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Intratesticular Pseudoaneurysm After Blunt Trauma

¹ Department of Radiology, Harborview Medical Center, University of Washington School of Medicine, 325 Ninth Ave., Box 359728, Seattle, WA 98104-2499.
² Department of Urology, Harborview Medical Center, University of Washington School of Medicine, Seattle, WA 98104-2499.

Received August 23, 1999; accepted after revision August 23, 1999.

 
This is another in the continuing series on radiology in trauma cases from the Harborview Medical Center. Editors: Fred A. Mann, Eric J. Stern, and Alexander B. Baxter.

Address correspondence to F.A. Mann.

Introduction

Top Introduction Discussion References

 
A 42-year-old man suffered blunt scrotal trauma after colliding with a pole. Left scrotal swelling and pain increased over 3 days, and the patient sought medical attention. We found no clinical evidence of hematocele (blood in the tunica vaginalis testis). Sonography revealed a left intratesticular hematoma without clear disruption of the tunica albuginea. A round anechoic structure measuring 11 mm in diameter in the left testicle with pulsatile high-resistance flow, a visible neck, and a feeding artery was consistent with a pseudoaneurysm (Fig. 1A,1B,1C). Because we found no evidence of testicular rupture, we elected to follow the patient with sonography. Serial sonograms over the next 4 days documented the thrombosis of the pseudoaneurysm.

View larger version (175K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A. —42-year-old man with intratesticular pseudoaneurysm after blunt trauma. Longitudinal sonogram of left testicle shows mixed echogenicity intratesticular hematoma with intact tunica vaginalis (arrows).

View larger version (111K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B. —42-year-old man with intratesticular pseudoaneurysm after blunt trauma. Transverse sonogram reveals 11-mm anechoic intratesticular pseudoaneurysm (arrow).

View larger version (79K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1C. —42-year-old man with intratesticular pseudoaneurysm after blunt trauma. Color Doppler sonogram reveals neck of pseudoaneurysm (arrows).

Discussion

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Of patients with scrotal trauma severe enough to seek medical attention, approximately 20% have testicular rupture [1]. Those with clinical evidence of hematocele undergo surgery to maximize the preservation of the gland [2]. Testicular salvage rate is greater than 80% when rupture is repaired within 72 hr. If surgery is delayed, orchiectomy may be required in more than 50% of patients [3, 4]. In patients without a clear indication for surgery, sonography is the technique of choice to examine the acutely traumatized scrotum [1, 4]. Although the reliability of sonography in detecting testicular rupture is controversial, many authors report sonography as an important adjunct, indicating surgery in a subset of patients for whom clinical examination findings alone remain ambiguous [1, 3, 4].

Scrotal sonography may identify hematocele, scrotal wall hematoma, testicular hematoma, contusion, or rupture. In rupture, a break in the tunica albuginea is seen with hemorrhage and spillage of the testicular contents. Sonography may occasionally reveal an underlying mass lesion; however, follow-up scans may be required to distinguish between a mass and a contusion.

A pseudoaneurysm represents a vessel rupture contained by a pseudocapsule. The typical sonographic appearance is that of an anechoic mass containing variably turbulent flow. The neck is often identified, with flow entering the aneurysm during systole and exiting during diastole, producing a to-and-fro pattern on Doppler imaging [5]. Although commonly perceived as the sequela of penetrating trauma, intraparenchymal pseudoaneurysms have been reported in the liver and the spleen as a result of blunt injury [6, 7]. To our knowledge, this is the first report of an intratesticular pseudoaneurysm.

Pseudoaneurysms in the abdominal viscera may thrombose spontaneously; however, because of the danger of late hemorrhage or uncontained rupture, close monitoring is recommended. Although some lesions are amenable to angiographic treatment with embolic agents, many pseudoaneurysms require surgery [5]. This trauma case illustrates the value of conservative therapy in treating an intratesticular pseudoaneurysm with an intact tunica albuginea. Periodic scrotal sonography will be performed to follow the long-term sequelae of the nonoperative treatment of an intratesticular pseudoaneurysm.

References

Top Introduction Discussion References

 

1. Lewis CA, Michell MJ. The use of real-time ultrasound in the management of scrotal trauma. Br J Radiol 1991;64: 792 -795[Abstract/Free Full Text]
2. Altarac S. Management of 53 cases of testicular trauma. Eur Urol 1994;25: 119 -123[Medline]
3. Herbener TE. Ultrasound in the assessment of the acute scrotum. J Clin Ultrasound 1996;24: 405 -421[Medline]
4. Martinez-Pineiro L, Cozar JM, Moreno JA, Martinez-Pineiro JA. Value of testicular ultrasound in the evaluation of blunt scrotal trauma without hematocele. Br J Urol 1992;69: 286 -290[Medline]
5. Landwehr P. Extremity arteries. In: Wolf KJ, Fobbe F, eds. Color duplex sonography. New York: Thieme Medical, 1995: 87
6. Galeon M, Goffette P, Van Beers BE, Pringot J. Post-traumatic intrahepatic pseudoaneurysm: diagnosis with helical CT angiography and management with embolization. J Belge Radiol 1997;80: 287 -288[Medline]
7. Patel NY, Cogbill TH, Gunderson LH. Angioembolization of multiple intrasplenic pseudoaneurysms as a result of blunt trauma. J Vasc Surg 1996;24: 299 -301[Medline]

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