IS Case 197: Ruptured testicle
Imaging Sciences URMC 2008
Publication Date: 2009-05-22
An 18-year-old male who was punched in the scrotum presented with pain and swelling of the right scrotum.
Rupture of tunica albuginea with contour abnormality.
Despite the vulnerable position of the testicles, testicular trauma is relatively uncommon. Blunt trauma accounts for approximately 85% of cases, and penetrating trauma accounts for 15%.
Patients who have sustained severe blunt trauma usually exhibit symptoms of extreme scrotal pain, frequently associated with nausea and vomiting. Physical examination often reveals a swollen, severely tender testicle with a hematoma. Prompt diagnosis of a ruptured testis is of utmost importance because of the direct relationship between early surgical intervention and testicular salvagability. More than 80% of testicles can be saved if surgery is performed within the first 72 hours.
Trauma can result in contusion, hematoma, fracture, or rupture of the testis. Scrotal US with color flow Doppler is helpful in determining the nature and extent of the injury. Sonographic findings in testicular rupture include interruption of the tunica albuginea, contour abnormality, a heterogeneous testis with irregular, poorly defined borders, scrotal wall thickening, and a hematocele. Color and power Doppler sonography are helpful because either can detect disruption of the normal capsular blood flow of the tunica vasculosa. Heterogeneous intratesticular lesions are caused by hemorrhage or infarction. With severe rupture, there is extensive extravasation of the seminiferous tubules from the torn tunica albuginea and morphology may be so distorted that it may be difficult to identify any normal-appearing parenchyma. Hematocele is a blood collection within the tunica vaginalis. On sonography, acute hematoceles are echogenic, whereas older hematoceles appear as fluid collections with low-level echogenicity, fluid-fluid levels, or septations.
Intratesticular fractures can occur in the absence of tunica rupture. This will produce isolated intratesticular lesions. Such lesions usually appear complex or solid and can overlap with the appearance of testicular tumors. Color Doppler is also valuable since most tumors contain detectable internal vascularity and localized post-traumatic lesions generally contain no detectable blood flow. In the setting of trauma, intratesticular lesions that have benign clinical and sonographic characteristics can be followed with serial scans to confirm improvement. If the lesions do not resolve or improve on short-term follow up, then the possibility of tumor should be reconsidered.
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