Contrast enhanced ultrasound identifies a spontaneous testicular haematoma and negates the need for orchidectomy

A 34-year-old male patient presented to the emergency department with a five-day history of left-sided testicular pain. There was no history of trauma or any obvious precipitant. Clinical examination revealed a tender, swollen left hemi-scrotum. The patient was referred for ultrasound to exclude spermatic cord torsion.

B-mode ultrasound identified a 36 x 29 mm heterogenous, hypoechoic mass in the upper pole of the left testis (Fig. 1A). Colour Doppler ultrasound (CDUS) imaging showed minimal flow within the lesion (Fig 1B). Strain Elastography demonstrated low stiffness - a soft lesion (Fig 1C). Contrast enhanced ultrasound (CEUS) (performed by intravenous administration of 4.8 mL of SonoVue™) revealed a well-defined lesion with no enhancement corresponding (Fig. 1D).

Follow up imaging at four weeks showed the lesion to be resolving. B-mode ultrasound showed that the mass had reduced in size (Fig 2A) and it had simultaneously started consolidating and with increasing stiffness on strain elastography (Fig 2B). CEUS continued to show no enhancement (Fig 2C).

Imaging of the left testis at six months demonstrated an underlying abnormality (Fig 3A) which enhanced homogeneously with a striated pattern on CEUS, indicating normal testicular tissue. (Fig 3B).

The right testis remained normal throughout.

In the context of trauma to the scrotum, intratesticular haematomas are a recognised complication, however, a spontaneous haematoma is unusual. Intratesticular haematomas can often be managed conservatively therefore distinguishing a haematoma from neoplasia is essential in avoiding unnecessary orchiectomy. This distinction assumes importance when there is no traumatic history to associate with a haematoma.

Ultrasound is the gold standard for imaging the scrotum. Multiparametric ultrasound (MPUS) combines conventional ultrasound (B-mode and CDUS) with elastography and CEUS [1]. CEUS uses microbubbles of sulphur hexafluoride encased in a phospholipid shell which, when administered intravenously, remains solely intravascular. Each microbubble (the size of a red blood cell) can be visualised, thus revealing parenchymal detail and allowing characterisation of tissues. More importantly is the ability to confidently differentiate perfused, ischaemic and avascular tissue. Not only does CEUS have the benefits of conventional ultrasound but it removes the need for iodinated contrast and is readily repeatable [2]. Elastography is a measure of tissue stiffness; the stiffer the tissue, the more likely the presence of malignancy.

The appearance of a haematoma on ultrasound varies over time. In the acute phase, haematomas often appear as hyperechoic or isoechoic and when chronic, they become hypoechoic or anechoic with healing [3]. As haematomas retract, they consolidate and become less homogenous and stiffer, as demonstrated on the elastography findings (Fig 1C and 2B).

Both a testicular malignancy or a haematoma may be painful or asymptomatic [4]; 10–20% of presenting scrotal trauma have incidentally detect neoplasm [3], with an accurate clinical history imperative. A B mode ultrasound cannot distinguish various testicular pathologies and will underestimate the size of a haematoma, especially if the haemorrhage is isoechoic and difficult to distinguish from healthy parenchyma [5].

CDUS may be useful in demonstrating a lack of vascular flow and suggest a benign abnormality but adding elastography helps further [6, 3]. A poorly vascularised primary testicular tumour remains possible, as does a ‘burn-out’ tumour [4]. Consequently, unless there is a clear history of trauma, patients will be managed surgically with an orchidectomy.

With testicular ultrasound, CEUS has been shown to accurately and confidently demonstrate the viability of parenchyma, delineate fracture lines and haematomas, and guide treatment for testis-sparing surgery or orchidectomy [2]. This case allowed us to do exactly that; the combination of MPUS and negative tumour markers, in the absence of a clinical history of trauma, allowed for definitive diagnosis and conservative management.

Written informed patient consent for publication has been obtained.