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12. Randhawa H, Blankstein U, Davies T.Scrotal trauma: a case report and review of the litera-
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Symptoms, Signs, Diagnostic Means,
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andGrading ofScrotal andTesticular
45
Trauma
45.1 Symptoms andSigns
It is a truism to say that the symptoms of scrotal and testicular injuries are obvious
because this is expected to be so for any supercial organ injury. The patient presents with pain and swelling after blunt trauma or an obvious laceration and bleeding
from a penetrating agent and readily gives the history of the incident. The pain
might be associated with nausea and vomiting. In mild cases, there are skin abrasion
and ecchymosis or a small shallow cut. In severe cases, there is a huge hematoma
and severe pain suggesting a testicular rupture or a large laceration deep to the testis.
In extreme cases, the testis is shattered or the patient presents with an amputated
testis and/or scrotum. After a rapid history and local wound evaluation, a general
evaluation must be conducted to rule out associated injuries that might or not be
prioritized over the testicular-scrotal injury.
A study among Israeli soldiers with scrotal trauma showed the occurrence of the
following symptoms: scrotal pain in 100%, scrotal tenderness in 71.7%, scrotal
edema in 16.2%, scrotal hematoma in 4.8%, and dysuria in 10%. Additionally, there
was microscopic hematuria (positive urine dipstick) in 11.8% [1].
In unilateral testicular trauma, the affected testis must be palpated very delicately
to avoid harming the patient and must always be compared with the contralateral
normal one. Assessment of the injured organs is made along with the evaluation of
the general condition of the patient as the patient might be in shock, sepsis, or anemia. The patient’s past history is also important to exclude preexisting hernia, presence or absence of both testes (e.g., previous surgery, undescended testis, hydrocele,
etc.), and medical conditions (hematological disease) [2].
Information about the patient’s age, marital status, and offspring is also important, especially in the management of severe bilateral testicular injury or trauma on
a solitary testicle.
© The Author(s), under exclusive license to Springer Nature Singapore Pte
Ltd. 2023
S. A. AL-Mamari, Urogenital Trauma: A Practical Guide,
https://doi.org/10.1007/978-981-99-6171-9_45
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45 Symptoms, Signs, Diagnostic Means, andGrading ofScrotal andTesticular Trauma
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382
45.2 Diagnostic Means
45.2.1 Ultrasonography (US)
Ultrasonography (US) is strongly recommended by all expert panels (i.e., European
association of urology (EAU), American Urological Association (AUA), British
Association Of Urological Surgeons (BAUS), and Société Internationale d’Urologie
(SIU)) as the rst-line imaging modality for scrotal trauma as it helps evaluate and
grade eventual testicular damage [3–6].
The advantages of US lie in its simplicity, its rapidity, its noninvasiveness, its
wide distribution, and its cost-effectiveness. US allows a rapid diagnosis of eventual
testicular rupture shown as a discontinuity of the echogenic tunica albuginea,
triggering an urgent surgery which is of paramount importance for salvaging the
testis. Color ow and duplex Doppler imaging are very useful for assessing testicular integrity (rupture), viability, and perfusion as well as for evaluating associated
vascular injuries such as pseudoaneurysms. Determining vascular integrity is of
critical importance, especially in cases of penetrating trauma and electrical burns [7,
8] (Table45.1).
With the ability to dene a loss of contour of the testicular parenchyma, abnormal heterogeneous echo pattern, adjacent hematoma, and eventual extrusion of the
seminiferous tubules, US has shown a 65–93.5% specicity and a 100% sensitiv-
ity to diagnose testicular rupture avoiding missing the diagnosis and the risk of
orchidectomy for delayed diagnosis [9–13] (Figs. 45.1 and 45.2). Moreover, US
also provides the diagnosis of other traumatic features such as hematocele (87%
sensitivity and 89% specicity), testicular hematoma (71% sensitivity and 77%
specicity), and testis avulsion (100% sensitivity and 97% specicity) [10].
Ultrasound should be requested even in cases with only mild scrotal pain and
limited post-traumatic swelling in the absence of tenderness as this scenario does
not exclude a testicular rupture [11] (Figs.45.3 and 45.4a, b).
It is important, however, to notice that a study has shown lower sensitivity and
specicity of ultrasound in detecting testicular trauma, with values of 70.8% and
71.2%, respectively [14]. While the experience of the radiologist denitely plays an
Table 45.1 Sonographic ndings in scrotal injuries
Injury type Sonographic ndings
Hematocele Acute: echogenic extra-testicular uid collections with internal echoes
Sub-acute to chronic: hypoechoic with multiple septations
Testicular
hematoma
Testicular
fracture
Testicular rupture Heterogeneous testicular parenchyma with contour deformity
From Lehnert etal. [8], with permission from Springer Nature.
Acute: May be isoechoic to normal testicular parenchyma. May mimic a
solid neoplasm
Sub-acute to chronic: Hypoechoic to testicular parenchyma with interval
decrease in size
Linear band of decreased parenchymal echogenicity
Associated with intratesticular hematoma and segmental infarction
Tunica disruption may be visible (the absence of this nding does not
exclude rupture)
45.2 Diagnostic Means
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Fig. 45.1 Left testicle sagittal plane. There is abnormal tunica albuginea thickening ([ ]) without
obvious disruption, a moderate-sized hematocele (asterisks), and a linear hypoechoic fracture line
(between white arrows) separating a heterogeneous appearing testicular parenchyma. Normal testicular parenchyma is present to the left with an abnormal appearance testicle to the right of the
fracture line, consistent with an intratesticular contusion. (From Blok etal. [13]. Creative Commons
attribution license)
Fig. 45.2 Left testicle
mid-transverse plane.
Complex uid collection
with low-level echoes
surrounding the left testicle
consistent with a
hematocele (asterisks) with
hypoechoic testicular
echogenicity consistent
with a fracture line
(arrow). (From Blok etal.
[13]. Creative Commons
attribution license)
383
important role in improving US accuracy, this study should raise attention to the fact
that the urologist should always consider early exploration in equivocal cases or
those whose imaging reports deviate from the expected results in view of the
history and physical examination. Always being alert is the best strategy to avoid
any delay in the management and give the best chance to the patient for testicular
salvaging.
Contrast-enhanced US (CEUS) has shown interest in detecting early and minimal intratesticular changes such as mild uid collection or hypoechoic and hypoperfused areas suggestive of minor vascular trauma and might be useful in cases
where the conventional US is not conclusive [15, 16].
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45 Symptoms, Signs, Diagnostic Means, andGrading ofScrotal andTesticular Trauma
Fig. 45.3 Ultrasound scan
showing ruptured testis,
with interruption of the
normal echoic line of
tunica albuginea (arrows)
at arrowhead. Extruded
seminiferous tubules (E)
have herniated through
tunica defect. Testis (T)
was markedly
heterogeneous. These
ndings were conrmed
intraoperatively and
successfully repaired.
(From Chandra etal. [11],
with permission from
Elsevier)
45.2.2 Magnetic Resonance Imaging (MRI)
Besides ultrasonography, MRI can also provide excellent information as secondline imaging means when ultrasound ndings are inconclusive [17] and have a
100% accuracy in diagnosing testicular rupture [18] (Figs.45.5a, b and 45.6a, b).
A few years ago, the Scrotal and Penile Imaging Working Group (SPI-WG)
appointed by the board of the European Society of Urogenital Radiology (ESUR)
elaborated recommendations for the use of scrotal MRI whereby the protocol should
include T1- and T2-weighted imaging, diffusion-weighted imaging, and dynamic
contrast-enhanced MRI for various indications including selected cases of
trauma [17].
45.2.3 Other Diagnostic Means
Little research exists pertaining to the role of CT scan in diagnosing scrotal injuries,
and it is generally admitted that this imaging is not the modality of choice for scrotal
trauma as MRI and ultrasound provide an excellent soft tissue contrast denition
and deliver no radiation to gonadal tissues [19].
Scrotoscopy has also been proposed as an aid in the diagnosis of testicular
trauma by allowing direct observation of the lesion in equivocal cases. It has rst
been introduced by Shak in Egypt in 1990 [20] and was initially aimed at elucidating questionable masses in the testis, epididymis, and spermatic cord. It also helped
in the testicular biopsy, pampiniform plexus venography, vasography, and even in
the treatment of intrascrotal lesions such as excision of testicular, epididymal, or
45.2 Diagnostic Means
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Fig. 45.4 (a, b)
Ultrasound scans showing
(top) intratesticular
hematoma and (bottom)
hematocele in two different
patients. (From Chandra
etal. [11], with permission
from Elsevier)
385
cord masses and cysts, drainage of testicular abscesses or secondary hydroceles,
injection of varicose veins, and vasal ligation. This minimally invasive method has
gained popularity among some Chinese Urologists who proposed it to diagnose
testicular rupture under epidural, spinal, general anesthesia, or even local anesthesia
386
ab
ab
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45 Symptoms, Signs, Diagnostic Means, andGrading ofScrotal andTesticular Trauma
Fig. 45.5 A 22-year-old man with testicular rupture after being kicked in the right scrotum at a
soccer game. (a) Fat-suppressed coronal T2-weighted MRI shows the corresponding rupture site
(arrows) at the superolateral aspect of the right testis. (b) Axial T2-weighted MRI shows the contour irregularity of the right testis. (From Kim et al. [18], with permission from Wolters
Kluwer Health)
Fig. 45.6 A 22-year-old man with epididymal hematoma after being kicked in the right scrotum
during Korean martial art. (a) Axial T2-weighted MRI shows the intact tunica albuginea (arrowheads) at the lower part of the right testis. (b) Sagittal T2-weighted MRI shows the continuity of
the tunica albuginea (arrowheads). However, its dark signal intensity line is less prominent in the
interface with the swollen epididymal tail. (From Kim etal. [18] with permission from Wolters
Kluwer Health)
45.3 Grading Systems
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387
by inltration of the spermatic cord [21]. However, scrotoscopy was limited only to
diagnosis as an open approach had to be performed for the repair of testicular rupture. Hence, when considering it as a sole diagnostic means, it can hardly compete
with ultrasound, which is less time-consuming and invasive and does not require
anesthesia, although scrotoscopy would logically be expected to have 100% accuracy. Moreover, in an anesthetized patient, it takes no time to incise the scrotum and
proceed to open exploration and repair with very low morbidity. One can imagine
that proceeding rst to a scrotoscopy before opening the scrotum would appear
superuous. Therefore, more studies are required to sculpt a comfortable seat for
scrotoscopy in the armamentarium of recommended imaging means in testicular trauma.
45.3 Grading Systems
Data from physical and imaging examinations should help classify the trauma
according to the AAST system published by Moore etal. in 1996 which was written
separately for testicular and scrotal trauma [22] (Tables 45.2 and 45.3).
This AAST grading system was evaluated by many subsequent studies [14, 23,
24] demonstrating its usefulness in rapidly differentiating serious cases requiring
urgent exploration and repair and mild cases requiring conservative management.
Table 45.2 AAST grading for testicular trauma
a
Grade
I Contusion/hematoma 1
II Subclinical laceration of tunica albuginea 1
III Laceration of tunica albuginea with <50%
IV
V Total testicular destruction or avulsion 2
From Moore etal. [22], with permission from Wolters Kluwer Health
a
Advance one grade for bilateral lesions up to grade V
Table 45.3 AAST grading
for scrotal trauma
Description of the injury
parenchymal loss
Major laceration of tunica albuginea with ≥50%
parenchymal loss
Description of Injury
Grade
I Contusion 1
II Laceration <25% of scrotal diameter 1
III
Laceration ≥25% of scrotal
diameter or stellate
IV Avulsion <50% 2
V
Avulsion ≥50%
From Moore et al. [22], with permission from Wolters
Kluwer Health
AIS-90
2
2
AIS-90
2
2
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45 Symptoms, Signs, Diagnostic Means, andGrading ofScrotal andTesticular Trauma
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