Clinical History
A 22-year-old male patient was admitted at the emergency department after being involved in a motor vehicle accident: driving a scooter he fell down and was hit by the handlebars on the scrotum. Reported severe scrotal pain, scrotal swelling and redness mainly on the right side. The skin was intact.
Imaging Findings
Ultrasonography with linear high frequency probe, mode B, colour and duplex Doppler mode was performed immediately.
It showed:
Enlarged heterogeneous right testicle with:
Linear irregular incomplete fracture with separation and angulation of both parts with important changes in testicular borders representing testicular fracture and rupture;
Several intra-testicular focal ill defined hypoechoic areas with fluid content representing intra-testicular haematomas
Intra-scrotal extra-testicle heterogeneous fluid collection representing haematocele.
Moderate scrotal wall thickness representing wall haematoma
With the exception of a very small area at the posterior part of the testicle that showed presence of vascularisation on the Power Doppler with normal flow pattern in spectral Doppler – the testicle did not show signs of vascular perfusion.
For the left testicle normal B mode and Doppler study was performed, and just some scrotal wall thickening was noted.
The patient was transferred to another emergency department because ours does not have urologists and the testicle was removed.
Discussion
Scrotal trauma is not common - less than 1% of trauma pathology – because of its anatomical location and mobility [1, 2].
Quick clinical history and physical examination are mandatory, because these are typical and time runs [2, 3].
It is important to know the injury mechanism since it determines the clinical and imaging findings – penetrating, thermal or blunt injury – the last one is more frequent and includes sports impacts and traffic accidents [2, 3] especially those involving motorcycles.
The patient presents with severe scrotal pain, swelling and wall haematoma. The skin on blunt trauma is usually intact.
Ultrasound with linear high frequency probe performed in B mode alone and using colour Doppler and duplex Doppler is the gold standard examination, and, on the base of its findings, the attending physicians will decide what to do [2].
Knowledge of normal scrotal ultrasound appearance is the first requisite to be fulfilled [2, 3]. With this we combine technical ultrasound skills and the complete understanding of all the findings that may be present after blunt trauma, and we can perform the perfect examination.
The testicle may show (the epididymis may also be involved):
Intra-testicular haematoma – solitary or multiple heterogeneous non vascular ill defined focal intra-testicular areas; echogenicity varies with time: hyperechogenic on acute phase; as time goes by starts do be hypoechogenic with fluid areas;
Testicular fracture – liner irregular thick hypoechogenic line through parenchyma; may or may not be complete with separation of two halves; very important to see if flow is present and how its pattern is;
Testicular rupture – defined by rupture of tunica albuginea internal layer and seen on ultrasound as a marked irregularity of testicular borders sometime with extrusion of testicular tissue [2, 3].
The scrotal pouch and wall may show:
Hydroceles – homogeneous anechoic fluid collection on scrotal pouch, between the two layers of tunica vaginalis;
Haematoceles – slightly heterogeneous fluid collection also between the two layers of tunica vaginalis; as time goes by and blood starts to clot becomes more heterogeneous and may show fluid-fluid levels;
Wall haematoma – import thickening of the wall; may also present as heterogeneous fluid dissecting the wall [2, 3].
If there is not rupture of the tunica albuginea there is indication for conservative management. In case of testicular rupture emergency surgery should be performed in order to try to save the testicle [1, 2, 3].
More commonly we see several of these findings together as in our case.
Differential Diagnosis List
Testicle fracture, rupture, haematoma, haematocele and wall haematoma.
Testicle torsion
Testicle acute infection
Final Diagnosis
Testicle fracture, rupture, haematoma, haematocele and wall haematoma.
