Case of the Month January 2023 – 14-year-old boy with right testicular pain

Is there a place for elastography for nerves evaluation? ~ Fabrizio Calliada (Italy)

January 23, 2023

Case of the Month February 2023 – Importance of diagnostic imaging in the management of a tumor lesion

February 14, 2023

Clinical history

A 14-year-old boy was referred to the emergency dept. at Copenhagen University Hospital with pain in his right testicle. He had a bicycle accident two days prior where the handlebars on his bicycle hit him in his lower abdomen and groin whilst falling. He sought medical attention due to progressively increasing pain in his right testicle.

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Question 2: How does image 2 confirm your initial suspicion?

It shows reduced flow which supports testicular torsion.
It shows an isoechoic/hyperechoic region without flow which supports intratesticular hematoma.
It shows a hypoechoic region in proximity to a discontinuity of the tunica albuginea which supports testicular rupture.
It shows abnormal right testicular contour and diffuse hyperaemia of the right epididymis which supports traumatic epididymitis.

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CORRECT ANSWER EXPLAINED BELOW

Correct answer to Q2 is: It shows a hypoechoic region in proximity to a discontinuity of the tunica albuginea which supports testicular rupture.

Discussion

Discontinuity of the tunica albuginea as a result of testicular rupture is an acute condition which requires surgery within 72 hours.^1,2 The rupture of the testis can lead to a release of spermatic antigens with subsequent production of antisperm antibodies by the immune system. This in turn can lead to infertility.³

Testicular trauma with subsequent testicular rupture is relatively rare.¹ The disruption of the tunica albuginea was not recognised on the initial scan. Instead, the hypoechogenic area without Doppler flow within the testicle was interpreted as an intratesticular hematoma. The extratesticular mass was rightfully interpreted as an extratesticular hematoma. The hematoma is highlighted by the black arrow on Image 2. On a follow-up scan the next day the testicular rupture was recognised. The hypoechogenic region had undergone further demarcation and was by then more consistent with an infarction.

Within 24 hours the 14-year-old boy underwent surgery where the right testicle was removed due to pronounced tissue necrosis.

Conclusion

Testicular rupture is an acute condition which requires surgery. When encountering an intratesticular hypoechogenic region without flow after relevant trauma the tunica albuginea should be thoroughly evaluated for any discontinuity. The findings on ultrasound may result in urgent surgery.

Conflicts of Interest:

No conflict of interest.

References

Addas F, Yan S, Hadjipavlou M, Gonsalves M, Sabbagh S. Testicular Rupture or Testicular Fracture? A Case Report and Literature Review. Case Rep Urol. 2018;2018:1-3. doi:10.1155/2018/1323780
Fahlbusch B, Fahlbusch M, Thon WF. Blunt testicular injury – conservative or surgical treatment? Aktuelle Urol. 2003;34(3):176-178. doi:10.1055/s-2003-40234
Aghamir SMK, Salavati A, Yousefie R, et al. Does Bone Marrow–derived Mesenchymal Stem Cell Transfusion Prevent Antisperm Antibody Production After Traumatic Testis Rupture? Urology. 2014;84(1):82-86. doi:10.1016/j.urology.2014.03.009

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