Differential Diagnosis and Management of Scrotal Bruising with Possible Trauma
Immediate Diagnostic Approach
Perform urgent scrotal ultrasound with Duplex Doppler imaging immediately to rule out testicular rupture, as early surgical intervention within 6-8 hours significantly improves testicular salvage rates (80-90%) and prevents complications including testicular atrophy and subfertility. 1, 2, 3
Critical Differential Diagnoses to Exclude
The key diagnoses that determine management in scrotal trauma include:
- Testicular rupture - Requires emergent surgical exploration and repair; identified by discontinuity of the echogenic tunica albuginea on ultrasound 1, 2
- Hematocele - Requires early surgical intervention for optimal outcomes 4
- Intratesticular hematoma - Can be managed conservatively if isolated without other injuries 4
- Scrotal wall hematoma - Managed conservatively 4
- Testicular fracture - May require surgical exploration depending on extent 2
Ultrasound Protocol and Findings
The ultrasound examination must include both grayscale and color Doppler assessment to evaluate for rupture and assess testicular viability. 1
Key Sonographic Features to Assess
Grayscale findings:
- Testicular contour abnormality or loss of normal contour 1
- Disruption or discontinuity of the tunica albuginea (most specific for rupture) 1, 2
- Direct visualization of fracture line 1
- Heterogeneous or hypoechoic testicular echotexture 1
- Intratesticular hematoma appearance varies by timing: hyperacute/acute hematomas appear heterogeneous or isoechoic, while chronic hematomas are smaller and hypoechoic to anechoic 1
Color/Power Doppler findings:
- Assessment of testicular perfusion and viability 2
- Identification of vascular injuries including pseudoaneurysms 2
- Evaluation for testicular infarction 1
Management Algorithm Based on Ultrasound Findings
Surgical Exploration Required (Emergent)
Proceed immediately to scrotal exploration, debridement, and tunical closure if ultrasound demonstrates: 1
- Testicular rupture (discontinuity of tunica albuginea) 1, 2
- Hematocele 4
- Loss of testicular contour with heterogeneous parenchyma 1
- Suspected testicular fracture with significant disruption 2
Surgical technique should include:
- Debridement of non-viable tissue 1
- Tunical closure when possible (tunica vaginalis grafts may be used if primary closure not feasible) 1
- Orchiectomy only if testis is non-salvageable 1
Conservative Management Appropriate
Conservative management with observation is appropriate for: 4
- Isolated intratesticular hematoma without rupture or other injuries 4
- Scrotal wall hematoma alone 4
- Minor contusions without structural disruption 5
Conservative management includes:
- Scrotal support and elevation 5
- Analgesia 5
- Serial clinical examinations 5
- Follow-up ultrasound if clinical deterioration occurs 3
Critical Clinical Pitfalls
- Clinical examination alone is frequently inaccurate in scrotal trauma - Physical examination is difficult due to pain and swelling, leading to incorrect triage decisions; ultrasound is essential for accurate diagnosis 3
- Delayed diagnosis increases orchidectomy risk - Early surgical intervention significantly reduces the need for delayed orchidectomy and improves testicular salvage 3
- Ultrasound may not always detect discrete fracture planes - When massive scrotal swelling is present, ultrasound remains valuable for determining testicular status even if subtle fractures are not visualized 4
- Sports-related injuries are the most common cause - 59% of blunt scrotal trauma cases in one series were sports-related, highlighting the need for protective equipment 5
Additional Considerations
If >30% of testicular volume is replaced by necrotic tissue or hematoma, there is increased risk of subsequent orchidectomy and need for testicular prosthesis. 5
MRI is not routinely indicated but may serve as a problem-solving tool when ultrasound findings are equivocal 1
CT imaging is not routinely used for initial evaluation of scrotal trauma 1