different imaging modalities and findings in genitourianry trauma

1. Genitourinary Tract Trauma
Dr Rohit Kumar Giri
First Year Resident
NAMS Bir Hospital

2. Location of Genitourinary trauma
Kidney- 67%
Ureter- 1%
Bladder-22%
Urethra-3%
External genitalia-7%

3. Renal Trauma
 90% - Blunt, 10%-Penetrating
 ~10% of patients with significant
abdominal trauma.
 When severe, associated with
injuries to other organs in upto 80%.
 when the kidney is the only organ
damaged the injury is minor in
around 98% of cases

4. Mechanism of renal trauma
• Blunt trauma: direct blow to the kidney.
• Penetrating trauma: stab or gunshot injury.
• High-velocity deceleration: pedicle injury (avulsion of renal vessels,
thrombosis of renal artery).
Major renal injury(grade 4 and 5):
- up to 25% of blunt, and in up to 70% of penetrating renal trauma
cases.

5. Predisposing factors:
• Pre existing renal abnormalities
-Vulnerable position: (more anterior location and proximity to rigid spine or iliac
crest)
transplant kidneys
horse shoe kidneys
crossed fused ectopia
-Increased bulk: Tumors (angiomyolipoma, RCC), Cysts,
Hydronephrosis)
• Pediatric kidneys: larger size.

6. Indications for renal imaging
• Penetrating
• Gross hematuria
• Microhematuria & Systolic BP<90 mmHg
• Pediatric:>50 rbc/hpf
• Mechanism of injury:
- Flank impact
- Deceleration injury (eg-fall from great height)

7. Indications( ..contd)
• Penetrating
-1/2 have grade 3,4 or 5 injuries.
- high index of suspicion if wounds to chest, flank or abdomen
• Adult Blunt : Degree of hematuria and SBP
- gross hematuria or microscopic +sBP<90mmHg(12.5 % major
injury)
-microhematuria+sBP>90mmHg(0.2%major injury)
• Paediatric Blunt:
-BP not reliable in children because hypotension is a late
manifestation of hypovolaemia.
-50 RBCs/hpf threshold.

8. Role of radiology
• Most contemporary trends in trauma care, including renal trauma,
• call for less invasive procedures, trauma imaging by a skilled
radiologist is important.
• Accurately distinguishing patients that can be managed
conservatively from those who need surgery, thus improving the
long-term outcome of patients.
• Radiologic interventions
-Renal artery angiography and embolisation/stenting.
-External drainage procedures (eg-Urinomas)

9. Classification of renal trauma-AAST
• Grade 1
Subcapsular hematoma, parenchymal contusion without laceration, or both
• Grade 2
Perirenal hematoma confined to Gerota fascia
Renal parenchymal laceration of ≤ 1-cm depth without urinary extravasation
• Grade 3
Renal parenchymal laceration of > 1-cm depth without collecting system rupture
or urinary extravasation
Any injury in the presence of a kidney vascular injury or active bleeding contained
within the Gerota fascia
• Grade 4
Parenchymal laceration extending into urinary collecting system with urinary
extravasation
Renal pelvis laceration, complete ureteropelvic disruption, or both
Active bleeding beyond the Gerota fascia into the retroperitoneum or peritoneum
Segmental renal vein or artery injury or segmental or complete kidney infarction(s)
caused by vessel thrombosis without active bleeding
• Grade 5
Shattered kidney with loss of identifiable parenchymal renal anatomy
Devascularized kidney with active bleeding
Main renal artery or vein laceration or avulsion of hilum

11. Updated Content in 2018 AAST Kidney Injury
Scale
Grade I Clinical descriptors for renal contusions have been removed
Contusions are recognized as being visible on MDCT
The term “nonexpanding” has been removed
Grade II The term “nonexpanding” has been removed
The term “renal retroperitoneum” has been replaced by “hematoma
confined within Gerota’s fascia”
The size of the laceration is now inclusive of 1 cm
Grade III Incorporates vascular injury (pseudoaneurysms and
arteriovenous fistulas) and active bleeding but previously were not

12. Grade IV: Incorporates renal pelvis laceration and complete
ureteropelvic disruption
Active bleeding is explicitly categorized
Injuries to the main renal vessels, excluding thrombosis, are now grade V
injuries (previously grade IV on 1989 AAST renal injury scale)
Segmental vascular compromise and infarction have been included but
previously were not described
Infarction as a sequela of vascular thrombosis has been added
Grade V: Active bleeding included
In addition to avulsion at the renal hilum, the main renal artery or vein
injury descriptor now also includes “laceration” All main renal vascular
injuries, excluding thrombosis, are reserved for grade V injuries

13. Federle Classification
• Category I- MINOR
-Contusion
-Cortical laceration not extending into a
calyx.
• Category II- MAJOR
-Cortical laceration extending into the collecting
system(renal fracture)
• Category III- CATASTROPHIC
-Renal pedicle injuries
-Shattered kidney
• Category IV
-PUJ Injuries.

14. Imaging modalities
• CT Scan
• IVU
• Antegrade / Retrograde pyelography
• USG
• Renal angiography +/- embolisation
• MRI

15. IVU
• Historical interest, largely replaced by cross sectional imaging.
• Quality of IVU in the setting of trauma is likely to be poor;
hypotensive patient - minimal or no secretion from both kidneys.
• Single shot IVU(full length film 15 mins after contrast
injection):in hemodynamically unstable patients destined for ER
laparotomy.
• Provides information regarding:
-presence of functioning contralateral kidney.
-some gross information about the injured kidney.

16. IVU (..contd)
• Absence of unilateral excretion: major vascular injury (usually RA
avulsion)
• Soft tissue swelling with loss of psoas outline: retroperitoneal,
perinephric and subcapsular hematomas.
• Disruption of PCS: extravasation of opacified urine (70% sensitivity
for urine leak)
• Intra-operative IVU in severely injured patients.

17. USG
• Advantages:
easily available, non invasive, high negative predictive
value(96-98%)
• Disadvantages:
-poor resolution (compared to CT)
-does not provide information about renal unction.
-significant trauma may be missed(upto 80%of
parenchymal lesions may be overlooked)

18. Findings in USG
• Acute parenchymal, subcapsular and perinephric hematomas
- echo poor areas.
• More heterogenous and echogenic with time.
• Disruption of renal parenchyma with capsular tears and
urinomas.
• Doppler-pedicle injuries.

19. Ultrasound gray-scale image shows normal right kidney.
Doppler study shows absent colour uptake in intrarenal arteries
s/o grade V injury.

20. CT of the same patient-non enhancement of right kidney(grade V)
with small perinephric and intraperitoneal hemorrhage.

21. Grade IV renal injury. Sonogram in an 8-year-old child with
posttraumatic renal infarction shows both kidneys with an
avascular area in the lower half of the affected kidney

22. Grade IV renal injury. Sonogram of the same patient shows
progressive shrinkage of the lower half as the kidney goes
ischemic autopartial nephrectomy

23. CT Scan
• Modality of choice, most accurate technique.
• Allows assessment of entire abdomen, including liver and spleen.
• Arterivenous phase
• Delayed scan@ 10-20 min
? omit if normal kidneys with no perinephric, retroperitoneal or
pelvic fluid.

24. • Technique:
- the abdomen and pelvis should be scanned from the
diaphragmatic dome to pubic symphysis with contrast.
-Protocol: >commence scanning 30 sec after the start of an
injection of 50-100ml of 300 strength contrast at 2-3 ml/sec,
collimation 7 mm, pitch 1.3.
>addition of 400-600 ml of oral contrast (4% diatriazoate)
immediately before scan helps in delineating associated
bowel injuries (stomach,duodenum and proximal jejunum).

25. • To perform a complete evaluation, the entire scan must be
scrutinized with 3 different window/level settings: soft tissue,
lung, and bone. The entire systemic review has been called
the "every-organ-on-every-slice" approach (West, 2000).

26. Grade I Injuries
• Contusions and subcapsular hematoma are key terms used in the
identification of grade I renal injury
• Contusions appear on portal venous phase CT images as globular,
ovoid, or round poorly demarcated areas of relatively poor
enhancement
• Subcapsular hematomas are confined by the renal capsule. These
are seen as non-enhancing crescentic or lentiform shaped fluid
collections that may exert some mass effect on the underlying
renal parenchyma

27. Grade I renal injury, contusion-shows ill-defined area of
hypoenhancement in the medial right kidney.

28. Grade I renal injury, subcapsular hematoma-Image shows crescentic high-
density fluid collection around the left kidney with well-defined outer margin

29. Grade I renal injury, subcapsular hematoma

30. Grade II Injuries
• Perinephric hematomas and renal parenchymal lacerations are
key terms used in the identification of grade II renal injury
• Hematoma contained within the Gerota fascia has been
postulated to have a tamponade effect on renal bleeding,
resulting in perinephric clot formation
• In grade II injuries, lacerations are superficial (≤ 1 cm), and
there is no urine leak

31. Grade II renal trauma-an ill-defined fluid collection in the left perinephric
space and subcapsular hematoma with deformity of the renal parenchyma.

32. Grade II renal injury-superficial (less than 1 cm deep) renal
parenchymal defect with a large perinephric hematoma

33. Axial IV contrast-enhanced abdominal CT image shows
laceration (arrowhead) 8.4 mm in size (line A) at anterior
aspect of mid pole of left kidney. Small lacerations or those that
have oblique course can be challenging to visualize on single
plane. Adjacent perirenal hematoma (arrow) should prompt
closer examination for subtle lacerations.

34. Grade III Injuries
• Grade III descriptors are deeper lacerations (> 1 cm) that do not
result in urine leak
• any injury occurring in the presence of a vascular injury is
considered to denote grade III injury. Vascular injuries include
pseudoaneurysm or arteriovenous fistula, These have been described
as a focal collection of vascular contrast enhancement that shows
decreasing attenuation with delayed imaging
• Active bleeding : It is defined by vascular contrast enhancement
(focal or diffuse) that increases in size and attenuation in the delayed
phase. If this is present, it must be contained within the Gerota fascia

35. Grade III renal laceration, IVU-diminished left nephrogram and
no urinary contrast extravasation, CT-renal parenchymal defect
with extension greater than 1 cm deep to near the renal pelvis

36. Grade III renal laceration

37. CECT image obtained in venous phase (B) shows laceration larger than 1 cm
(size, 12.4 mm ) to lower pole of right kidney (arrow) with adjacent high-
attenuation perirenal fluid.
CECT image (C) obtained in delayed phase (10 minutes after administration of
contrast medium) does not show urine leak, confirming injury is grade III.

38. A 45-Year-Old Man Imaged Following a Stab Injury to His Left Flank.
(A) Axial unenhanced multidetector computed tomography image shows
a large left perinephric haematoma (asterisk). (B) Axial portal venous
phase imaging demonstrates a high-density focus representing a
pseudoaneurysm (arrow), which remains isodense to the aorta on
delayed images (C).

39. Grade IV Injuries
• Include injuries to the renal parenchyma and collecting system as
well as vascular injuries
• Lacerations extending deep to involve the collecting system with
urinary extravasation are included,
• Delayed imaging usually shows urine leaking into the perirenal
space, as evidenced by the attenuation of the uncontained contrast
medium matching the high attenuation of urine within the collecting
system

40. • Segmental renal vascular injury: These injuries can manifest as
segmental infarctions of the renal parenchyma that are seen on
MDCT as a wedge-shaped area of non-enhancement, with the wider
base at the renal capsule and the apex pointing toward the renal
hilum, segmental or complete renal infarction due to vessel
thrombosis in the absence of active bleeding
• active bleeding extending beyond the Gerota fascia: Active bleeding
into the kidney or surrounding tissue appears as patchy ‘flame-
shaped’ or linear dense contrast material surrounded by less dense
hematoma on arterial-phase images, The attenuation of the
extravasated contrast material is similar to that of the opacified aorta

41. A Axial CECT shows low-attenuation perirenal fluid (long arrow) medial to left kidney,
indicating possibility of injury to collecting system. Short arrow shows mildly displaced
fracture of left transverse process of L3
B, Axial CECT delayed phase at same level as image in A, obtained after 10 minutes in
bone window confirms presence of low-attenuation perineal fluid (long arrow) caused
by urine extravasation partially outlining renal pelvis (short arrow).
C, Axial CECT delayed phase abdominal CT image acquired at level inferior to left
lower renal pole 10 minutes after administration of contrast medium shows contrast
medium within mid left ureter (long arrow), which indicates some continuity of
collecting system on left side, despite urine leak(short arrow)

42. A, Axial CECT shows large left perirenal hematoma, confined by Gerota fascia with
active bleeding (arrow) and non enhancing segments (arrowheads) within medial left
kidney, indicating devascularization secondary to segmental vascular injury.
B, Axial CECT shows hyperenhancing focus (arrow) within large lower pole
laceration. On delayed phase images (not shown), this focus showed decreased
attenuation and size, confirming pseudoaneurysm. In isolation, pseudoaneurysm can be
found in grade III injury. However, according to 2018 AAST kidney injury scale, when
more than one grade of injury is present in same kidney, overall grade assigned
conforms to higher grade of injury.

43. (A) Arterial-phase multidetector computed tomography image demonstrates a
large left perinephric hemorrhage with an oval focus of high density adjacent to
the posterior aspect of the mid-kidney (arrow). (B) Portal venous phase image
at the level of the lower pole shows the focus has remained dense and
increased in size (arrows), diagnostic of active bleeding

44. Grade IV renal injury segmental infarction. Shows a segmental
area of nonenhancement in the upper medial left kidney without
associated renal laceration.

45. Grade V Injuries
• Shattered kidney, avulsion or laceration of the main renal artery, main
renal vein, or both, and devascularized kidney with active bleeding are key
terms used in the identification of grade V renal injury
• Shattered kidney: the loss of identifiable renal parenchymal anatomy, The
renal parenchyma is separated into multiple fragments, some of which may
be devascularized, this is the severest form of parenchymal laceration and
it usually occurs with urine leak and active bleeding
• Hilar vascular injuries are not common
• Complete arterial tears result in retroperitoneal hematomas with possible
active bleeding

46. Grade V renal injury. Shattered left kidney

47. A B
30-year-old pedestrian who was struck by car
A, Axial IV contrast-enhanced portal venous phase abdominal CT image shows right perirenal
hematoma with hemorrhage mostly located medial to right kidney and surrounding renal hilar
structures. Saccular outpouching from anterior wall of distal renal vein (arrow) indicates vascular
injury.
B, Axial IV contrast-enhanced delayed phase abdominal CT image shows striated nephrogram of
right kidney (linear areas of hyperenhancement in renal cortex), which may result from shearing
stress to parenchyma. No active extravasation was seen between two phases, and there was no
collecting system injury.

48. Grade V renal injury, devascularization. CECT shows dissection of
the origin of the left renal artery, with no perfusion of the left kidney.
Also, a hematoma can be noted along the anterior renal fascia.

49. MRI
• MRI provides excellent detail of the renal anatomy but offers
no clear advantage over CT, and is less able to detect
extravasation.
• A rare indication for MRI in the renal trauma setting may be
severe contrast allergy

50. Treatment and prognosis
• grade I - conservative management
• grade II - conservative management under close observation
• grade III - conservative management under close observation.
May be managed surgically if undergoing laparotomy for other
abdominal injuries
• grade IV - surgical management, especially if undergoing
laparotomy for other abdominal injuries
• grade V - surgical management

51. Complications
•Urinoma
•Perinephric Abscess
•Pseudoaneurysm
•Secondary bleeding
•Hypertension
•Renal insufficiency
•Urinary fistula
•Pyelonephritis

52. Ureteric trauma
• <1% of urinary tract trauma
• Mechanism of injury:
External:
Penetrating injuries
Deceleration injuries:
-PUJ avulsion,
-less often upper 1/3rd of ureter
-more frequent in children(sufficient flexibility
to produce hyperflexion injuries)
Iatrogenic: gynecologic surgery for malignancy.
• Hematuria may be absent in one third of cases

53. AAST Ureteral Injury Scale
Grade Type of Injury Description of Injury
I Hematoma Contusion of hematoma without
devascularization
II Laceration <50% transection
III Laceration >50% transection
IV Laceration Complete transection with <2%
devascularization
V Laceration complete transection with
>2% devascularization

54. Imaging Findings:
• IVU:
 -mild to moderate fullness of the PCS and extravasation at the site of tear.
 - complete tear-ureter fails to opacify below the tear.
 -fistulations to other structures.
• Retrograde pyelogram:
 -findings as above.
 -limited use in acute setting.
• CT: Delayed excretory phase images are usually required to make the
diagnosis
Contrast extravasation
Formation of urinoma
Occurance of Ureteric discontinuity

55. Iatrogenic ureteric injury. Excretory phase coronal computed
tomography image shows contrast extravasation from the proximal
ureter into surrounding retroperitoneal urinoma (arrow).

56. Bladder trauma
•Causes:
Trauma
Spontaneous
•Trauma:
Blunt
Penetrating

57. • Blunt trauma: most common
- in patients with multi injury trauma
- predisposed by full bladder at the time of trauma.
- pelvic fractures(especially anterior ring) commonly associated
-7 % symphysis pubis diastasis associatr with bladder trauma.
• Spontaneous:
• pre-existing bladder wall abnormalities &/or excessive
straining
-bladder tumor, cystitis, perivesical inflammation, BOO,
neurogenic bladder, previous radiotherapy.
• Iatrogenic trauma:
Surgery particularly caesarean section and transurethral bladder
resection( usually for tumor)

58. Classification
1 Contusion (incomplete or partial tear of the bladder
mucosa, imaging findings usually normal)
2 Intraperitoneal rupture(contrast material seen
around bowel loops and in the major peritoneal
spaces)
3 Interstitial bladder injury(rare, contrast material
dissects into bladder wall but not outside the
bladder)
4 Extraperitoneal rupture(contrast seen within the perivesical
space and a variable number of adjacent extraperitoneal
spaces, depending upon the severity of injury)
5 Combined intraperitoneal and extraperitoneal rupture.

59. Imaging modalities
•Conventional cystography
•CT Cystography

60. Conventional Cystography
• Advantages:
-nearly 100% sensitive for detecting rupture, provided that
adequate distention is accomplished and that post voiding images
are obtained.
• Disadvantages:
-time consuming,
-require extra radiography in addition to necessary trauma
evaluation.
-not useful in evaluating trauma to other viscera.

61. CT Cystography
• Technique:
- performed with ~350- 400 mL of contrast material
administered in a retrograde fashion before the study.
Washout study:
• Advantages of CT Cystography
-less time consuming.
-concomitant injury to other viscera(most importantly the
kidneys)
• The absence of free fluid in the abdomen during the CT is a
strong negative predictor of bladder injury.

62. Imaging findings
• Extraperitoneal rupture:
-commonest bladder injury(90% of cases)
-associated with anterior pelvic ring fracture in 90% of cases.
-extravasation of contrast into the perivesical space-
- in florid extravasation, contrast may extend
anterosuperiorly along the anterior pelvic and
abdominal wall upto umbilicus, or posteriorly around
the rectum in presacral space.
-associated tear of urogenital diaphragm allowing the
contrast to appear within the perinerum, thigh and
scrotum.
• The extravasated contrast stays close to the bladder and has a
sharp irregular margins.

63. (CT) cystogram demonstrating a simple extraperitoneal bladder
rupture with fluid in the perivesical space

64. (CT) cystogram demonstrating a complex extraperitoneal
bladder rupture with contrast material extending through the
fascial planes of the pelvis.

65. • Intraperitoneal rupture
-contrast extravasates into the peritoneal cavity and has a
more cloudy nebulous appearance.
-usually tear is along the dome of bladder which is the
weakest part.
-associated pelvic fractures seen in 75%

66. Conventional cystogram demonstrating an intraperitoneal
bladder rupture.

67. Computed tomography (CT) cystogram demonstrating an
intraperitoneal bladder rupture.

68. Urethral trauma
• Almost entirely restricted to males
unless there is major pelvic trauma
in females.
• Should be suspected
-pelvic trauma associated with
hematuria or retention
-especially blood at the
urethral meatus.

69. Male urethral injuries
Type Membranous
urethra
Bulbar
Urethra
Contrast
Extravasation
Perineum Retropubi
c space
I Contusion or
partial tear
Normal or
stretched
No No
II Rupture above
UGD
Normal or
stretched
No Yes
III Rupture below
UGD
Ruptured Yes No

70. Classification of Urethral Injuries
Grade Colapinto & McCallum
I Posterior urethra
stretched but intact
II Posterior urethral tear
above intact urogenital
diaphragm (UGD)
III Posterior urethral tear
with extravasation
through torn UGD
IV —
IVa —
V —
Goldman & Sandler
Posterior urethra stretched but
intact
Partial or complete posterior
urethral tear above intact UGD
Partial or complete tear of
combined anterior and posterior
urethra with torn UGD
Bladder neck injury with
extension to the urethra
Injury to bladder base with
extravasation simulating type IV
(pseudo-grade IV)
Isolated anterior urethral injury

71. Retrograde urethrogram reveals a type I urethral injury with
minimal stretching and slight luminal irregularity of the
posterior urethra. No extravasation of contrast material is
present

72. Retrograde urethrogram - type II urethral disruption.
Extravasation of contrast material (solid arrow) from the
posterior urethra is seen superior to an intact urogenital
diaphragm (dashed arrow).

73. Retrograde urethrogram - type III urethral injury.
Extravasation is located in both the extraperitoneal pelvis and
in the perineum (above and below the urogenital diaphragm).

74. Anterior urethral trauma
• Mechanisms:
-iatrogenic (attempted catheterisation,instrumentation)
-blunt perineal trauma(straddle injury):bulbar urethra and
corpus spongiosum are compressed against the inferior
aspect of anterior pelvic ring.

75. Straddle injury. Retrograde urethrogram shows a type 5
urethral injury with extravasation of contrast material from the
distal bulbous urethra.

76. Findings
• Rupture
-partial:contrast extravasation with some filling of proximal
urethra.
-complete:failure of filling of proximal urethra
• Stricture (usually <1cm or so in length).

77. Complications
• Stricture
• Impotence (up to ~10%)
• Incontinence (2%)

78. Penile fracture
• Fracture of the penis occurs exclusively with an erection, with
aggressive vaginal intercourse being the most common cause
• It is related to excessive bending of the erect penis and thrusting
against the pubic symphysis
• The patient usually reports a cracking sound, immediate pain,
and rapid detumescence

79. 44-year-old man who heard popping sound during sexual intercourse.
(a)Transverse sonogram of penis shows defect in tunica albuginea of
left corpus cavernosum (arrows) and large surrounding hematoma.
(b)Photograph of penis shows ecchymosis, giving “eggplant”
appearance to penis
a b

80. SCROTAL TRAUMA
• Causes:
Blunt
Penetrating
Degloving
Electric burn
• Ultrasound is the imaging technique of choice in acute
scrotal trauma except in degloving injury.

81. • Trauma often may result in hematoma, hydrocele, hematocele,
testicular fracture, or testicular rupture
• Intratesticular hematomas are common after trauma.
• The ultrasound appearance depends on the time between
occurrence of trauma and ultrasound evaluation.
• Acute hematomas are typically isoechoic to the normal
testicular parenchyma and can be difficult to identify.

82. Intratesticular hematoma. (a) Sagittal gray-scale US image shows an ill-
defined hypoechoic area (arrows) that represents a hematoma in the
posterior part of the left testis. (b) Sagittal color Doppler image shows
flow in the testis, except in the area of hematoma, where there is a
testicular fracture

83. Hydroceles in two patients. (a) Transverse US image of the left scrotum
shows a large hydrocele that has displaced the testis (T) anteriorly. (b)
Sagittal image shows a very large right-sided hydrocele that contains
fine internal septa, with the right testis (area demarcated by cursors)
displaced posteriorly.

84. Hematocele due to testicular rupture immediately after blunt scrotal
trauma. Transverse US images (b slightly superior to a) show uniformly
echogenic fluid surrounding the testis (T), a finding indicative of blood
in a hematocele. EPI-epididymis.

85. • Testicular rupture implies tearing of the tunica albuginea with
extrusion of testicular parenchyma into the scrotal sac.
• The margins of the testis are poorly defined and the
echogenicity of the testis is heterogeneous.
• The use of colour Doppler is essential as rupture of the tunica
albuginea will almost always be associated with a loss of
vascularity to a portion of or the entire testis.

86. Testicular fracture. (a) Transverse US image of the testis shows a
hypoechoic irregular linear area (arrow) indicative of a fracture. (b)
Transverse color Doppler image depicts normal flow throughout the
testis, except in the area of the fracture (arrow).

87. Testicular rupture. (a) Sagittal gray-scale US image demonstrates
extrusion of the testicular contents (arrows) through the tunica
albuginea. (b) Color Doppler image shows multiple hypoechoic foci
with no flow (arrowheads) in the periphery of the testis, findings
indicative of hematomas or infarcts.

88. • Trauma to the testis can also result in dislocation or torsion.
• Dislocation most commonly results from impact of the
scrotum against the fuel tank in motorcycle accidents.
• Testicular dislocation, typically into the inguinal canal, may
be detected by CT or ultrasound.
• Testicular torsion is preceded by trauma in 5–8% of cases.

89. References
• Textbook of radiology and imaging David Sutton 7th edition
• Grainger and Allison’s Diagnostic Radiology 7th edition
• Coming Together: A Review of the American Association for the
Surgery of Trauma’s Updated Kidney Injury Scale to Facilitate
Multidisciplinary Management-AJR Article
• US of Acute Scrotal Trauma: Optimal Technique, Imaging Findings,
and Management - RSNAArticle
• Radiopedia
• Images from internet