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Case Report
False Diagnosis of Ruptured Testes
in a Case of Traumatic Dislocation
Caroline A. Kilian, BS, David A. Paz, MD, Sameer A. Patel, MD,
Matthew J. Austin, MD, Katherine M. Richman, MD,
Dolores H. Pretorius, MD
T
esticular trauma can be a surgical emergency, and in general, surgical intervention must be performed within 3 days of the trauma for testicular salvage.1,2 Both sonography, with and without color Doppler imaging, and
computed tomography (CT) are useful diagnostic tests to evaluate the scrotal
contents and abnormalities. Straddle injuries, often from motorcycle accidents, can
rarely cause testicular dislocation and are usually accompanied by scrotal hematoma
and pelvic fracture.3 With abdominal CT and color Doppler sonography, the dislocated
testicle and its blood flow are usually located, although at the initial time of injury, they
may go undetected.3 Victims typically are in their second and third decades of life, and
the dislocation is most likely secondary to accidental trauma. We present a case in
which a patient was thought to have shattered testes and was emergently taken to the
operating room, where the testes were found to have normal blood flow bilaterally but
to be displaced superiorly by a scrotal hematoma.
Case Report
Abbreviations
CT, computed tomography
Received October 16, 2008, from the University of
Arizona, Tucson, Arizona USA (C.A.K.); and
Department of Radiology, University of California,
San Diego, La Jolla, California USA (D.A.P., S.A.P.,
M.J.A., K.M.R., D.H.P.). Revision requested
November 7, 2008. Revised manuscript accepted
for publication November 25, 2008.
Address correspondence to Dolores H. Pretorius,
MD, Department of Radiology, University of
California, 9300 Campus Point Dr, 7756, La Jolla, CA
92037 USA.
E-mail: [email protected]
A 22-year-old Mexican man was making an illegal attempt
at crossing the Mexican border into the United States
when he landed on a metal pipe, had a probable straddle
injury, as evidenced by perineal blood, and was initially
seen at a clinic on the border. He was transferred to the
trauma bay at our institution, where physical examination
revealed a large scrotal hematoma. Initial urinalysis
results were negative for blood, and a retrograde urethrogram revealed no evidence of active extravasation. Pelvic
CT revealed a large scrotal hematoma and air consistent
with a right pneumohemiscrotum. Further evaluation
with sonography revealed a band of hypoechoic material
extending bilaterally with trace to no internal flow and
hyperemic scrotal skin (Figure 1); initially this was thought
to represent shattered testes. In retrospect, the testes were
not in the images provided because of their displacement
superiorly.
© 2009 by the American Institute of Ultrasound in Medicine • J Ultrasound Med 2009; 28:549–553 • 0278-4297/09/$3.50
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False Diagnosis of Ruptured Testes in Traumatic Dislocation
Figure 1. Sonography of the scrotum. A, Sagittal image showing a hypoechoic
structure in the scrotum measuring 6.1 × 2.9 cm, which was originally thought to
represent the left shattered testicle. B, Transverse midline view of the same region
as shown in A revealing that the hypoechoic structures seen on both sides actually connect and reside within the scrotal skin rather than the scrotal sac. C, Color
Doppler image of same area as in B showing minimal flow within the hypoechoic
structures. No images were actually able to show intact testes.
A
Urologic exploration for possible orchiectomy
revealed a scrotal hematoma with small but otherwise normal testes bilaterally and no damage
to the spermatic cord. Both testes were delivered
back into the scrotum after copious irrigation,
and the scrotum was closed. The patient was
ambulating the next day and was discharged
with narcotic pain medication and a Foley
catheter with a leg bag, and outpatient follow-up
was scheduled. In reviewing the CT scan and
additional reformatted images, the testes were
present within the inguinal areas, measuring 3.8
× 2.8 × 2.2 cm on the right and 3.7 × 2.7 × 2.2 cm
on the left (Figures 2–4).
Discussion
B
C
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Terminology used to evaluate patients with testicular trauma includes testicular rupture, fractured/shattered testicle, testicular hematoma,
testicular hematocele, testicular avulsion, and
dislocated testes. Mimickers of testicular rupture
include a massive extratesticular hematocele
and an intratesticular hematoma.4 Additionally,
these mimickers can accompany traumatic testicular dislocation. In the setting of large swelling
and hemorrhage, it is not always clear whether
the trauma has led to rupture of the tunica albuginea of the testes or damage to the scrotum. It is
known that testicular rupture occurs in 50% of
patients with traumatic hematocele.5,6
Sonography has traditionally been the primary
tool used for evaluation of testicular trauma
because of low cost, portability, accessibility, lack
of ionizing radiation to the area, the multiplanar
approach, the real-time nature, and the ability to
assess for blood flow with color and pulsed
Doppler imaging. Sonography is used to evaluate
all of the scrotal contents, but the testes must be in
the field of view to make an accurate diagnosis.
The sonographer must scan the entire scrotum
and the inguinal regions to look for the testes; this
was not done in the case presented here because
the scrotum was large and filled with blood, and it
was thought that the testes were ruptured.
Absence of a normal testis and mixed echogenic
debris imaged within the scrotum should suggest
fragments of a shattered testis.7 Color Doppler
imaging should be used to assess for testicular
blood flow, even in fragments, to assess for possiJ Ultrasound Med 2009; 28:549–553
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A
B
Figure 2. Contrast-enhanced CT of the lower pelvis. A, Axial image at the level of the lower pelvis showing an enlarged scrotum with
heterogeneous attenuated fluid noted within the scrotal skin as well as hematoceles (arrow). B, Axial image more cephalad showing
ovoid soft tissue densities in the subcutaneous tissues of the groin, representing superiorly dislocated testes (arrows).
ble salvage.7 Guichard et al8 studied 22 cases of
testicular fracture with 6 false-positive results, as
was seen in our case. The specific sonographic
criteria used to diagnose testicular rupture/
fracture in their series included heterogeneous
parenchyma, loss of contour definition of the
testis, and a breached tunica albuginea.8 Color
Doppler sonography is also useful for diagnosing
testicular dislocation; however, the sonographer
must image the inguinal regions to identify the
testes.3 Lack of blood flow can be seen in a
hematoma or an infarction as well as in testicular
rupture by detecting a disruption in the normal
capsular blood flow of the tunica vasculosa.4
Figure 3. Reformatted CT. A, Magnified coronal reformation showing an enlarged scrotum with a large hematoma in the skin as well
as hematoceles (short arrow). The testes reside superiorly in the subcutaneous tissues of the groin (long arrows). B, Magnified
parasagittal reformation showing superiorly located testes (long arrow), likely secondary to a trauma-induced spasm of the cremasteric muscle. Note the fluid-filled scrotum (short arrow) that correlates with the hematoma seen on sonography.
A
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B
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False Diagnosis of Ruptured Testes in Traumatic Dislocation
Figure 4. Surface-rendered 3-dimensional CT reformation showing contour
abnormalities in the regions of both subcutaneous tissues of the groin (arrows),
representing the testes dislocated superiorly.
Multiplanar reformatted images from CT offer
great potential in evaluating patients with trauma; however, there are currently only a few cases
reported in the literature describing the benefits
of this new technology. Reformation techniques
have been used in evaluating for skeletal trauma;
however, they have only recently been used to
evaluate the abdomen and pelvis.3,9–12 In the case
presented here, the reformatted images were
very helpful in retrospectively diagnosing the
type of scrotal injury and in better understanding
the relationship of the testes, scrotum, and
inguinal region (Figures 3 and 4); this has also
been reported by Ezra et al.5 Unfortunately, the
reformatted images in this case were obtained
after the patient had been taken to the operating
room, and we suspect that if they had been
obtained initially, the dislocation of the testes
would have been identified.
Testicular dislocation is relatively uncommon,
having been reported in approximately 75 cases
before 20085; it occurred only once in 33 men
with scrotal trauma in a series reported by
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Guichard et al.8 Ko et al13 reported that testicular
dislocation was initially missed in 9 patients with
groin trauma. Testicular dislocation, initially
described in 1936 by Herbst and Polkey, is most
frequently associated with straddle injuries,
yielding superolateral displacement secondary
to a mass effect.14 In motorcycle trauma, as in our
case, the traumatic impact of the gasoline tank is
the most common culprit, with most dislocations occurring immediately, although it may
progressively develop over days to weeks and
rarely reduces spontaneously. Dislocation may
be unilateral or bilateral, may be deep or superficial, may include torsion of the spermatic cord,
and may have migration of the dislocated testis
to the abdomen in the setting of an inguinal
hernia.8,14 Ezra et al5 reported that the ductus
deferens, spermatic veins, and testicular artery
may also be dislocated with the testis. A spasm of
the cremasteric muscle has been implicated as a
contributing factor to testicular dislocation, as
well as underlying anomalies (a wide external
ring, an indirect inguinal hernia, and atrophic
testes) that can be additional predisposing factors.3 Additionally, undescended testes, whether
preexisting or due to a trauma-induced spasm of
the cremasteric muscle, should be discovered
before surgery.
Clinical assessment of dislocation often begins
with the physical examination, which reveals a
palpable painful mass in the inguinal, prepubic,
or crural location, but severe trauma with pain
and altered anatomy can often limit reliability.
Tsai et al3 suggested that it is important to look
for dislocation and rupture of the testes when
there is a scrotal hematoma because hematoceles and hematomas are common injuries that
accompany testicular dislocation. Imaging
studies used for evaluation include sonography
and CT, as discussed above. Urologic consultation and early reduction is recommended, as
was performed in this case. This is important to
prevent sequelae such as infertility and histologic malignant changes.3
In conclusion, sonography has traditionally
been the primary mode of diagnosis for scrotal
trauma; however, the use of CT (with 3-dimensional reformatting) may be helpful in improving
the accuracy of posttraumatic scrotal diagnosis.
Hematoceles and hematomas often accompany
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testicular dislocation but may also mimic the
injury. Straddle injuries can cause testicular dislocation that, without the use of proper imaging
modalities, can be confused with testicular fracture or a shattered testis. Coupling sonography
and CT can yield a more accurate and rapid
diagnosis, thereby minimizing posttraumatic
sequelae with an increased likelihood of testicular salvage.
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