Contrast-enhanced ultrasound in testicular trauma: role in directing exploration, debridement and organ salvage

Abstract

ABSTRACT. We describe the use of contrast-enhanced ultrasound as an additional imaging technique during an ultrasound examination of a traumatised testis, allowing for confident testicular preserving surgery to be performed. Testicular trauma often arises as a consequence of a road traffic accident, a sporting mishap or a straddle injury. It tends to affect the younger male, in whom preservation of the testis is an important consideration. Clinical examination is difficult in the acute setting where establishment of the need for early surgical exploration is important and is notoriously inaccurate. Often greyscale ultrasound with the addition of colour Doppler techniques is the most useful investigation tool, readily identifying the appearance of testicular injury and so establishing the need for surgical exploration [1]. The appearances of testicular fracture, rupture, haematoma and haematocoele are readily identified on sonography, giving the surgeon a clear understanding of the status of the injury to the scrotal content and the need for exploration [2]. The establishment of continued blood flow to the injured testis has traditionally been based on the presence of colour Doppler signal; enabling the surgeon to tailor the surgery to either perform an orchidectomy or plan organ-sparing surgery. However, colour Doppler techniques have limitations; operator experience, movement artefact, patient discomfort and tissue reflectivity all play a part in diminishing the accuracy of the technique [3]. The use of contrastenhanced ultrasound (CEUS) is firmly established in many organs in the body, but less widely used in the testis [4]. CEUS is an ideal technique to ascertain the vascular supply to an organ, as the contrast agent is purely an intravascular agent and increases the sensitivity of detection of blood flow.We describe the use of CEUS as a tool for precise assessment of viable testicular tissue post-scrotal trauma, allowing a rapid and precise delineation of viable testicular tissue enabling organ-sparing treatment in testicular trauma. Case historyA 39-year-old male presented to the accident and emergency department following trauma to the right testis. The injury was sustained during a cricket match, when the patient collided with the wicket whilst fielding, not wearing any gonadal protection. There was no relevant medical or drug history and the patient was otherwise fit and well. On examination the right testis was swollen and tender, with difficulty in ascertaining the status of the contents of the scrotal sac. Observations were stable; blood biochemistry and haematology were unremarkable. An ultrasound examination was requested. An ultrasound examination was performed using a Siemens S2000 (Siemens, Mountain View, CA), with a linear array high frequency 9L4 transducer, with settings suitable for a scrotal examination. The left testis was unremarkable. The contour of superior pole of the right testis was ill-defined and suggestive of a tunica albuginea

Contrast enhanced harmonic ultrasonography for the evaluation of acute scrotal pathology. A pictorial essay.

“…Color Doppler evaluation does not reveal any signal at this level [14,21]. CEUS detects best the viable testicular tissue and its delimitation as well as the fracture line [2,27] and the aspect is correlated with the severity of the trauma: in testicular contussion there is a homogeneous, . In order to evaluate the remaining viable tissue, CEUS was performed.…”

A review of ultrasound imaging in scrotal emergencies

“…Colour Doppler imaging provides an overview of vascularity but has limitations. Contrast-enhanced ultrasound (CEUS) with SonoVue TM (Bracco SpA, Milan, Italy) allows more accurate delineation of areas of nonperfused testicular tissue and should always be employed if the colour Doppler examination is equivocal [2][3][4].…”

“…Colour Doppler imaging guides management by determining the degree of ischaemic parenchyma which requires resection; however if parenchymal blood flow is preserved, conservative management can be undertaken [33]. CEUS may play a larger role in the future to determine the extent of viable testicular tissue and allow testis-conserving surgery [4].…”

Focal testicular lesions: colour Doppler ultrasound, contrast-enhanced ultrasound and tissue elastography as adjuvants to the diagnosis

“…More importantly, CEUS allows a conclusive demonstration of the lack of vascularity that is likely to be encountered in benign lesions [3]. Demonstration of an avascular abnormality, which is likely to be benign in nature and may resolve, would allow the option of ''watchful waiting'' with ultrasound, without subjecting the patient to unnecessary surgery [4].…”