor vehicle collision and penetrating injuries. Scrotal trauma patients present with acute pain, and accurate diagnosis is necessary to minimize complications and prevent loss of the testis. A thorough history and detailed physical examination are essential for an accurate diagnosis. High-resolution USG with Doppler flow evaluation is the investigation of choice for the evaluation of scrotal abnormalities. [2] It is noninvasive and can be used to quickly evaluate scrotal contents, testicular integrity and blood flow.

A thorough knowledge of scrotal and testicular anatomy is essential for evaluating testicular injuries.


   Anatomy Top


The outermost layer of the scrotum is the scrotal skin, which is rugose. The next layer is formed by a series of fascia, which are contiguous with the fascia of the abdominal wall, penis and perineum; the individual layers are not appreciated on USG. The next layer is the tunica vaginalis, which is composed of an outer (parietal) layer and an inner (visceral) layer, a potential space where fluid accumulates. The tunica albuginea is a tough, white, fibrous, capsule-like layer surrounding the seminiferous tubules of the testis; this layer is well appreciated on USG as an echogenic structure. The visceral layer of the tunica vaginalis adheres to this layer.

The tunica albuginea extends inward posteriorly to form the mediastinum testis, the point where the vessels and ducts traverse the testicular capsule. The epididymis attaches posterolaterally.

Scrotal injuries can be classified as extratesticular and intratesticular types.

Extratesticular injuries

Scrotal wall/extratesticular hematoma

Scrotal wall abrasion or wall thickening is commonly associated with blunt scrotal trauma. Hematomas are also a common finding and may appear as focal thickening of the scrotal wall or as fluid collections [Figure 1]A and B within the scrotal wall. [2],[3] Hematomas appear echogenic on USG when acute and evolve with age [Figure 2]A-C. Extratesticular hematomas [Figure 3]A-C are located in the extratesticular soft tissues other than the scrotal wall, and have an appearance similar to scrotal wall hematoma. These are managed conservatively, unless very large.
Figure 1 (A, B): Sagittal (A), Transverse (B) images in a patient with history of scrotal trauma a week ago: Note anechoic collection in left scrotal wall (arrow), representing an evolving hematoma

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Figure 2 (A-C): Sagittal (A), Transverse (B) images demonstrate an hyperechoic layer in the scrotal wall that represents scrotal wall hematoma (straight arrows) with an associated hematocele (Curved arrow). Note that the left testicle is itself intact. Sagittal (C) image of another patient demonstrates similar findings of scrotal wall hematoma (arrow

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Figure 3 (A-C): A Transverse (A), Sagittal (B) images demonstrate an ill-defined hyperechoic area that represents a hematoma (arrows) posterior to the right testis suggestive of extratesticular hematoma. Transverse (C) image of an extratesticular hematoma (arrows) in another patient located posterior to the left testis. Scrotal wall thickening is also noted

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Hydroceles or hematoceles

Hydroceles may occur in up to 25% of patients with major trauma [Figure 4]A and B. Rupture of the bulbous urethra may result in extravasation of urine into the scrotum, which may mimic a hydrocele.
Figure 4 (A, B): Left (A) and Right (B) transverse images demonstrate bilateral hydroceles (arrows) in a patient with blunt scrotal trauma

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Similar to hydroceles, hematoceles are complex collections that separate the visceral and parietal layers of the tunica vaginalis [Figure 5]A and B. Like hematomas, they are acutely echogenic and become more complex and more hypoechoic with age. Subacute and chronic hematoceles may contain fluid-fluid levels or low-level internal echoes and septae. [4],[5]
Figure 5 (A, B): Transverse images demonstrate scrotal wall thickening (star) with hematocele in a patient with blunt scrotal trauma. Note fibrinous septations (arrows). A homogeneous intact testicle is also noted

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The presence of a large acute hematocele may result in decreased blood flow to the testis due to extrinsic pressure on the vessels and thus may mimic testicular torsion or partial torsion. [6] The presence of a large hematocele warrants surgical exploration irrespective of any USG evidence of tunica albuginea rupture. In children, hematoceles may occur secondary to abdominal trauma. [7]

Epididymal injuries

Isolated epididymal injuries are not very common and these are usually associated with testicular injuries. Contusion or traumatic epididymitis appears as an enlarged and heterogeneous epididymis [Figure 6]A and B on USG with increased vascularity and sometimes associated with hematocele. [8] This mimics infectious epididymitis on USG and the history of trauma differentiates traumatic epididymitis from its infectious counterpart. Small hematomas may also be demonstrated in traumatic epididymitis [Figure 6]C and D.
Figure 6 (A-D): Sagittal (A) and Transverse (B) images in a patient with history of blunt scrotal trauma demonstrating heterogeneous and thickened epididymis (arrows), representing traumatic epididymitis. Sagittal (C) and Transverse (D) images of another patient with blunt scrotal trauma demonstrating heterogeneous and thickened left epididymis with a small hematoma (arrows). An associated hematocele (curved arrow) is also noted

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Intratesticular injuries

a. Intratesticular hematoma: Intratesticular hematomas are usually focal and fairly well defined [Figure 7]A and B and may be multiple [Figure 8]A and B. They are usually hyperechoic in the acute phase or hypoechoic (as the hemorrhage evolves) and lack vascularity. [4] When hematomas become infected, an increase in peripheral vascularity may be noted [Figure 9]A and B. A large intratesticular hematoma appears heterogeneous and normal testicular tissue may barely be seen [Figure 10]A-E. Doppler imaging helps in differentiating from testicular tumors. Testicular hematomas may be treated conservatively with scrotal support, pain medication and ice packs, unless very large, in which case surgical exploration and debridement may be necessary.
Figure 7 (A, B): Transverse images in a patient with blunt trauma to the scrotum demonstrating heterogeneous area that represents an intratesticular hematoma (arrows) in the left testis

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Figure 8 (A, B): Transverse images demonstrating well-defined heterogeneous areas that represent hematomas (arrows) in the left testis, suggestive of intratesticular hematomas in patient with history of blunt scrotal trauma

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Figure 9 (A, B): Sagittal (A) demonstrating an intratesticular heterogeneous hypoechoic area (arrow) and sagittal (B) Doppler image with peripheral vascularity (arrow) in a patient with history of scrotal trauma a week ago, representing a evolving hematoma (possibly infected)

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Figure 10 (A-E): Sagittal (A) and transverse (B) images in a mentally challenged patient with history of scrotal swelling demonstrating large heterogeneous echogenic area in the right scrotal sac, from which the testicle is not separately visualized, suggestive of testicular hematoma (arrows). Image (C) on Doppler, note the low resistance flow in the testicular tissue. computed tomography-Topogram (D) and axial (E) images of the same patient with enlarged scrotum (arrow) and a large hyperdense structure in the right scrotal sac consistent with a testicular hematoma (curved arrow)

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Testicular fracture

This serious injury usually appears as a linear hypoechoic band [Figure 11]A and B extending across the testicular parenchyma. [9],[10],[11] The contour remains smooth with the shape of the testicle maintained. The tunica albuginea is intact. An associated hematocele or testicular hematoma may be seen. The fracture line may not be visible if filled with isoechoic hematoma. Doppler imaging plays an important role in determining vascular integrity.

Testicular fractures are treated conservatively if normal flow is identified in the surrounding testicular parenchyma. If flow is absent, emergent exploration is indicated, as this finding represents ischemia.
Figure 11 (A, B): Transverse images of the left testis demonstrate a hypoechoic linear area (arrow) indicative of a testicular fracture in a patient with history of kick to the scrotum. Tunica albuginea was intact (not completely shown on images). Associated hematocele (curved arrow) is also noted

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Testicular rupture

In testicular rupture there is discontinuity of the echogenic tunica albuginea with hemorrhage and extrusion of testicular contents into the scrotal sac [Figure 12]A-E. This is an indication for emergency scrotal exploration to salvage the testis.
Figure 12 (A-E): Transverse (A) image with history of blunt scrotal trauma demonstrating left testicular rupture with extrusion of contents (arrows). Transverse (B) image, Doppler demonstrating preserved testicular vascularity. Large hematocele (curved arrow) is also noted. Transverse (C) image of same patient with left testicular rupture demonstrating discontinuity of Tunica albuginea (arrow). Transverse (D) and Sagittal (E) images of another patient with testicular rupture demonstrating discontinuity of Tunica albuginea (arrow) and extrusion of contents (curved arrow)

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In this type of injury, USG also demonstrates poorly defined testicular margins and heterogeneous echotexture, with areas of hemorrhage or infarction. [11],[12],[13] Associated findings may include scrotal wall thickening and hematocele. In a study by Buckley and McAninch, in their series of 65 patients with blunt scrotal trauma, based on USG findings of a heterogeneous echotexture and contour abnormality, they demonstrated a sensitivity of 100% and a specificity of 93.5% in the diagnosis of testicular rupture. [13] Kim et al. demonstrated that loss of definition of the tunica albuginea is the only significant predictor for the diagnosis of testicular rupture in patients with blunt scrotal trauma. [14]

Color Doppler imaging is essential and invaluable to assess traumatic injuries to the testis. [15],[16] Tunica albuginea rupture is almost always associated with a disruption of vascularity to the testicular parenchyma due to close apposition of the tunica vasculosa to the tunica albuginea. This may result in loss of vascularity to a portion of or the entire testis [Figure 13]A-C, depending on the grade of injury. The avascular and lacerated portion of the ruptured testis is usually debrided, and the viable portions are left behind. Orchiectomy is performed if there is no or little vascularity.
Figure 13 (A-C): Sagittal (A) lateral aspect of the right testis demonstrating extruded testicular contents in a patient with blunt scrotal trauma. Transverse (B) Grey-Scale and Doppler (C) images demonstrating hypoechoic testis without color flow (arrow), indicating infarction. Also noted are small focal hyperechoic areas (curved arrows) within the infarcted testis representing (barely) viable portions of the right testis

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   Summary Top


USG in scrotal trauma reveals a wide spectrum of morphology, ranging in severity from simple scrotal wall edema to testicular rupture and infarction. As the management is determined by the severity of the injury, it is important for the sonologist to be well versed with the appearance of each type of injury along this spectrum. Accurate USG diagnosis is therefore the essence of appropriate therapy in scrotal trauma.

 
   References Top

1.Deurdulian C, Mittelstaedt CA, Chong WK, Fielding JR. US of acute scrotal trauma: Optimal technique, imaging findings, and management. Radiographics 2007;27:357-69.  Back to cited text no. 1
    
2.Ragheb D, Higgins JL Jr. Ultrasonography of the scrotum: Technique, anatomy, and pathologic entities. J Ultrasound Med 2002;21:171-85.  Back to cited text no. 2
    
3.Micallef M, Ahmad I, Ramesh N, Hurley M, McInerney D. Ultrasound features of blunt testicular injury. Injury 2001;32:23-6.  Back to cited text no. 3
    
4.Bhatt S, Ghazale H, Dogra VS. Sonographic evaluation of scrotal and penile trauma. Ultrasound Clin 2007;2:45-56.  Back to cited text no. 4
    
5.Haddad FS, Manne RK, Nathan MH. The pathological, ultrasonographic and computerized tomographic characteristics of chronic hematocele. J Urol 1988;139:594-5.  Back to cited text no. 5
    
6.Dogra VS, Bhatt S, Rubens DR. Sonographic evaluation of testicular torsion. Ultrasound Clin 2006;1:55-66.  Back to cited text no. 6
    
7.Koumanidou C, Manopoulou E, Pantazis J, Dermentzoglou V, Georgoulis P, Vakaki M, et al. Scrotal hematocele as an unusual presentation of blunt abdominal trauma in three male infants. J Clin Ultrasound 2000;28:190-3.  Back to cited text no. 7
    
8.Gordon LM, Stein SM, Ralls PW. Traumatic epididymitis: Evaluation with color Doppler sonography. AJR Am J Roentgenol 1996;166:1323-5.  Back to cited text no. 8
    
9.Jeffrey RB, Laing FC, Hricak H, McAninch JW. Sonography of testicular trauma. AJR Am J Roentgenol 1983;141:993-5.  Back to cited text no. 9
    
10.Dogra VS, Gottlieb RH, Oka M, Rubens DJ. Sonography of the scrotum. Radiology 2003;227:18-36.  Back to cited text no. 10
    
11.Blaivas M, Brannam L. Testicular ultrasound. Emerg Med Clin North Am 2004;22:723-48, ix.  Back to cited text no. 11
    
12.Guichard G, El Ammari J, Del Coro C, Cellarier D, Loock PY, Chabannes E, et al. Accuracy of ultrasonography in diagnosis of testicular rupture after blunt scrotal trauma. Urology 2008;71:52-6.  Back to cited text no. 12
    
13.Buckley JC, McAninch JW. Use of ultrasonography for the diagnosis of testicular injuries in blunt scrotal trauma. J Urol 2006;175:175-8.  Back to cited text no. 13
    
14.Kim SH, Park S, Choi SH, Jeong WK, Choi JH. Significant predictors for determination of testicular rupture on sonography: A prospective study. J Ultrasound Med 2007;26:1649-55.  Back to cited text no. 14
    
15.Muttarak M, Thinyu S, Lojanapiwat B. Clinics in diagnostic imaging (114). Rupture of the right testis. Singapore Med J 2007;48:264-8.  Back to cited text no. 15
    
16.Gross M. Rupture of the testicle: The importance of early surgical treatment. J Urol 1969;101:196-7.  Back to cited text no. 16
    

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Correspondence Address:
Meka Srinivasa Rao
Flat No. 111, Prime Blue Forest Apts, Rajpalya, Hoody, Mahadevpura Post, Bangalore
India
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DOI: 10.4103/0971-3026.111482

PMID: 23833421

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13]



 

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