Overview
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.[1] Other causes include direct trauma, motor vehicle accidents, and straddle injuries. Patients present with an acute scrotum and history of trauma.[2] 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.
Longitudinal ultrasonogram of the left testis reveals multiple hypoechoic areas in the inferior pole, consistent with a contusion injury, secondary to gunshot wound. 
Transverse ultrasonogram of both testes demonstrates variable echo texture in the scrotal wall secondary to hemorrhage resulting from a motor vehicle accident. Preferred examination
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]
US is 80% specific for detecting tunica albuginea fracture.
Recentstudies
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.[14]
For excellent patient education resources, visit eMedicine's Men's Health Center. Also, see eMedicine's patient education article Testicular Pain.
Radiography
Radiographs are used to detect associated injuries.
Computed Tomography
Computed tomography (CT) scanning is used to detect other, associated injuries in patients involved in motor vehicle accidents.[15]
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.[16]
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.[17]
Ultrasonography
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.)
Longitudinal ultrasonogram of the left testis reveals multiple hypoechoic areas in the inferior pole, consistent with a contusion injury, secondary to gunshot wound. Transverse ultrasonogram of both testes demonstrates variable echo texture in the scrotal wall secondary to hemorrhage resulting from a motor vehicle accident. 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. Dec 2008;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. May 12 2008;1(1):4. [Medline].
Dogra V, Bhatt S. Acute painful scrotum. Radiol Clin North Am. Mar 2004;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. Apr 2003;227(1):18-36.
Bhatt S, Dogra VS. Role of US in testicular and scrotal trauma. Radiographics. Oct 2008;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. Nov 2008;27(11):1629-38. [Medline].
Lee JC, Bhatt S, Dogra VS. Imaging of the epididymis. Ultrasound Q. Mar 2008;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. Dec 2007;46(12):1697-703. [Medline].
Lin EP, Bhatt S, Rubens DJ, Dogra VS. Testicular torsion: twists and turns. Semin Ultrasound CT MR. Aug 2007;28(4):317-28. [Medline].
Bhandary P, Abbitt PL, Watson L. Ultrasound diagnosis of traumatic testicular rupture. J Clin Ultrasound. Jun 1992;20(5):346-8. [Medline].
Herbener TE. Ultrasound in the assessment of the acute scrotum. J Clin Ultrasound. Oct 1996;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. Oct 1995;165(4):879-83. [Medline].
Waldert M, Klatte T, Schmidbauer J, Remzi M, Lackner J, Marberger M. Color Doppler Sonography Reliably Identifies Testicular Torsion in Boys. Urology. Nov 12 2009;[Medline].
Ezra N, Afari A, Wong J. Pelvic and scrotal trauma: CT and triage of patients. Abdom Imaging. Jul 2009;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. Apr 2009;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. Jan 2009;66(1):239-42. [Medline].
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