Question 2: Trauma to testes

Question  2

Cricket ball to groin in young adult. Describe how you would perform scrotal US on this patient and your possible findings

Performing scrotal US in the context of trauma

• Private area
• Chaperone
• Analgesia
• Gloved hand
• Patient supine
• Ample gel and warm if possible
• Place towel beneath sac – get patient to cross ankles. Towel may be placed between the thighs
• Penis held against anterior abdominal wall and held by the patient covered in a towel
• High frequency linear probe (7 -14 MHz) with colour and spectral Doppler Preset testicular
• Initially both testes are examined in the transverse plane to produce “spectacle view “ to compare both testes
• Compare size and echogenicity of each testis and epididymis with those of the contralateral testis and epididymis.
• Examine the asymptomatic side first to set the grey-scale and colour Doppler gains to allow optimal comparison with the affected side
• Examine both in both transverse and longitudinal plane
• Colour Doppler confirms vascular supply
• Colour Doppler and pulsed Doppler US should be optimized to depict low flow velocities, and blood flow in the testis and surrounding scrotal structures should be documented by acquiring Doppler spectral of the intra testicular arterial flow in both testes.
• Ideally, three spectral Doppler recordings should be obtained in each testicle (preferably, in upper, middle, and lower thirds). Power Doppler also may be used to visualize the intratesticular blood flow in patients with acute scrotal pain.

Ultrasound findings

Although ultrasonography can distinguish various testicular injuries it cannot be used alone for the diagnosis of testicular rupture. If ultrasonography   cannot definitively exclude
testicular rupture and if clinically a tear of the tunica albuginea is suspected, surgical exploration is indicated . There is debate whether surgical exploration when there is a haematocoele of  more > than 3 X the size of the contralateral testes as 80% of of patients with large haematocoeles have testicular rupture not detected by ultrasound MRI is more sensitive than ultrasound in the evaluation of testicular rupture. The following are some of the injuries possible and identifiable using ultrasound.

1. Testicular rupture. Spilling out of testicular contents from tunica albuginea

  • Discontinuity of tunica albuginea
  • Irregular heterogeneous testicular margins
  • Heterogeneous echotexture
  • Haematocele . If present may be difficult to evaluate the tinuca albuginea.
  • Diminished Doppler flow to areas which have disruptions of portions of their blood supply. This is because with disruption of the tunica albuginea, there is also disruption of the tunica vasculosa so rupture of the testes results in loss of vascularity to a portion or the entirety of the testes depending on the grade of injuryTraumatic Torsion : absent testicular blood flow

2. Fracture

  • linear, hypoechoic, avascular area within the testis, with or without tunica albuginea rupture

4. Dislocation (testes absent from scrotum)

5. Intratesticular haematoma

  • Mixed echogenicity, initially high echogenicity and then lower echogenicity with complex cystic structures over time
  • May be single or multiple
  • may be small or large
  • May be hyperacute, acute or chronic (if patient presented late)
  • May or may not be associated with other testicular injuries
  • Colour Doppler helps differentiate a haematoma from a tumour. Haematomas do not demonstate colour flow

6. Scrotal wall haematoma

  • Thickened scrotal wall with echogenic or hypoechoic areas

7. Epididymal injury

  • May be fractured or ruptured
  • Fragmented or absent epididymis

8. Urethral injury

9. Penile haematoma / penile fracture

11. Spermatic cord haematoma

  • Mass with variable echogenicity (echogenic to complex anechoic)located superior to the testis

12. Pseudoaneurysm

  • Ying yang sign and to and from pattern at colour and spectral Doppler imaging

 

References : 

  1. Academic Emergency Medicine July 1995 Volume 2, Issue 7 Pages 575–665 Emergency Management of Blunt Testicular Trauma John P. Mulhall, MD, Sheryl G. A. Gabram, MD,
  2. Radiographics  2008  Role of US in Testicular and Scrotal Trauma Shweta Bhatt, MD • Vikram S. Dogra, MD
  3. Medical and Surgical  Urology: Diagnosis and Management of Testicular InjuriesPapoutsoglou N1,2* and Thiruchelvam N2

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