Pressed for time: The sonographic signs of testicular compartment syndrome

Testicular compartment syndrome (TCS) is the compromise of microcirculation as a result of extraluminal compression or increased venous resistance, which leads to hypoxia and eventual infarction. Injury occurs as a result of increased pressure within a small or low-compliance compartment resulting in a reduction or complete loss of perfusion to the tissues and subsequent ischemia. Compartment syndrome is most commonly reported in the upper and lower limbs; however the testicles are susceptible and sensitive to expansive processes due to the low compliance of the surrounding tunica albuginea. This case report aims to add to the small number of case reports currently available on this topic. There are multiple known causes of compartment syndromes such as crush injury, arterial occlusion, fractures associated with trauma and prolonged malposition of the limb. Due to the fragility of the capillaries and testicular microvasculature any expansive conditions of the testicle or scrotum such a hydrocele, abscess, epididymitis or epididymo-orchitis can cause TCS. As TCS results in hypoxia, it is considered a urological emergency and the success of intervention is time dependant. Ultrasound is well-recognised as the modality of choice for testicular imaging as it does not use ionising radiation, is non-invasive and readily available. Technological advancements have resulted in high resolution imaging which is highly sensitive to scrotal pathology when used in conjunction with colour and spectral Doppler. Ultrasound can provide detailed information about testicular perfusion and detect hypervascularity; the cardinal sign of inflammation. With spectral Doppler, sonographic assessment of the testes can differentiate between inflammatory causes of pain and torsion or other surgically treatable urgent conditions. Therefore, the success of surgical intervention for patients with TCS may be highly dependent upon its diagnosis and the recognition of sonographic signs. This case report aims to raise awareness about TCS for both treating physicians and sonographers and demonstrates two possible outcomes that may result from different management strategies. This case report also highlights the relevance of reversed end diastolic flow (REDF) and the importance of spectral Doppler in sonographic assessment of the testes.