Testicular Trauma Imaging
- Author: Vikram S Dogra, MD; Chief Editor: Eugene C Lin, MD more...
Testicular trauma is uncommon because of its anatomic location and the mobility of testes within the scrotum. Most testicular trauma occurrences are related to sports injuries. Other causes include direct trauma, motor vehicle accidents, and straddle injuries. Patients present with an acute scrotum and history of trauma. Diagnosis is made in combination with clinical history and physical and ultrasound (US) findings.[3, 4, 5] Testicular rupture is a urologic emergency, and more than 80% of ruptured testes can be saved if surgery is performed within 72 hours. See the images below.
Ultrasonography (US) is the imaging modality of choice. If US fails to reveal contusion, hematoma, or testicular rupture, perform surgical exploration.[5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16]
US is 80% specific for detecting tunica albuginea fracture.
The American Institute of Ultrasound in Medicine has published guidelines (in association with the American College of Radiology, Society for Pediatric Radiology, and Society of Radiologists in Ultrasound) on the evaluation of testicular and extratesticular structures.
In a retrospective study of 298 boys with acute scrotum suggesting testicular torsion (TT), color Doppler ultrasonography (CDUS) had a 96.8% sensitivity, 97.9% specificity, 92.1% positive predictive value, and 99.1% negative predictive value for testicular torsion (TT). According to Waldert et al, approximately 20% of boys who present with acute scrotum have TT, and color Doppler is a reliable modality for making the diagnosis.
Radiographs are used to detect associated injuries.
Computed tomography (CT) scanning is used to detect other, associated injuries in patients involved in motor vehicle accidents.
Magnetic Resonance Imaging
According to Parenti et al, CDUS is irreplaceable as the initial approach for scrotal disease and trauma, but magnetic resonance imaging (MRI) is an ideal second-line modality. The authors followed 801 patients between 2000 and 2007 with scrotal disease or trauma who underwent CDUS, followed by MRI in 46 of the patients.
In the study, CDUS revealed an inflammatory process in 277 patients, testicular trauma in 112, funicular torsion or torsion of the vestigial remnant in 44, and testicular neoplasm findings in 35. MRI identified 3 intraparenchymal hematomas, 1 intrascrotal cavernous body rupture, 1 testicular abscess with intrascrotal fistula, 2 testicular infarctions, and 15 neoplasms. MRI excluded focal abnormalities in 10 patients with testicular microlithiasis, in 3 with chronic orchitis, and in 4 with atrophic involution. MRI confirmed the finding of inguinal hernia in 3 cases. The authors concluded that MRI offers useful, occasionally decisive, information because of its ability to identify unexpected findings.
Kim et al explained that because of its high soft-tissue contrast and its multiplanar capability, MRI can be a useful alternative diagnostic modality for blunt scrotal trauma, especially when ultrasonography results in an inconclusive diagnosis. In 7 patients with blunt scrotal trauma, the diagnostic accuracy of MRI was 100%. Three cases with testicular rupture were diagnosed accurately, with interruption of the dark signal intensity line of the tunica albuginea being pathognomonic for the diagnosis of testicular rupture. Two cases in which there was an inconclusive diagnosis by ultrasonography, diagnoses of epididymal hematomas were correctly made by MRI. The remaining 2 cases showed concordant results with the surgical findings.
US is the modality of choice for imaging. US has a 100% sensitivity and an 80% specificity for testicular trauma. However, hemorrhage from an underlying tumor or incarcerated hernia may cause a false-positive diagnosis.[5, 6, 7, 8, 9, 10, 11, 12, 13]
Direct visualization of a testicular fracture line in US is rare, being observed only in approximately 17% of patients. Demonstration of disruption of the tunica vasculosa is diagnostic of testicular rupture. Other US findings include scrotal wall thickening, hematocele, and testicular hematoma. US appearance of a hematocele varies depending on the length of time since trauma occurred. (See the images below.)
Acute hematoceles are echogenic, and subacute and chronic hematoceles appear as fluid collections and may have fluid-fluid levels or low-level internal echoes. Hematocele is the most common finding.
In one study of 19 patients that evaluated US features of scrotal injuries caused by gunshot wounds, testicular rupture was detected sonographically in 6 patients.
US in patients with surgically confirmed testicular rupture revealed heterogeneous echogenicity and loss of smooth oval contour.
Adams RJ, Attia M, Cronan K. Report of 4 cases of testicular rupture in adolescent boys secondary to sports-related trauma. Pediatr Emerg Care. 2008 Dec. 24(12):847-8. [Medline].
Okonkwo KC, Wong KG, Cho CT, Gilmer L. Testicular trauma resulting in shock and systemic inflammatory response syndrome: a case report. Cases J. 2008 May 12. 1(1):4. [Medline].
Dogra V, Bhatt S. Acute painful scrotum. Radiol Clin North Am. 2004 Mar. 42(2):349-63. [Medline].
Dogra VS, Bhatt S. Categorical Course in Diagnostic Radiology: Acute Scrotal Pain: Imaging Evaluation for a More Specific Diagnosis. Ramchandani P, ed. Oak Brook, Ill; Radiological Society of North America: Genitourinary Radiology;. 2006: 255-70.
Dogra VS, Gottlieb RH, Oka M. Sonography of the scrotum. Radiology. 2003 Apr. 227(1):18-36.
Bhatt S, Dogra VS. Role of US in testicular and scrotal trauma. Radiographics. 2008 Oct. 28(6):1617-29. [Medline].
Cassar S, Bhatt S, Paltiel HJ, Dogra VS. Role of spectral Doppler sonography in the evaluation of partial testicular torsion. J Ultrasound Med. 2008 Nov. 27(11):1629-38. [Medline].
Lee JC, Bhatt S, Dogra VS. Imaging of the epididymis. Ultrasound Q. 2008 Mar. 24(1):3-16. [Medline].
Bonkat G, Ruszat R, Forster T, Wyler S, Dogra VS, Bachmann A. [Benign space-occupying cysts in the testis. An overview]. Urologe A. 2007 Dec. 46(12):1697-703. [Medline].
Lin EP, Bhatt S, Rubens DJ, Dogra VS. Testicular torsion: twists and turns. Semin Ultrasound CT MR. 2007 Aug. 28(4):317-28. [Medline].
Bhandary P, Abbitt PL, Watson L. Ultrasound diagnosis of traumatic testicular rupture. J Clin Ultrasound. 1992 Jun. 20(5):346-8. [Medline].
Herbener TE. Ultrasound in the assessment of the acute scrotum. J Clin Ultrasound. 1996 Oct. 24(8):405-21. [Medline].
Learch TJ, Hansch LP, Ralls PW. Sonography in patients with gunshot wounds of the scrotum: imaging findings and their value. AJR Am J Roentgenol. 1995 Oct. 165(4):879-83. [Medline].
Delaney LR, Karmazyn B. Ultrasound of the pediatric scrotum. Semin Ultrasound CT MR. 2013 Jun. 34(3):248-56. [Medline].
Guideline developed in collaboration with the American College of Radiology, Society for Pediatric Radiology, Society of Radiologists in Ultrasound. AIUM Practice Guideline for the Performance of Scrotal Ultrasound Examinations. J Ultrasound Med. 2015 Aug. 34 (8):1-5. [Medline].
Waldert M, Klatte T, Schmidbauer J, Remzi M, Lackner J, Marberger M. Color Doppler Sonography Reliably Identifies Testicular Torsion in Boys. Urology. 2009 Nov 12. [Medline].
Ezra N, Afari A, Wong J. Pelvic and scrotal trauma: CT and triage of patients. Abdom Imaging. 2009 Jul. 34(4):541-4. [Medline].
Parenti GC, Feletti F, Brandini F, Palmarini D, Zago S, Ginevra A, et al. Imaging of the scrotum: role of MRI. Radiol Med. 2009 Apr. 114(3):414-24. [Medline].
Kim SH, Park S, Choi SH, Jeong WK, Choi JH. The efficacy of magnetic resonance imaging for the diagnosis of testicular rupture: a prospective preliminary study. J Trauma. 2009 Jan. 66(1):239-42. [Medline].