eMedicine Specialties > Radiology > Genitourinary

Testicle, Trauma

Vikram S Dogra, MD, Professor of Diagnostic Radiology, Urology, and Biomedical Engineering, University of Rochester School of Medicine; Director, Division of Ultrasound, Associate Chair of Education and Research, Department of Imaging Sciences, University of Rochester Medical Center

Updated: Nov 16, 2009

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.

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)

Radiography

Findings

Radiographs are used to detect other associated injuries.

Computed Tomography

Findings

CT is used to detect other associated injuries in patients involved in motor vehicle accidents.¹⁴

Magnetic Resonance Imaging

According to Parenti et al, color Doppler ultrasonography (CDUS) is irreplaceable as the initial approach for scrotal disease and trauma, but 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. 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 abilitytoidentifyunexpectedfindings.³

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.⁴

Ultrasonography

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.

Findings

• Direct visualization of a testicular fracture line is rare and 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.
• 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.

Degree of Confidence

US is the modality of choice for imaging. US has 100% sensitivity and 80% specificity for testicular trauma.

False Positives/Negatives

Hemorrhage from underlying tumor or incarcerated hernia may cause a false-positive diagnosis.

Intervention

• No radiologic intervention exists.
• Surgically explore and repair the rupture early in patients with testicular rupture.
• Discuss the possibility of orchiectomy with the patient.

Patient Education: For excellent patient education resources, visit eMedicine's Men's Health Center. Also, see eMedicine's patient education article Testicular Pain.

Multimedia

Media file 1: Longitudinal sonogram of the left testis reveals multiple hypoechoic areas in the inferior pole, consistent with the contusion injury, secondary to gunshot wound.

Media file 2: Transverse sonogram of both testes demonstrates variable echo texture in the scrotal wall secondary to hemorrhage resulting from a motor vehicle accident.

References

1. 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].

2. 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].

3. Dogra V, Bhatt S. Acute painful scrotum. Radiol Clin North Am. Mar 2004;42(2):349-63. [Medline].

4. 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.

5. Dogra VS, Gottlieb RH, Oka M. Sonography of the scrotum. Radiology. Apr 2003;227(1):18-36.

6. 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].

7. 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].

8. Phonsombat S, Master VA, McAninch JW. Penetrating external genital trauma: a 30-year single institution experience. J Urol. Jul 2008;180(1):192-5; discussion 195-6. [Medline].

9. Bhatt S, Dogra VS. Role of US in testicular and scrotal trauma. Radiographics. Oct 2008;28(6):1617-29. [Medline].

10. 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].

11. Lee JC, Bhatt S, Dogra VS. Imaging of the epididymis. Ultrasound Q. Mar 2008;24(1):3-16. [Medline].

12. 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].

13. Lin EP, Bhatt S, Rubens DJ, Dogra VS. Testicular torsion: twists and turns. Semin Ultrasound CT MR. Aug 2007;28(4):317-28. [Medline].

14. Ezra N, Afari A, Wong J. Pelvic and scrotal trauma: CT and triage of patients. Abdom Imaging. Jul 2009;34(4):541-4. [Medline].

15. Anderson KA, McAninch JW, Jeffrey RB. Ultrasonography for the diagnosis and staging of blunt scrotal trauma. J Urol. Nov 1983;130(5):933-5. [Medline].

16. Bhandary P, Abbitt PL, Watson L. Ultrasound diagnosis of traumatic testicular rupture. J Clin Ultrasound. Jun 1992;20(5):346-8. [Medline].

17. Cass AS, Luxenberg M. Testicular injuries. Urology. Jun 1991;37(6):528-30. [Medline].

18. Haas CA, Brown SL, Spirnak JP. Penile fracture and testicular rupture. World J Urol. Apr 1999;17(2):101-6. [Medline].

19. Herbener TE. Ultrasound in the assessment of the acute scrotum. J Clin Ultrasound. Oct 1996;24(8):405-21. [Medline].

20. 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].

21. McAninch JW, Kahn RI, Jeffrey RB. Major traumatic and septic genital injuries. J Trauma. Apr 1984;24(4):291-8. [Medline].

22. 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].

23. Schuster G. Traumatic rupture of the testicle and a review of the literature. J Urol. Jun 1982;127(6):1194-6. [Medline].

Keywords

testicular trauma, testicular fracture, testicular rupture, testicular contusion, testicular hematoma, celomic, coelomic

Contributor Information and Disclosures

Author

Vikram S Dogra, MD, Professor of Diagnostic Radiology, Urology, and Biomedical Engineering, University of Rochester School of Medicine; Director, Division of Ultrasound, Associate Chair of Education and Research, Department of Imaging Sciences, University of Rochester Medical Center
Vikram S Dogra, MD is a member of the following medical societies: American College of Radiology, American Institute of Ultrasound in Medicine, American Roentgen Ray Society, Association of Program Directors in Radiology, Radiological Society of North America, Society of Radiologists in Ultrasound, and Society of Uroradiology
Disclosure: Nothing to disclose.

Pharmacy Editor

Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.

Managing Editor

Matthew D Rifkin, MD, Director, Department of Radiology, Good Samaritan Hospital
Disclosure: Nothing to disclose.

CME Editor

Robert M Krasny, MD, Resolution Imaging Medical Corporation
Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.

Chief Editor

Eugene C Lin, MD, Consulting Radiologist, Virginia Mason Medical Center; Clinical Assistant Professor of Radiology, University of Washington School of Medicine
Eugene C Lin, MD is a member of the following medical societies: American College of Nuclear Medicine, American College of Radiology, Radiological Society of North America, and Society of Nuclear Medicine
Disclosure: Nothing to disclose.

Related eMedicine topics

Testicular Trauma

Testicular Torsion (Emergency Medicine)

Testicular Torsion  (Radiology)

Scrotal Trauma

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