Testicular injuries: haematomas and ruptures
Testicular haematoma (Testicular haematomas) in the acute phase poses a complex diagnostic challenge, as the hemorrhage is usually isoechogenic relative to the normal organ parenchyma. If ultrasound findings remain inconclusive, a repeat examination after 12–24 hours is indicated to rule out a occult haematoma. Patients are managed conservatively, but ultrasound follow-up is necessary until the haematoma completely resolves. This is due to the high incidence of infectious complications and necrosis, which may ultimately require orchiectomy.
Testicular rupture (Testicular rupture) occurs when the integrity of the tunica albuginea (tunica albuginea) is compromised. Through the resulting defect, the organ parenchyma herniates into the scrotal cavity.
- Ultrasound findings: The contours of the testis become blurred, and the echogenicity of the parenchyma becomes heterogeneous.
- Mandatory use of color Doppler ultrasound (CDU): Rupture is almost always accompanied by a loss of vascularization in part or all of the testis. The volume of tissue that retains blood supply dictates the method of surgical treatment.
- MRI: Indicated when the ultrasound picture is equivocal. The main diagnostic sign is a break in the integrity of the tunica albuginea, which normally exhibits a low MR signal.
Displacement of the testis: dislocation and torsion
Severe mechanical impact can lead to a change in the anatomical position of the testis.
- Testicular dislocation (Testicular dislocation): A typical mechanism is striking the fuel tank in motorcycle accidents. The organ is displaced, most commonly into the inguinal canal. Ultrasound or computed tomography (CT) is used to confirm the localization. Delayed diagnosis is critically dangerous: it leads to cellular changes in the tissues and predisposes to malignant transformation (malignancy).
- Testicular torsion (Testicular torsion): In 5–8% of all clinical cases, torsion is preceded by physical trauma.
Traumatic penile injuries
Penile fracture (Penile fractures) is a specific injury that occurs, as a rule, as a result of vigorous intercourse or masturbation. The pathogenetic basis is the rupture of the corpus cavernosum (corpus cavernosum) and its tunica albuginea (tunica albuginea). In the erect state, the capsule physiologically thins, making it extremely vulnerable to sudden bending.
- Clinical presentation: The patient notes a characteristic popping or cracking sound, acute pain, and rapid loss of erection (detumescence). A full physical examination is usually limited due to severe painful edema.
- Associated injuries: In 10–20% of cases, fracture is accompanied by injury to the corpus spongiosum (corpus spongiosum) and urethra.
A different mechanism underlies corporal laceration (Corporal laceration). It occurs as a result of direct trauma to the non-erect (flaccid) penis, for example, from a direct kick or penetrating wound.
Imaging methods and radiologic semiotics
Ultrasonography (US) Allows precise determination of the localization of the rupture (appearing as an interruption of the thin echogenic line of the tunica albuginea) and estimation of the size of the adjacent haematoma. When using color Doppler mode and compression of the penile shaft with the transducer, blood flow can be visualized directly through the defect in the tunica albuginea.
Magnetic resonance imaging (MRI) Tomograms clearly reveal a disruption in the continuity of the hypointense tunica albuginea, which may be accompanied by an adjacent haematoma. MRI has high spatial resolution for visualizing ruptures of the tunica spongiosum (tunica spongiosum) and associated injuries of the anterior urethra.
Clinical practice examples:
- Falling off a bicycle (striking the saddle): Perineal trauma can lead to a complete transverse rupture of the urethra. On MRI (T2-weighted images, sagittal and axial projections) in such cases, a high position of the prostate gland and urinary bladder is noted, and the Foley catheter balloon may be visualized inflated directly within the lumen of the ruptured urethra.
- Direct kick to the scrotum: Leads to extensive hemorrhages. Ultrasound reveals a large haematoma of the injured testis, closely adjoining the healthy contralateral testis.
Briefly: answers to topical questions
Into which anatomical regions can the testis become displaced in traumatic dislocation?
In traumatic dislocation, the testis typically shifts into the inguinal canal. Such an injury often occurs when striking the fuel tank during motorcycle accidents. Computed tomography or ultrasonography is used to diagnose this condition. Delayed diagnosis of dislocation leads to cellular tissue changes and predisposes to malignant transformation.
What are the indications for surgical intervention in closed scrotal trauma?
Indications for surgical intervention in scrotal trauma include testicular rupture and the development of severe complications.
- Testicular rupture (Testicular rupture) — accompanied by herniation of the parenchyma into the scrotal cavity and loss of vascularization. Early surgical exploration within the first 72 hours reduces the rate of orchiectomy to 9%.
- Infection and necrosis — may develop against the background of an unresolved testicular haematoma (Testicular haematomas), which may also necessitate orchiectomy.
The volume of viable tissue in a rupture determines the specific surgical treatment method. At the same time, a normal ultrasound picture avoids unnecessary surgical exploration.
Class and exam questions
Why is acute testicular haematoma difficult to detect on initial ultrasound?
In the acute phase, extravasated blood (haematoma) is often isoechogenic to the normal testicular parenchyma, blending with surrounding tissues. In such cases, repeat ultrasound in 12–24 hours is mandatory.
Why is color Doppler ultrasound mandatory when testicular rupture is suspected?
Color Doppler mapping assesses blood supply. In rupture, vascularization of part or all of the testis is lost, and the volume of remaining viable tissue dictates the course of surgical management.
What are the clinical symptoms of a penile fracture?
The condition is characterized by a popping/cracking sound of the erect penis, acute pain, rapid loss of erection (detumescence), and the development of pronounced painful edema.
What is the main danger of delayed diagnosis of testicular dislocation?
Prolonged presence of the testis in an atypical location (e.g., in the inguinal canal) leads to irreversible cellular changes and significantly increases the risk of malignant transformation.
What else to study on this topic
- MR anatomy and signal intensity of the normal tunica albuginea of the testis and penis.
- Sonographic differential diagnosis of haematomas and neoplastic lesions of the testicular parenchyma.
- Management algorithm for patients with associated injuries of the urethra and corpus spongiosum.
- Radiologic features of the sequelae of untreated testicular torsion (necrosis).
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