DOI: 10.1148/rg.272065117
US of Acute Scrotal Trauma: Optimal Technique, Imaging Findings, and Management1
Corinne Deurdulian, MD,
Carol A. Mittelstaedt, MD,
Wui K. Chong, MD and
Julia R. Fielding, MD
1 From the Department of Imaging, W.G. "Bill" Hefner V.A. Medical Center, 1601 Brenner Ave, Salisbury, NC 28144 (C.D.); and Abdominal Imaging Section, Department of Radiology, University of North Carolina School of Medicine, Chapel Hill, NC (C.A.M., W.K.C., J.R.F.). Presented as an education exhibit at the 2005 RSNA Annual Meeting. Received June 7, 2006; revision requested June 30 and received September 14; accepted September 26. All authors have no financial relationships to disclose.
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Figure 2a. Normal anatomy. Gray-scale US images of normal testes in sagittal (a) and transverse (b) planes demonstrate a uniformly gray echotexture. In b, both testes have the same echotexture. The mediastinum of the testis (arrow) is depicted in a as a horizontal echogenic band.
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Figure 2b. Normal anatomy. Gray-scale US images of normal testes in sagittal (a) and transverse (b) planes demonstrate a uniformly gray echotexture. In b, both testes have the same echotexture. The mediastinum of the testis (arrow) is depicted in a as a horizontal echogenic band.
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Figure 3a. Tunica albuginea. Sagittal US images of the testes in two different patients with hydroceles show the tunica albuginea as an echogenic line (white arrows) that outlines the testis. In a, small punctate echogenic foci are visible within the testis, findings consistent with microlithiasis. A scrotal pearl (black arrow) also is depicted.
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Figure 3b. Tunica albuginea. Sagittal US images of the testes in two different patients with hydroceles show the tunica albuginea as an echogenic line (white arrows) that outlines the testis. In a, small punctate echogenic foci are visible within the testis, findings consistent with microlithiasis. A scrotal pearl (black arrow) also is depicted.
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Figure 4a. Normal epididymis. Sagittal US images depict a normal epididymal head (area between the cursors in a) and body with tail (arrows in b). The echotexture of the epididymis is similar to that of the testis. The view of the body and tail was obtained by scanning in a coronal plane.
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Figure 4b. Normal epididymis. Sagittal US images depict a normal epididymal head (area between the cursors in a) and body with tail (arrows in b). The echotexture of the epididymis is similar to that of the testis. The view of the body and tail was obtained by scanning in a coronal plane.
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Figure 5a. Intratesticular hematoma in a patient with continued scrotal swelling 1 year after blunt trauma. (a) Transverse US image of the scrotum demonstrates a normal-sized right testis (RT) surrounded by fluid, with a large complex cystic mass in place of the left testis. (b) Transverse view obtained with power Doppler imaging in the region of the left testis shows a complex fluid-filled mass with dimensions of 12.1 x 11.2 cm and with multiple septa. No normal parenchyma is identifiable in the left testis, and there is no visible flow, findings indicative of replacement of the entire testis by a hematoma.
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Figure 5b. Intratesticular hematoma in a patient with continued scrotal swelling 1 year after blunt trauma. (a) Transverse US image of the scrotum demonstrates a normal-sized right testis (RT) surrounded by fluid, with a large complex cystic mass in place of the left testis. (b) Transverse view obtained with power Doppler imaging in the region of the left testis shows a complex fluid-filled mass with dimensions of 12.1 x 11.2 cm and with multiple septa. No normal parenchyma is identifiable in the left testis, and there is no visible flow, findings indicative of replacement of the entire testis by a hematoma.
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Figure 6a. Intratesticular hematoma. (a) Sagittal gray-scale US image shows an ill-defined hypoechoic area (arrows) that represents a hematoma in the posterior part of the left testis. (b) Sagittal color Doppler image shows flow in the testis, except in the area of hematoma, where there is a testicular fracture.
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Figure 6b. Intratesticular hematoma. (a) Sagittal gray-scale US image shows an ill-defined hypoechoic area (arrows) that represents a hematoma in the posterior part of the left testis. (b) Sagittal color Doppler image shows flow in the testis, except in the area of hematoma, where there is a testicular fracture.
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Figure 7a. Extratesticular hematoma in a patient with scrotal swelling after a right inguinal hernia repair. Transverse US images demonstrate a large hypoechoic region (8.6 x 3.8 x 4.7 cm) within the right-sided scrotal wall on the gray-scale image (a) and no internal flow on the color Doppler image (b), findings that are indicative of an extratesticular hematoma (H). The right testis in b appears to have normal internal flow.
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Figure 7b. Extratesticular hematoma in a patient with scrotal swelling after a right inguinal hernia repair. Transverse US images demonstrate a large hypoechoic region (8.6 x 3.8 x 4.7 cm) within the right-sided scrotal wall on the gray-scale image (a) and no internal flow on the color Doppler image (b), findings that are indicative of an extratesticular hematoma (H). The right testis in b appears to have normal internal flow.
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Figure 8a. Hydroceles in two patients. (a) Transverse US image of the left scrotum shows a large hydrocele that has displaced the testis (T) anteriorly. (b) Sagittal image shows a very large right-sided hydrocele that contains fine internal septa, with the right testis (area demarcated by cursors) displaced posteriorly.
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Figure 8b. Hydroceles in two patients. (a) Transverse US image of the left scrotum shows a large hydrocele that has displaced the testis (T) anteriorly. (b) Sagittal image shows a very large right-sided hydrocele that contains fine internal septa, with the right testis (area demarcated by cursors) displaced posteriorly.
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Figure 9a. Hematocele due to testicular rupture immediately after blunt scrotal trauma. Transverse US images (b slightly superior to a) show uniformly echogenic fluid surrounding the testis (T), a finding indicative of blood in a hematocele. EPI = epididymis.
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Figure 9b. Hematocele due to testicular rupture immediately after blunt scrotal trauma. Transverse US images (b slightly superior to a) show uniformly echogenic fluid surrounding the testis (T), a finding indicative of blood in a hematocele. EPI = epididymis.
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Figure 10a. Older hematocele. Sagittal US images obtained approximately 1 week (a) and 6 weeks (b) after trauma show uniform echotexture and internal flow in both testes, but with differences in the echotexture of the hematoma. A complex cystic mass (arrow in a) anterior to the left testis represents a hematoma with a hematocele. The mass demarcated by cursors in b had a more complex and more masslike appearance that was believed to be due to a clot. At surgery after 6-week follow-up US, a large amount of fluid and an old clot were found with an intact testis. LT T = left testis, RT T = right testis.
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Figure 10b. Older hematocele. Sagittal US images obtained approximately 1 week (a) and 6 weeks (b) after trauma show uniform echotexture and internal flow in both testes, but with differences in the echotexture of the hematoma. A complex cystic mass (arrow in a) anterior to the left testis represents a hematoma with a hematocele. The mass demarcated by cursors in b had a more complex and more masslike appearance that was believed to be due to a clot. At surgery after 6-week follow-up US, a large amount of fluid and an old clot were found with an intact testis. LT T = left testis, RT T = right testis.
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Figure 11a. Postoperative hematocele. (a) Transverse US image obtained 2 months after surgical repair of a large right inguinal hernia demonstrates complex layering of fluid (arrow) in the right scrotal sac, a finding consistent with a hematocele. (b) Sagittal US image obtained after a right inguinal hernia repair in another patient shows a septate fluid collection with fine echoes (arrows) anterior to the testis (area between the cursors). At Doppler imaging in both patients, flow in the testis was normal.
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Figure 11b. Postoperative hematocele. (a) Transverse US image obtained 2 months after surgical repair of a large right inguinal hernia demonstrates complex layering of fluid (arrow) in the right scrotal sac, a finding consistent with a hematocele. (b) Sagittal US image obtained after a right inguinal hernia repair in another patient shows a septate fluid collection with fine echoes (arrows) anterior to the testis (area between the cursors). At Doppler imaging in both patients, flow in the testis was normal.
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Figure 12a. Testicular fracture. (a) Transverse US image of the testis shows a hypoechoic irregular linear area (arrow) indicative of a fracture. (b) Transverse color Doppler image depicts normal flow throughout the testis, except in the area of the fracture (arrow).
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Figure 12b. Testicular fracture. (a) Transverse US image of the testis shows a hypoechoic irregular linear area (arrow) indicative of a fracture. (b) Transverse color Doppler image depicts normal flow throughout the testis, except in the area of the fracture (arrow).
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Figure 13a. Testicular fractures and intratesticular hematomas. (a) Sagittal gray-scale image of the right testis shows a markedly heterogeneous testis with ill-defined hypoechoic areas that represent intratesticular blood. No peritesticular fluid is visible, and the tunica albuginea appears intact. Because of the extensive hematomas, the specific fracture site is not identifiable. (b) Color Doppler image shows appropriate flow within the traumatized testis.
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Figure 13b. Testicular fractures and intratesticular hematomas. (a) Sagittal gray-scale image of the right testis shows a markedly heterogeneous testis with ill-defined hypoechoic areas that represent intratesticular blood. No peritesticular fluid is visible, and the tunica albuginea appears intact. Because of the extensive hematomas, the specific fracture site is not identifiable. (b) Color Doppler image shows appropriate flow within the traumatized testis.
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Figure 14a. Ruptured testis with hematocele (same patient as in Fig 9). (a–c) Sagittal gray-scale US images of the left testis demonstrate an oblong testis with a heterogeneous echotexture and very irregular outline, with two areas of discontinuity in the tunica albuginea, a defect in the superior pole of the testis (arrows in a), and a defect in the middle part of the testis (arrows in b). The echogenic fluid surrounding the testis is consistent with a hematocele. (d) Sagittal color Doppler image shows flow within the testis. At surgery, the tunica albuginea was found to have ruptured in two places.
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Figure 14b. Ruptured testis with hematocele (same patient as in Fig 9). (a–c) Sagittal gray-scale US images of the left testis demonstrate an oblong testis with a heterogeneous echotexture and very irregular outline, with two areas of discontinuity in the tunica albuginea, a defect in the superior pole of the testis (arrows in a), and a defect in the middle part of the testis (arrows in b). The echogenic fluid surrounding the testis is consistent with a hematocele. (d) Sagittal color Doppler image shows flow within the testis. At surgery, the tunica albuginea was found to have ruptured in two places.
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Figure 14c. Ruptured testis with hematocele (same patient as in Fig 9). (a–c) Sagittal gray-scale US images of the left testis demonstrate an oblong testis with a heterogeneous echotexture and very irregular outline, with two areas of discontinuity in the tunica albuginea, a defect in the superior pole of the testis (arrows in a), and a defect in the middle part of the testis (arrows in b). The echogenic fluid surrounding the testis is consistent with a hematocele. (d) Sagittal color Doppler image shows flow within the testis. At surgery, the tunica albuginea was found to have ruptured in two places.
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Figure 14d. Ruptured testis with hematocele (same patient as in Fig 9). (a–c) Sagittal gray-scale US images of the left testis demonstrate an oblong testis with a heterogeneous echotexture and very irregular outline, with two areas of discontinuity in the tunica albuginea, a defect in the superior pole of the testis (arrows in a), and a defect in the middle part of the testis (arrows in b). The echogenic fluid surrounding the testis is consistent with a hematocele. (d) Sagittal color Doppler image shows flow within the testis. At surgery, the tunica albuginea was found to have ruptured in two places.
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Figure 15a. Ruptured testis with hematoma due to a fall onto a pole. (a) Transverse US image of the left testis shows a heterogeneous echotexture with internal cystic areas that represent hematomas, discontinuity (arrows) in the tunica albuginea, and an extratesticular hematoma (H). (b) Power Doppler image shows no flow in the extratesticular hematoma (H), decreased flow within the testis, and discontinuity (arrows) in the tunica albuginea.
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Figure 15b. Ruptured testis with hematoma due to a fall onto a pole. (a) Transverse US image of the left testis shows a heterogeneous echotexture with internal cystic areas that represent hematomas, discontinuity (arrows) in the tunica albuginea, and an extratesticular hematoma (H). (b) Power Doppler image shows no flow in the extratesticular hematoma (H), decreased flow within the testis, and discontinuity (arrows) in the tunica albuginea.
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Figure 16a. Testicular rupture. (a) Sagittal gray-scale US image demonstrates extrusion of the testicular contents (arrows) through the tunica albuginea. (b) Color Doppler image shows multiple hypoechoic foci with no flow (arrowheads) in the periphery of the testis, findings indicative of hematomas or infarcts. At surgery, extrusion of more than 50% of the testicular contents through the tunica albuginea was found.
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Figure 16b. Testicular rupture. (a) Sagittal gray-scale US image demonstrates extrusion of the testicular contents (arrows) through the tunica albuginea. (b) Color Doppler image shows multiple hypoechoic foci with no flow (arrowheads) in the periphery of the testis, findings indicative of hematomas or infarcts. At surgery, extrusion of more than 50% of the testicular contents through the tunica albuginea was found.
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Figure 17a. Testicular rupture in a patient with groin pain and swelling after an athletic injury (knee to the right side of the groin). Sagittal US images show the right testis with an abnormal contour and somewhat bilobed shape (arrows); hypoechoic and anechoic areas within the inferior pole of the testis, especially visible in b; and irregularity of the tunica albuginea (arrows), which is best depicted in the video clip (Movie 6 radiographics.rsnajnls.org/cgi/content/full/27/2/357/DC1). The area of heterogeneous tissue at the inferior pole of the testis (arrows in a) is believed to represent extruded testicular contents. On color Doppler images (not shown), blood flow was seen in the superior to middle parts of the testis but not in the inferior part. At surgery, the nonviable-appearing parenchyma that extruded through the tunica albuginea was removed and the rupture was repaired.
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Figure 17b. Testicular rupture in a patient with groin pain and swelling after an athletic injury (knee to the right side of the groin). Sagittal US images show the right testis with an abnormal contour and somewhat bilobed shape (arrows); hypoechoic and anechoic areas within the inferior pole of the testis, especially visible in b; and irregularity of the tunica albuginea (arrows), which is best depicted in the video clip (Movie 6 radiographics.rsnajnls.org/cgi/content/full/27/2/357/DC1). The area of heterogeneous tissue at the inferior pole of the testis (arrows in a) is believed to represent extruded testicular contents. On color Doppler images (not shown), blood flow was seen in the superior to middle parts of the testis but not in the inferior part. At surgery, the nonviable-appearing parenchyma that extruded through the tunica albuginea was removed and the rupture was repaired.
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Figure 18a. Penetrating trauma. Transverse US images obtained in a patient with a gunshot wound to the scrotum show tiny hyperechoic foci (small arrows in a) that represent air and buckshot, with a focal hypoechoic area (demarcated by cursors in b) that represents intratesticular hematoma. Accumulated blood (large arrows) is depicted posterior to the testis, within the scrotal sac. The testis, which is demarcated by cursors in a, is difficult to define in b because of the surrounding blood and damage to the testis. Soft-tissue thickening of the scrotal wall also is visible.
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Figure 18b. Penetrating trauma. Transverse US images obtained in a patient with a gunshot wound to the scrotum show tiny hyperechoic foci (small arrows in a) that represent air and buckshot, with a focal hypoechoic area (demarcated by cursors in b) that represents intratesticular hematoma. Accumulated blood (large arrows) is depicted posterior to the testis, within the scrotal sac. The testis, which is demarcated by cursors in a, is difficult to define in b because of the surrounding blood and damage to the testis. Soft-tissue thickening of the scrotal wall also is visible.
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Figure 19a. Testicular ischemia in a patient with scrotal pain and swelling after open surgical repair of a hernia. (a) Transverse US image shows a heterogeneous hypoechoic testis that is surrounded by a complex hydrocele. (b) Color Doppler image demonstrates no intratesticular flow. The mesh that was used to repair the hernia had obstructed the venous return and caused ischemia. After the mesh was released around the spermatic cord, the testicular flow improved. At follow-up US, increased flow was seen in the left testis.
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Figure 19b. Testicular ischemia in a patient with scrotal pain and swelling after open surgical repair of a hernia. (a) Transverse US image shows a heterogeneous hypoechoic testis that is surrounded by a complex hydrocele. (b) Color Doppler image demonstrates no intratesticular flow. The mesh that was used to repair the hernia had obstructed the venous return and caused ischemia. After the mesh was released around the spermatic cord, the testicular flow improved. At follow-up US, increased flow was seen in the left testis.
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Figure 20a. Scrotal electrical burn injury. (a) Sagittal gray-scale image demonstrates a hypoechoic left testis. (b) Sagittal color Doppler image shows no flow within the left testis, a finding suggestive of infarction. On other color Doppler images (not shown), the right testis had a similar appearance. Image resolution at US was somewhat limited because of burn damage to the skin. At surgery, diffuse parenchymal coagulative necrosis, subcutaneous fat necrosis, and acute inflammation were found.
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Figure 20b. Scrotal electrical burn injury. (a) Sagittal gray-scale image demonstrates a hypoechoic left testis. (b) Sagittal color Doppler image shows no flow within the left testis, a finding suggestive of infarction. On other color Doppler images (not shown), the right testis had a similar appearance. Image resolution at US was somewhat limited because of burn damage to the skin. At surgery, diffuse parenchymal coagulative necrosis, subcutaneous fat necrosis, and acute inflammation were found.
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Copyright © 2007 by the Radiological Society of North America.
