The affected testis was scanned longitudinally, transversely, and obliquely in real time, and findings were compared with those of the contralateral gonad when indicated. Care was taken to exert minimal pressure on the testicles to avoid provoking mechanical reductions in perfusion.
Video recordings of the examinations were edited to eliminate nonessential phases and transferred to a personal computer in. The recordings were later examined by three operators who had not been involved in the examinations themselves O. The degree of concordance between the baseline sonogram and the CEUS examination was rated with an arbitrary scoring system in which 0 indicated lack of concordance and scores of 1, 2, and 3 reflected low, moderate, and high concordance, respectively. Next, the relevance of the additional information obtained with CEUS was rated none no additional information ; low additional information obtained that was not important for diagnosis or treatment ; moderate additional information that was somewhat relevant but not enough to radically modify case management ; or high relevant additional information that radically modified management.
The definitive diagnosis was based on surgical findings when surgery was necessary and on follow-up findings clinical, sonography, CEUS in the other cases. In all of the cases we examined, CEUS was completed with no adverse effects, and the results were regarded as qualitatively acceptable for inclusion in the study. The final diagnoses for the other 24 patients were as follows: A total of 14 patients had hematoceles: In the 24 patients with positive findings, concordance between US and CEUS findings was classified as grade 0 absent in 4 cases; grade 1 low in 3; grade 2 moderate in 8; and grade 3 high in 9 Figs.
The 4 cases with no concordance grade 0 included 1 patient whose baseline examination was indicative of a testicular fracture. The second and third patients in this subgroup presented baseline US evidence of local lacerocontusive damage, but CEUS revealed complete rupture of the testicles. In the fourth case, the baseline examination was suggestive of focal intraparenchymal hemorrhage, but CEUS was negative for traumatic injury, revealing instead pre-existing, nontraumatic lesions multiple hamartomas probably associated with the Cowden syndrome, according to the surgical pathology report Table 1 , Fig.
False negative US finding in a case of testicular rupture. US a reveals only a single intratesticular lesion arrow.
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The basic US examination reveals a hypoechoic band extending from the anterior to the posterior margin of the lower peripolar region arrow , which is suggestive of fracture a. CEUS reveals accentuated locoregional perfusion arrow that is already evident in the early phase b and decreases progressively without disappearing in the later phases, findings indicative of an arteriovenous malformation. The basic US examination reveals a areas of spontaneous non-calcific hyperechogenicity that were suggestive of focal intratesticular hemorrhages.
The absence on CEUS of hypovascular areas or bands within the testis b,c together with inhomogeneous enhancement, in some cases focal, excluded the possibility that the lesions seen on the basic examination were traumatic. Indeed they were ultimately diagnosed as hamartomas related to the Cowden syndrome. In only one case of rupture with multiple fragments that were highly visible on both the baseline and CEUS examinations , the use of power Doppler after the injection of contrast medium proved to be superior to gray-scale CEUS for pinpointing the site of active hemorrhage Fig.
Examination of the upper abdomen during the later phases of the CEUS examination revealed no lesions involving the parenchymal organs of this region. It is important to note, however, that contrast enhancement was also associated with some loss of resolution, and this explains why the baseline US examination sometimes provided better visualization of small-volume intrascrotal fluid collections that were not frankly corpuscular.
In any case, none of the patients with negative findings on CEUS presented significant functional alterations involving hormone secretion or spermatogenesis during follow-up, which ranged from 6 months to around 5 years. In patients who did not undergo surgery, follow-up included both US and CEUS capable of revealing even small lesions that could not be visualized with other means until healing was complete intervals that ranged from 5 days to approximately 3 months with a mean of 4 weeks.
Basal US assessment with color Doppler is suggestive of lacerocontusive foci with interruption of the tunica albuginea a. CEUS reveals focal contusions and lacerocontusions with no evidence of tunica albuginea discontinuity b,c.
Power Doppler after administration of contrast agent reveals extravasation arrow caused by active hemorrhage b. Early reports on the use of CEUS in the work-up of scrotal pathology indicated that it could be used to identify abscesses and areas of necrosis, which appear as nonenhanced areas [13,14] ; to document increases in the mean contrast-medium transit time in the presence of a varicocele  ; to evaluate tumor vascularization  ; to facilitate extraction of sperm from infertile patients by pinpointing better perfused areas of the gonad  ; and to characterize and follow-up ambiguous cases of segmental ischemia .
Testicular trauma could thus represent a new field of application for CEUS. Severe trauma generally produces hematoceles, hematomas, fractures, or complete rupture of the testis. The most common causes are sports-related injuries, motor vehicle accidents, and straddle injuries, which are associated in many cases with pelvic fractures.
If the tunica albuginea appears intact on US, the injury can be treated conservatively. However, surgery must be performed immediately when the continuity of the capsule appears interrupted an unequivocal sign of testicular rupture ; when complete vessel transections are present; when the testis is not being perfused; or when there are ambiguous baseline US findings in a patient with clinical findings that are highly suggestive of testicular rupture [4,22,23].
Surgical treatment involves debridement and suturing of the tunica albuginea [1,3] and re-anastomosis of any microvessels that have been completely transected. Identifying the testicular fracture plane on gray-scale US can be very difficult. Gray-scale US is also poorly suited for differentiating hematomas from extruded testicular contents and—even more fundamental—for verifying the integrity of the tunica albuginea.
This structure can be difficult to identify even when it is intact, and it is extremely difficult to pinpoint small areas of discontinuity . Sonographic diagnosis of testicular rupture is based on findings of poorly defined testicular margins, echotexture heterogeneity, and above all discontinuities in the tunica albuginea. Rapid, accurate diagnosis is fundamental for planning treatment that can save the gonad.
Our experience includes two cases of testicular rupture that were diagnosed with CEUS after the gray-scale examination yielded false negative findings. In the few cases studied with CEUS uniform enhancement of the entire testicle seems to exclude the presence of major traumatic lesions. Based on our preliminary findings, CEUS seems to provide additional information in cases of blunt scrotal trauma that is not furnished by gray-scale US or color-power Doppler studies.
It provides more complete information on testicular vascularization, which is essential for excluding infarctions which—especially when complete--can already be suspected on the basis of complementary color-power-Doppler , and useful information on lesion features such as visibility, size, and margin characteristics, which are not easy to evaluate on the basal examination . It is also valuable, however, when the testis is ruptured. Compared with the basic US examination, CEUS also seems to offer higher resolution and improved diagnostic certainty in the identification of intrascrotal corpuscular fluid collections, which are frequently present in the early stages of scrotal trauma.
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