Introduction
Background
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 sonogram of the left testis reveals multiple hypoechoic areas in the inferior pole, consistent with the contusion injury, secondary to gunshot wound.
Transverse sonogram of both testes demonstrates variable echo texture in the scrotal wall secondary to hemorrhage resulting from a motor vehicle accident.
Recent studies
According to Parenti et al, color Doppler ultrasonography (CDUS) is irreplaceable as the initial approach for scrotal disease and trauma but MRI may be considered 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. 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.6
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. In 2 cases in which there was an inconclusive diagnosis by ultrasonography, MRI helped make the diagnosis of epididymal hematoma. The remaining 2 cases showed concordant results with the surgical findings.7
Pathophysiology
Trauma to a testis is uncommon because of its mobility and position. Trauma can be penetrating8 or blunt (more common). Impingement of the testis against the symphysis pubis or ischial ramus is the most common mechanism of injury resulting from blunt trauma.
Frequency
United States
More than 50% of testicular ruptures occur during sporting events. Motor vehicle accidents account for 9-17% of testicular injuries.
International
The international incidence is the same as in the US.
Mortality/Morbidity
Testicular rupture is a urologic emergency, and more than 80% of ruptured testes can be saved if surgery is performed within 72 hours.
Age
The age at which testicular trauma occurs most commonly is 16-20 years; however, it can occur at any age.
Anatomy
A normal testis develops in the celomic cavity and begins to descend into the scrotum at 36 weeks, guided by the contractile cordlike structure termed the gubernaculum testis. Testicular size depends on age and stage of sexual development. Before age 12 years, testicular volume is 1-2 mL. Mean testicular volume at 16 years is 14 mL. Prepubertal testes are of low-to-medium level echogenicity.
US is the most common imaging study used to evaluate the testes. On US, a normal adult testis has medium-level echoes and measures approximately 5 X 3 X 2 cm. The tunica albuginea is the fibrous covering of the testicle. Capsular arteries (division of testicular artery) run under the tunica albuginea, forming the tunica vasculosa. Septa extend from the tunica albuginea into the testicle, dividing the testes into lobules.
The posterior surface of the tunica albuginea is reflected into the interior of the gland, forming the incomplete septum termed the mediastinum of the testis. Sonographically, this appears as an echogenic band running across the testis. Each lobule is composed of multiple seminiferous tubules that open via tubules (tubuli recti) into dilated spaces termed the rete testes within the mediastinum. These in turn communicate via efferent ductules in the epididymal head. The epididymis is composed of a head, body, and tail, the ducts of which continue as the vas deferens in the spermatic cord.
Presentation
Patients present with symptoms of an acute scrotum and history of trauma. Physical examination reveals scrotal edema and ecchymosis of the scrotal skin. The scrotum is tender to the touch, and discrete testis may be difficult to palpate because of surrounding edema and/or hematoma.
Preferred Examination
US is the imaging modality of choice. If US fails to reveal contusion, hematoma, or testicular rupture, perform surgical exploration.7,9,10,11,12,13
Limitations of Techniques
US detects testicular contusion, hematoma, or rupture well. US is 80% specific for detecting tunica albuginea fracture.
Differential Diagnoses
Epididymitis
Testicle, Malignant Tumors
Testicle, Trauma
Testicular Torsion
Other Problems to Be Considered
Hematocele (may be secondary to extratesticular causes or testicular trauma, despite lack of definite US evidence of testicular rupture)
Testicular tumors (10-15% first present after scrotal trauma; therefore, follow intratesticular abnormalities if surgical intervention is not performed immediately)
More on Testicle, Trauma |
 Overview: Testicle, Trauma |
| Imaging: Testicle, Trauma |
| Follow-up: Testicle, Trauma |
| Multimedia: Testicle, Trauma |
| References |
| Further Reading |
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References
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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].
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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.
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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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].
McAninch JW, Kahn RI, Jeffrey RB. Major traumatic and septic genital injuries. J Trauma. Apr 1984;24(4):291-8. [Medline].
Sasso F, Gulino G, Di Pinto A. [Correlation between ultrasonography imaging and surgical findings in scrotal trauma]. Arch Ital Urol Androl. Apr 1995;67(2):159-62. [Medline].
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Further Reading
Related eMedicine topics
Testicular Trauma
Testicular Torsion (Emergency Medicine)
Testicular Torsion (Radiology)
Scrotal Trauma
Keywords
testicular trauma, testicular fracture, testicular rupture, testicular contusion, testicular hematoma, celomic, coelomic
