British Journal o f c i d o g y ( I 992). 69. 286290
01992 British Journal of Urology
Value of Testicular Ultrasound in the Evaluation of Blunt Scrota1Trauma without Haematocele L. MARTINEZ-PINEIRO, Jr., E. CEREZO, J. M. COZAR, J. A. AVELLANA, J. A. MORENO and J. A. MARTINEZ- P INE IRO Department of Urology and Ultrasound Unit of Department of Internal Medicine, La Paz Hospital, Faculty of Medicine, UniversidadAutdnoma, Madrid, Spain
Summary-The value of ultrasound in testicular trauma with haematocele has been questioned inasmuch as the injured testis should always be explored surgically. Ultrasonography, however, plays an important role in the diagnosis and follow-up of patients with blunt scrotal trauma without haematocele. We have evaluated 17 such patients with real-time ultrasound. In 9 cases the testis and epididymis were normal to palpation, although in 6 of them parenchymal lesions, mainly subcapsular haematomas and parenchymal contusions not amenable to surgical intervention, were detected with ultrasonography. Seven patients presented with changes in the testicular or epididymal morphology at palpation and in 1 case the testes were not palpable. Ultrasonography was of great value, indicating surgery in 6 of these patients where physical examination alone was not sufficient to establish the need for surgical exploration.
Since the report by Albert (1980), testicular ultrasound has been used as a complementary examination in the evaluation of scrotal trauma and has shown good specificity and sensitivity (Friedman et al., 1981 ; Anderson et al., 1983; Jeffrey et al., 1983; Lupentin et al., 1983; Fournier et al., 1985; MacDermott et al., 1988). Its value in the presence of a clinically evident haematocele has been questioned (Cass, 1983; Vaccaro et al., 1986), as surgical exploration has shown better results than conservative management (Cass and Luxenberg, 1988),suggesting that surgery should be undertaken regardless of the results of ultrasonography. Testicular ultrasound is indicated in cases of a traumatised scrotum with normal or swollen testes but without evident haematocele and in cases of scrotal oedema, haemorrhage or previous hydrocele that preclude palpation of the underlying testis. We present 17 patients with blunt testicular trauma without haematocele who were evaluated with ultrasound. Accepted for publication 30 April 1991
Patients and Methods Between 1986 and 1990 we have seen 17 patients with testicular contusion without haematocele following blunt scrotal trauma. Their ages ranged from 4 to 40 years (mean 23.4). There was no known history of scrotal abnormalities before injury. The most common aetiology was sports-related activity (10 patients), followed by injury at work (3), assault (2), traffic accident (1) and domestic lesions (1). Real-time scrotal ultrasonography was performed in every case, using a 7.5 MHz transducer. Patients treated conservatively were followed up with ultrasound scans.
Results On physical examination the testes were always palpable, except in 1 patient in whom scrotal inflammation and oedema precluded palpation. In this patient ultrasonography showed normal testes (Table). Nine patients presented with normal testes and epididymes at palpation, although ultrasound detected 2 sub-tunica haematomas (Fig. l), 2 parenchymal contusions (Fig. 2) and 2 cases of
286
287
TESTICULAR ULTRASOUND IN BLUNT SCROTAL TRAUMA WITHOUT HAEMATOCELE
Table Comparison of Physical Examination, Ultrasonography and Treatment Patient no. Physical exploration
14 15 (Fig. 4) 16 (Fig. 5 )
Diffuse swelling of the whole scrotum Tender normal testes and epididymes Tender normal right testis Scrotal haematoma with tender normal left testis Tender normal right testis Tender normal right testis Tender normal left testis Tender normal left testis Scrotal haematoma with tender normal right testis Superficial scrotal haematoma with tender normal left testis Tender normal left testis with enlarged tail of epidid ymis Tender normal left testis with enlarged epididymis Right tender testis with a small palpapable nodule in the lower pole Tender right swollen testis Tender right swollen testis Tender right swollen testis
17
Tender right swollen testis
1
2 3 4 5
6 (Fig. 1) 7 8 (Fig. 2) 9 10
11 12 (Fig. 3)
13
Ultrasound
Management
Thickened scrotal layers, normal testes Minimal bilateral hydrocele Normal testis Thickened oedematous scrotum, normal testes 5-mm sub-tunica haematoma Double sub-tunica haematoma 15 and 5 mm 8-mm intratesticular contusion Contusion of upper testicular pole Thickened scrotum and slight inflammation of tail of epididymis Inflammation of tail of epididymis
Conservative Conservative Conservative Conservative
Inflammation of tail of epididymis
Conservative
25-mm haematoma-contusion of epididymis
Surgical drainage
Sub-tunica haematoma 20 x 10 mm in lower pole and 5-mm intraparenchymal haematoma Contusion of 2/3 of testis Contusion of 90% of testis Intratesticular contusion-haematoma with ruptured tunica Intratesticular contusion-haematoma of lower pole with ruptured tunica
Surgical drainage
Conservative Conservative Conservative Conservative Conservative Conservative
Orchiectomy Lost, orchiectomy Surgical repair Surgical repair
Fig. 1 (A) Longitudinal scan of right testis showing normal testicular parenchyma (PT) and 5-mm focal sub-tunica hypoechoic lesion surrounded by a sonolucent area (outlined by arrowheads) corresponding to a sub-tunica haemorrhage surrounded by a parenchymal contusion. (B) Parallel scan reveals another hypoechoic subtunica area 15 x 4 mm in the posterior aspect of the testis (arrowheads). Minimal hydrocele (0).
288
BRITISH JOURNAL OF UROLOGY
Fig. 2 (A) Longitudinal scan showing hypoechoic area (H) 14 x 40 mm along the upper pole of the testis corresponding to a parenchymal contusion. (B) Follow-up scan 40 days later shows partial resolution of the lesion.
Fig. 3 Transverse scan of normal left testis (PT). Hypoechoic area of 25mm with internal echoes in the epididymis (M) corresponding to an epididymal contusion and haematoma. Arrowheads outline the limit of the epididymal capsule.
Fig. 4 Longitudinal scan of right testis showing disorganised pattern of echogenicity and 2 focal areas of sonolucency representing a contusion of almost the whole testis with 2 areas of parenchymal infarction and haemorrhage. Neither testicular rupture nor haematocele was detected.
epididymitis; none required surgery and all were managed conservatively. Seven patients (nos 11-17) presented with palpable testes but with a variety of changes in the testicular or epididymal morphology (Table). Scrotal ultrasonography showed epididymitis (1 case),
epididymal haematoma (1) (Fig. 3), sub-tunica haematoma (1) and major testicular contusions (4) (Fig. 4); 2 of these 4 patients had a rupture of the tunica albuginea (Fig. 5). Five of these 7 patients were treated surgically : 2 underwent evacuation of the haematomas, 2 debridement of necrotic tubules
TESTICULAR ULTRASOUND IN BLUNT SCROTAL TRAUMA WITHOUT HAEMATOCELE
Fig. 5 Oblique scan of right testis showing 2 intratesticular hypoechoic areas (H) corresponding to parenchymal contusions with haematoma. The superior extrudes through the tunica albuginea where a discrete fracture plane (arrowhead) can be seen, representing a testicular rupture without haematocele.
with suture repair of the tunica albuginea and 1 an orchiectomy. All post-operative courses were uneventful. One patient was managed conservatively and 1 refused any kind of treatment.
Discussion The value of ultrasound in testicular trauma with haematocele has been questioned, since the injured testis should be explored surgically in all cases. Surgically treated patients resume normal activities earlier than those treated conservatively, and the number of orchiectomies is lower (Cass and Luxenberg, 1988). Ultrasonography, however, plays an important role in the diagnosis of blunt scrotal trauma without haematocele (Kratzik et al., 1989). In the present series, physical exploration diagnosed correctly only 5/17 injuries. Palpation of the testis and epididymes was normal in 9 patients even when ultrasound revealed obvious lesions in 6 . However, none of these patients required surgery
289
and they progressed satisfactorily with conservative management. Ultrasound was helpful in assessing healing of the lesions. Of 6 patients who presented with a swollen testis or epididymis, 5 underwent surgery (6 if we include no. 15). None had had a haematocele and physical examination alone had not been sufficient to establish the indication for surgical exploration. This was performed only when ultrasound sugested a ruptured tunica, major testicular contusion .r testicular or epididymal haematoma. The surgi;a1 findings correlated exactly with the ultrasound images. In view of the good results obtained with conservative treatment of patient no. 8 (Fig. 2), such treatment should perhaps also have been tried in patient no. 13. We do not know the minimum size of contusion or haematoma for which surgical treatment is indicated. Lesions measuring less than one-third of the testis will probably heal with conservative treatment alone, while the larger lesions or those accompanied by rupture of the tunica will require surgical repair or orchiectomy. Blunt scrotal trauma without haematocele is difficult to assess by physical examination alone. In the majority of patients in whom the testis and epididymis are normal at palpation no surgery will be needed, although in two-thirds of them a parenchymal lesion exists that is detectable only by ultrasonography. These patients should be followed up with regular scrotal ultrasound examinations until resolution. When the normal morphology of the testis or epididymis is altered, surgery is needed in a high percentage of cases. Ultrasonography is of considerable value in deciding on surgical or conservative treatment. Contusions or haematomas measuring less than one-third of the testis will probably heal with conservative treatment alone, whereas those that are larger or where the tunica is ruptured will require surgical repair or orchiectomy. Larger series of patients are needed to confirm these recommendations. In the presence of gross swelling and thickening of the scrotal layers that prevent palpation of the testis, ultrasonography is a rapid method of ascertaining testicular integrity.
290
References Albert, E. N. (1980). Testicular ultrasound for trauma. J . Urol., 124,558-559. Anderson, K. A., McAninch, J. W., Jeffrey, R. B. e l d.(1983). Ultrasonography for the diagnosis and staging of blunt scrotal trauma. J . Urol., 130,933-935. Cass, A. S. (1983). Testicular trauma. J . Urol., 129, 299-300. Cass, A. S. and Luxenberg, M. (1988). Value of early operation in blunt testicular contusion with hematocele. J . Urol., 139, 746747. Fournier, G. R., Jr., Laing, F. C., Jeffrey, R. B. efal. (1 985). High resolution scrotal ultrasonography: a highly sensitive but nonspecific diagnostic technique. J. Urol., 134,490-493. Friedman, S. G., Rose, J. G. and Winston, M. A. (1981). Ultrasound and nuclear medicine evaluation in acute testicular trauma. J . Urol., 125,748-749. Jeffrey, R. B., Laing, F. C., Hricak, H. e t d . (1983). Sonography of testicula trauma. A . J . R., 141,993-995. Kratzik, Ch., Hainz, A., Kuber, W. et al. (1989). Has ultrasound influenced the therapy concept of blunt scrotal trauma? J . Urol., 142, 1243-1246.
BRITISH JOURNAL OF UROLOGY
Lupentin, A. R., King, W., 111, Rich, P. J. ef d. (1983). The traumatized scrotum. Radiology, 148, 203-207. MacDermott, J. P.,Gray, B. K. and Hamilton Stewart, P. A. (1988). Traumatic rupture of the testis. Br. J . Urol., 62, 179181. Vaccaro, J. A., Davis, R., Belville, W. D. erd. (1986). Traumatic hematocele: association with rupture of the testicle. J . Urol., 136, 1217-1218.
The Authors L. Martinez-Piiieiro, MD, Assistant Urologist. E. Cerezo, MD, Consultant Gastroenterologist. J . M. Cozar, MD, Urology Resident. J . A. Avellana, MD, Consultant Urologist. J. A. Moreno, MD, Urology Resident. J. A. Martinez-Piiieiro, MD, PhD, Chief of the Urology Department and Associate Professor of Urology. Requests for reprints to: L. Martinez-Piiieiro, Avda. San Luis 95,3G, 28033 Madrid, Spain.
01992 British Journal of Urology
Value of Testicular Ultrasound in the Evaluation of Blunt Scrota1Trauma without Haematocele L. MARTINEZ-PINEIRO, Jr., E. CEREZO, J. M. COZAR, J. A. AVELLANA, J. A. MORENO and J. A. MARTINEZ- P INE IRO Department of Urology and Ultrasound Unit of Department of Internal Medicine, La Paz Hospital, Faculty of Medicine, UniversidadAutdnoma, Madrid, Spain
Summary-The value of ultrasound in testicular trauma with haematocele has been questioned inasmuch as the injured testis should always be explored surgically. Ultrasonography, however, plays an important role in the diagnosis and follow-up of patients with blunt scrotal trauma without haematocele. We have evaluated 17 such patients with real-time ultrasound. In 9 cases the testis and epididymis were normal to palpation, although in 6 of them parenchymal lesions, mainly subcapsular haematomas and parenchymal contusions not amenable to surgical intervention, were detected with ultrasonography. Seven patients presented with changes in the testicular or epididymal morphology at palpation and in 1 case the testes were not palpable. Ultrasonography was of great value, indicating surgery in 6 of these patients where physical examination alone was not sufficient to establish the need for surgical exploration.
Since the report by Albert (1980), testicular ultrasound has been used as a complementary examination in the evaluation of scrotal trauma and has shown good specificity and sensitivity (Friedman et al., 1981 ; Anderson et al., 1983; Jeffrey et al., 1983; Lupentin et al., 1983; Fournier et al., 1985; MacDermott et al., 1988). Its value in the presence of a clinically evident haematocele has been questioned (Cass, 1983; Vaccaro et al., 1986), as surgical exploration has shown better results than conservative management (Cass and Luxenberg, 1988),suggesting that surgery should be undertaken regardless of the results of ultrasonography. Testicular ultrasound is indicated in cases of a traumatised scrotum with normal or swollen testes but without evident haematocele and in cases of scrotal oedema, haemorrhage or previous hydrocele that preclude palpation of the underlying testis. We present 17 patients with blunt testicular trauma without haematocele who were evaluated with ultrasound. Accepted for publication 30 April 1991
Patients and Methods Between 1986 and 1990 we have seen 17 patients with testicular contusion without haematocele following blunt scrotal trauma. Their ages ranged from 4 to 40 years (mean 23.4). There was no known history of scrotal abnormalities before injury. The most common aetiology was sports-related activity (10 patients), followed by injury at work (3), assault (2), traffic accident (1) and domestic lesions (1). Real-time scrotal ultrasonography was performed in every case, using a 7.5 MHz transducer. Patients treated conservatively were followed up with ultrasound scans.
Results On physical examination the testes were always palpable, except in 1 patient in whom scrotal inflammation and oedema precluded palpation. In this patient ultrasonography showed normal testes (Table). Nine patients presented with normal testes and epididymes at palpation, although ultrasound detected 2 sub-tunica haematomas (Fig. l), 2 parenchymal contusions (Fig. 2) and 2 cases of
286
287
TESTICULAR ULTRASOUND IN BLUNT SCROTAL TRAUMA WITHOUT HAEMATOCELE
Table Comparison of Physical Examination, Ultrasonography and Treatment Patient no. Physical exploration
14 15 (Fig. 4) 16 (Fig. 5 )
Diffuse swelling of the whole scrotum Tender normal testes and epididymes Tender normal right testis Scrotal haematoma with tender normal left testis Tender normal right testis Tender normal right testis Tender normal left testis Tender normal left testis Scrotal haematoma with tender normal right testis Superficial scrotal haematoma with tender normal left testis Tender normal left testis with enlarged tail of epidid ymis Tender normal left testis with enlarged epididymis Right tender testis with a small palpapable nodule in the lower pole Tender right swollen testis Tender right swollen testis Tender right swollen testis
17
Tender right swollen testis
1
2 3 4 5
6 (Fig. 1) 7 8 (Fig. 2) 9 10
11 12 (Fig. 3)
13
Ultrasound
Management
Thickened scrotal layers, normal testes Minimal bilateral hydrocele Normal testis Thickened oedematous scrotum, normal testes 5-mm sub-tunica haematoma Double sub-tunica haematoma 15 and 5 mm 8-mm intratesticular contusion Contusion of upper testicular pole Thickened scrotum and slight inflammation of tail of epididymis Inflammation of tail of epididymis
Conservative Conservative Conservative Conservative
Inflammation of tail of epididymis
Conservative
25-mm haematoma-contusion of epididymis
Surgical drainage
Sub-tunica haematoma 20 x 10 mm in lower pole and 5-mm intraparenchymal haematoma Contusion of 2/3 of testis Contusion of 90% of testis Intratesticular contusion-haematoma with ruptured tunica Intratesticular contusion-haematoma of lower pole with ruptured tunica
Surgical drainage
Conservative Conservative Conservative Conservative Conservative Conservative
Orchiectomy Lost, orchiectomy Surgical repair Surgical repair
Fig. 1 (A) Longitudinal scan of right testis showing normal testicular parenchyma (PT) and 5-mm focal sub-tunica hypoechoic lesion surrounded by a sonolucent area (outlined by arrowheads) corresponding to a sub-tunica haemorrhage surrounded by a parenchymal contusion. (B) Parallel scan reveals another hypoechoic subtunica area 15 x 4 mm in the posterior aspect of the testis (arrowheads). Minimal hydrocele (0).
288
BRITISH JOURNAL OF UROLOGY
Fig. 2 (A) Longitudinal scan showing hypoechoic area (H) 14 x 40 mm along the upper pole of the testis corresponding to a parenchymal contusion. (B) Follow-up scan 40 days later shows partial resolution of the lesion.
Fig. 3 Transverse scan of normal left testis (PT). Hypoechoic area of 25mm with internal echoes in the epididymis (M) corresponding to an epididymal contusion and haematoma. Arrowheads outline the limit of the epididymal capsule.
Fig. 4 Longitudinal scan of right testis showing disorganised pattern of echogenicity and 2 focal areas of sonolucency representing a contusion of almost the whole testis with 2 areas of parenchymal infarction and haemorrhage. Neither testicular rupture nor haematocele was detected.
epididymitis; none required surgery and all were managed conservatively. Seven patients (nos 11-17) presented with palpable testes but with a variety of changes in the testicular or epididymal morphology (Table). Scrotal ultrasonography showed epididymitis (1 case),
epididymal haematoma (1) (Fig. 3), sub-tunica haematoma (1) and major testicular contusions (4) (Fig. 4); 2 of these 4 patients had a rupture of the tunica albuginea (Fig. 5). Five of these 7 patients were treated surgically : 2 underwent evacuation of the haematomas, 2 debridement of necrotic tubules
TESTICULAR ULTRASOUND IN BLUNT SCROTAL TRAUMA WITHOUT HAEMATOCELE
Fig. 5 Oblique scan of right testis showing 2 intratesticular hypoechoic areas (H) corresponding to parenchymal contusions with haematoma. The superior extrudes through the tunica albuginea where a discrete fracture plane (arrowhead) can be seen, representing a testicular rupture without haematocele.
with suture repair of the tunica albuginea and 1 an orchiectomy. All post-operative courses were uneventful. One patient was managed conservatively and 1 refused any kind of treatment.
Discussion The value of ultrasound in testicular trauma with haematocele has been questioned, since the injured testis should be explored surgically in all cases. Surgically treated patients resume normal activities earlier than those treated conservatively, and the number of orchiectomies is lower (Cass and Luxenberg, 1988). Ultrasonography, however, plays an important role in the diagnosis of blunt scrotal trauma without haematocele (Kratzik et al., 1989). In the present series, physical exploration diagnosed correctly only 5/17 injuries. Palpation of the testis and epididymes was normal in 9 patients even when ultrasound revealed obvious lesions in 6 . However, none of these patients required surgery
289
and they progressed satisfactorily with conservative management. Ultrasound was helpful in assessing healing of the lesions. Of 6 patients who presented with a swollen testis or epididymis, 5 underwent surgery (6 if we include no. 15). None had had a haematocele and physical examination alone had not been sufficient to establish the indication for surgical exploration. This was performed only when ultrasound sugested a ruptured tunica, major testicular contusion .r testicular or epididymal haematoma. The surgi;a1 findings correlated exactly with the ultrasound images. In view of the good results obtained with conservative treatment of patient no. 8 (Fig. 2), such treatment should perhaps also have been tried in patient no. 13. We do not know the minimum size of contusion or haematoma for which surgical treatment is indicated. Lesions measuring less than one-third of the testis will probably heal with conservative treatment alone, while the larger lesions or those accompanied by rupture of the tunica will require surgical repair or orchiectomy. Blunt scrotal trauma without haematocele is difficult to assess by physical examination alone. In the majority of patients in whom the testis and epididymis are normal at palpation no surgery will be needed, although in two-thirds of them a parenchymal lesion exists that is detectable only by ultrasonography. These patients should be followed up with regular scrotal ultrasound examinations until resolution. When the normal morphology of the testis or epididymis is altered, surgery is needed in a high percentage of cases. Ultrasonography is of considerable value in deciding on surgical or conservative treatment. Contusions or haematomas measuring less than one-third of the testis will probably heal with conservative treatment alone, whereas those that are larger or where the tunica is ruptured will require surgical repair or orchiectomy. Larger series of patients are needed to confirm these recommendations. In the presence of gross swelling and thickening of the scrotal layers that prevent palpation of the testis, ultrasonography is a rapid method of ascertaining testicular integrity.
290
References Albert, E. N. (1980). Testicular ultrasound for trauma. J . Urol., 124,558-559. Anderson, K. A., McAninch, J. W., Jeffrey, R. B. e l d.(1983). Ultrasonography for the diagnosis and staging of blunt scrotal trauma. J . Urol., 130,933-935. Cass, A. S. (1983). Testicular trauma. J . Urol., 129, 299-300. Cass, A. S. and Luxenberg, M. (1988). Value of early operation in blunt testicular contusion with hematocele. J . Urol., 139, 746747. Fournier, G. R., Jr., Laing, F. C., Jeffrey, R. B. efal. (1 985). High resolution scrotal ultrasonography: a highly sensitive but nonspecific diagnostic technique. J. Urol., 134,490-493. Friedman, S. G., Rose, J. G. and Winston, M. A. (1981). Ultrasound and nuclear medicine evaluation in acute testicular trauma. J . Urol., 125,748-749. Jeffrey, R. B., Laing, F. C., Hricak, H. e t d . (1983). Sonography of testicula trauma. A . J . R., 141,993-995. Kratzik, Ch., Hainz, A., Kuber, W. et al. (1989). Has ultrasound influenced the therapy concept of blunt scrotal trauma? J . Urol., 142, 1243-1246.
BRITISH JOURNAL OF UROLOGY
Lupentin, A. R., King, W., 111, Rich, P. J. ef d. (1983). The traumatized scrotum. Radiology, 148, 203-207. MacDermott, J. P.,Gray, B. K. and Hamilton Stewart, P. A. (1988). Traumatic rupture of the testis. Br. J . Urol., 62, 179181. Vaccaro, J. A., Davis, R., Belville, W. D. erd. (1986). Traumatic hematocele: association with rupture of the testicle. J . Urol., 136, 1217-1218.
The Authors L. Martinez-Piiieiro, MD, Assistant Urologist. E. Cerezo, MD, Consultant Gastroenterologist. J . M. Cozar, MD, Urology Resident. J . A. Avellana, MD, Consultant Urologist. J. A. Moreno, MD, Urology Resident. J. A. Martinez-Piiieiro, MD, PhD, Chief of the Urology Department and Associate Professor of Urology. Requests for reprints to: L. Martinez-Piiieiro, Avda. San Luis 95,3G, 28033 Madrid, Spain.
![[The value of sonography in scrotal trauma].](/assets/img/hold.png)
