Testicular Rupture Missed on Whole-Body Trauma CT: Scrotal Ultrasound Is Mandatory in Blunt Scrotal Trauma

Case Presentation:

A 20-year-old male presented after a motorcycle accident. Whole-body contrast-enhanced computed tomography (CT) included the scrotum and was reported normal.

Persistent left scrotal pain prompted ultrasound (US) 90 minutes later, demonstrating a large hematocele, heterogeneous intratesticular echotexture, and discontinuity of the tunica albuginea, diagnostic of testicular rupture. Colour Doppler showed preserved intratesticular vascularity. Differentials: hematocele without rupture, intratesticular hematoma, fracture with intact tunica.

Retrospective CT review revealed left testicular enlargement, scrotal fluid, and an intratesticular hyperdense finding representing haemorrhage, all missed prospectively. The tunical tear was not resolvable on CT.

Surgery confirmed a 1 cm tunical defect with extruded, partly necrotic tubules; the testis was salvaged after debridement.

Teaching points:

1. The CT was not normal but misread testicular asymmetry, scrotal fluid, and hyperdensity were overlooked. The scrotum belongs in the polytrauma search pattern. Even so, CT cannot depict the tunical tear; US is mandatory in blunt scrotal trauma.
2. US established the structural diagnosis, identifying the tunical tear and hematocele confirmed at surgery.
3. Viability was assessed less accurately: necrosis at surgery exceeded the colour Doppler impression. Contrast-enhanced ultrasound (CEUS) depicts microvascular perfusion and devascularized parenchyma more sensitively and could have better characterized the vascular injury.