Multiparametric ultrasound in acute scrotum: a comprehensive review with special emphasis on contrast-enhanced ultrasound.

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Learn more: PMC Disclaimer | PMC Copyright Notice J Ultrasound . 2025 Apr 18;28(2):305–321. doi: 10.1007/s40477-025-01017-8 Multiparametric ultrasound in acute scrotum: a comprehensive review with special emphasis on contrast-enhanced ultrasound Maria Laura Schillirò 1, ✉, # , Valeria Lonardo 2, ✉, # , Francesca Iacobellis 1, # , Martina Caruso 1, # , Costanza Camillo 1 , Chiara D’Errico 1 , Francesco Verde 1 , Francesco Muto 1, 2 , Giuseppina Dell’Aversano Orabona 1 , Chiara Rinaldo 1 , Dario Grimaldi 1 , Vittorio Sabatino 1 , Enrico Scarano 3 , Maurizio Carrino 4 , Luigi Pucci 4 , Vito Cantisani 5 , Gianfranco Vallone 6 , Marco Di Serafino 1, 6, # Author information Article notes Copyright and License information 1 Department of General and Emergency Radiology, Antonio Cardarelli” Hospital, 80131 Naples, Italy 2 Advanced Biomedical Sciences Department, University of Naples Federico II, Naples, Italy 3 Department of Radiology, “San Carlo” Hospital, 85100 Potenza, Italy 4 Department of Andrology “Antonio Cardarelli” Hospital, 80131 Naples, Italy 5 Department of Radiological Sciences, Oncology and Pathology, Policlinico Umberto I, Sapienza University of Rome, 00161 Rome, Italy 6 Department of Life and Health, University of Molise “V. Tiberio2, Campobasso, Italy ✉ Corresponding author. # Contributed equally. Received 2025 Jan 16; Accepted 2025 Mar 31; Collection date 2025 Jun. © Società Italiana di Ultrasonologia in Medicina e Biologia (SIUMB) 2025. Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law. PMC Copyright notice PMCID: PMC12145392  PMID: 40249502 Abstract Acute scrotum poses diagnostic challenges due to its diverse etiology and potential severity. Multiparametric ultrasound has proven to be a fundamental and valuable imaging modality in this context, improving early-phase sensitivity through various techniques, including B-Mode, color Doppler, power Doppler, pulsed Doppler, microflow studies, and elastography. In this context, Contrast-Enhanced Ultrasound (CEUS) emerges as a rapid, safe, and valuable tool in enhancing diagnostic accuracy and therapeutic decisions for acute scrotal conditions. This study involves a detailed analysis of various ultrasound imaging techniques and investigates the optimal circumstances and methods for employing CEUS in emergency situations to improve diagnostic accuracy and therapeutic decisions. Multiparametric ultrasound plays a crucial role in diagnosing various pathologies, including testicular torsion, appendage torsion, inflammation, ischemia/infarction, and trauma. CEUS provides real-time assessment of vascular perfusion, aiding in early diagnosis and accurate characterization of scrotal pathologies and significantly reducing the need for unnecessary surgical interventions, especially in trauma cases. Its role in differentiating between various pathologies and guiding therapeutic decisions underscores its importance in clinical practice, contributing significantly to improve patient outcomes. Keywords: Multiparametric ultrasound, Contrast-enhanced ultrasound (CEUS), Acute scrotum, Testicular torsion, Testicular inflammation, Testicular infarction Introduction Timely intervention is critical in managing acute scrotal symptoms, often requiring urgent surgical measures. While clinical examination serves as an initial step, various diagnostic tools, including grayscale ultrasound (B-MODE), elastography, color Doppler ultrasound (CD-US), pulsed-Doppler, and power Doppler ultrasound (PD-US), offer high diagnostic accuracy across different testicular pathologies [ 1 ]. B-Mode provides detailed anatomical information about the scrotum and its contents. It also assists in differentiating between intratesticular and extratesticular lesions, essential for determining the ap-propriate management approach. Ultrasound elastography, a non-invasive imaging technique, is particularly useful in assessing tissue stiffness. This method displays tissue stiff-ness objectively in gray-scale or colored images, providing valuable information about tissue damage. This approach is advantageous due to its ease, affordability, safety, and repeatability. The latest EFSUMB guidelines on testicular elastography focus exclusively on distinguishing between benign and malignant lesions. All forms of elastography show promise in evaluating focal lesions, confirming tissue stiffness with both Strain Elastography (SE) and Shear Wave Elastography (SWE) techniques, although there may be overlap in results between benign and malignant neoplasms. Currently, elastography is considered a complement to other ultrasound techniques rather than a standalone technique (The EFSUMB Guidelines and Recommendations for the Clinical Practice of Elastography in Non-Hepatic Applications: Update 2018—Recommendation 20) [ 2 ]. However, in cases of testicular lesions, SWE values may vary between different machines and are not interchangeable, while the presence of fibrotic areas near the tunica albuginea can complicate the evaluation of adjacent lesions. CD-US and PD-US provide information about blood flow within the testicles and surrounding structures, helping differentiate between conditions with normal and com-promised blood flow. Additionally, CD- and PD-US can detect hyperemia or increased blood flow associated with inflammatory conditions. PD-US is particularly valuable in pediatric cases or those with slow blood flow. Moreover, Superb Microvascular Imaging (SMI) is an advanced ultrasound technique that offers improved sensitivity in detecting low-velocity and small-diameter blood vessels compared to conventional Doppler techniques. It provides detailed visualization of microvascular flow patterns, allowing for enhanced assessment of tissue perfusion and microcirculation dynamics. Pulsed-Doppler provides valuable information about blood flow characteristics, utilizing pulses of ultrasound to assess velocity and direction. Nevertheless, interpretation of ultrasound images can vary with operator experience, prompting consideration of Contrast-Enhanced Ultrasound (CEUS). CEUS provides high-er sensitivity in detecting slow flows within poorly vascularized lesions compared to conventional Doppler methods, enhancing diagnostic certainty, especially in uncertain cases. Understanding the capabilities and limitations of CEUS is crucial, particularly in acute scrotal scenarios where precise assessment of healthy and vascularized parenchyma is pivotal. CEUS excels in differentiating hypovascularized lesions from those with a complete absence of vascularization, thereby facilitating accurate diagnosis and treatment planning. Its value extends across various testicular conditions, including torsion, inflammation, trauma, ischemia, neoplasms, and other benign lesions. Particularly noteworthy is its effectiveness in trauma and the incidental discovery of neoplastic lesions in emergency settings, highlighting its significance. With neoplastic lesions found in over 10–20% of patients with scrotal trauma [ 3 ], CEUS plays a crucial role in problem-solving, evaluating complications, conducting lesion follow-up, and planning organ preservation. Proficiency in execution technique, combined with thorough clinical assessment, and utilization of B-mode/Doppler, and elastography studies, ensures high diagnostic accuracy. CEUS demonstrates elevated sensitivity and specificity, along with positive and negative predictive values (sensitivity 93%, specificity 94%, positive predictive value 87%, negative predictive value 97%) [ 4 ]. The execution technique The execution technique remains consistent across studies involving B-mode, Doppler, and CEUS, which should always be conducted in conjunction, with contrast-enhanced study as an adjunct. The patient is positioned supine, and with a towel placed under the scrotum to aid in studying anatomical structures [ 5 ]. During testicular examinations, the penis is lifted, preferably directing it away from the testicle under ex-amination. Both testicles are studied, starting with the unaffected one, to ensure proper grayscale and color gain settings here (Fig. 1 ). Fig. 1. Open in a new tab An important tip to keep in mind is to start the examination and to set up the US image on the healthy side, in this case the left one ( a ), to avoid doubt and mistake. In image ( b ) is shown the right testis with inhomogeneous hypoechoic structure, without color signal at the Doppler evaluation, due to advanced ischemic-necrotic injury A high-frequency linear probe is typically used, whereas a lower-frequency convex probe may be employed in specific cases, such as massive hydrocele, for improved penetration. During the B-mode examination, assessment includes evaluating testicular volume, echostructure, margins, the presence of collections within the tunica vaginalis, and other anomalies and findings. The testis typically exhibits homogeneous echogenicity with a mildly coarse echo-texture, while the tunica albuginea forms an echogenic outline outlining the mediastinum testis. The epididymal head is generally round and isoechoic or mildly hypoechoic, with a thickness ranging from 5 to 12 mm. Moving down the posterior aspect of the testicle, the epididymal body measures 2–4 mm in thickness, while the epididymal tail curves at the inferior pole, transitioning into the ductus deferens with a thickness ranging from 2 to 5 mm [ 5 ]. Elastography comprises two main branches: strain and shear wave elastography. Strain elastography (SE) involves manually applying pressure to assess tissue deformation, while shear wave elastography (SWE) calculates tissue stiffness by measuring the speed of shear waves [ 6 ]. In testicular examinations, elastography helps evaluate lesions by comparing their stiffness to surrounding tissue, aiding in diagnosis when conventional ultrasound results are inconclusive. The visual elasticity score (VES) is used to measure lesion stiffness, typically employing a 5-point or 6-point scale, with a cutoff point of 3 VES to differentiate between'stiff'and'soft'lesions (> 3 = stiff, < 3 = soft)[ 6 – 8 ] (Fig. 2 ) (Table 1 ). Fig. 2. Open in a new tab Elastography: There are no lesions observed on B-mode imaging, and the color map of the strain elastogram from a normal testicle displays predominantly green and blue hues in central parenchymal areas, surrounded by red bands Table 1. Visual elasticity score 1 Visual elasticity score Description 1 The lesion is almost completely green but with some red spots 2 The entire lesion is homogeneously green 3 The lesion is almost completely green but with some small blue spots 4 The lesion is green at the periphery with a central blue area 5 The lesion is almost completely blue with central small green or red areas 6 The lesion is completely blue Open in a new tab 1 Konstantatou et al. J Ultrasound Med 2019;38:223–232[ 7 , 8 ] Thereafter, a color Doppler study is performed, comparing testicular vascularization with the contralateral side to detect any asymmetries or differences in vascular signal. For Doppler evaluation, the ultrasound machine is adjusted for low flow velocities by lowering the Pulse Repetition Frequency (PRF) to the lowest possible value [ 9 ]. Spectral analysis helps to assess the branches of the testicular artery to identify anomalies in the waveform pattern and to evaluate the venous system and/or the presence of any vascular abnormalities. The velocity flows typically present in the capsular and intra-testicular arteries show low vascular resistance, characterized by high levels of antegrade diastolic flow during the cardiac cycle, typical of parenchymal structures (Fig. 3 ). Fig. 3. Open in a new tab Suggestions for correct US color-Doppler setting: it is important to optimize the sensitivity for slow flows reducing the PRF and setting the wall filters to minimum values, note the difference in figures a, b and c ( a ), ( b ), ( c ). Furthermore, it is important to properly set up the color scale for better visualization of the scrotal vascular anatomy (note changes in a, b and c). Normal testis color-Doppler evaluation ( d ); normal spectrogram sampled on an intraparenchymal arterial vessel (sample) with normal parenchymal flow characterized by elevated diastole ( e ) Testicular examinations should include both longitudinal and transverse scans, sampling the Resistance Index (RI) at the upper pole, mid-third, and lower pole, with RI values generally falling between 0.46 and 0.78 [ 10 ]. Any deviation from this range should be considered a red flag and interpreted in the context of our clinical diagnostic suspicion. In assessing acute scrotal conditions, the primary diagnostic aim is to differentiate between hypovascular and avascular lesions, identify residual healthy parenchyma post-twisting or derotation, and characterize complications such as abscesses, which may be ambiguous and misinterpreted on B-mode and color Doppler imaging alone. Superb Microvascular Imaging (SMI) is an advanced ultrasound technique designed to improve the visualization of microvascular structures within tissues. Specifically in the realm of testicular disease, SMI enhances the detection and characterization of vascular abnormalities like tumors, ischemia, or inflammatory conditions (Fig. 4 ). Fig. 4. Open in a new tab SMI value: ( a ) SMI evaluation emphasizes the hyperemia of scrotal tissues in a case of severe inflammation; ( b ) The cystic mass does not show signs of vascularity on SMI evaluation: it is indicative of a spermatocele. The spermatocele arises from an obstruction of the efferent ducts. Both epididymal cysts and spermatoceles appear as anechoic masses, well-defined and indistinguishable on ultrasound. Typically, the spermatocele has the appearance of a septated cystic mass Contrast-enhanced ultrasound (CEUS) provides a practical solution by increasing confidence in lesion vascularity interpretation and enhancing the visualization of scrotal and cord vessels, thereby facilitating appropriate clinical management. The contrast medium (Sonovue, Bracco) consists of microbubbles of sulfur hexafluoride encapsulated by phospholipid shells. When microbubbles encounter ultrasound, they start oscillating nonlinearly, generating harmonic frequencies received by the transducer. The optimal resonance frequency is typically between 3–5 MHz, suitable for abdominal applications. These harmonic frequencies help differentiate microbubbles from linear echoes of static tissues, enabling contrast visualization on the display [ 3 ]. Studying the testicle poses a challenge due to its superficial nature, which requires higher frequencies, resulting in fewer microbubbles capable of resonating. To optimize testicular enhancement, a complete dose of contrast agent, usually 4.8 mL, is administered through a 20-gauge cannula, followed by a 10 mL injection of 0.9% saline solution [ 11 ]. This helps prevent premature destruction of microbubbles caused by higher mechanical index (MI) values. MI settings typically range from 0.08 to 0.05, depending on equipment, transducer, and contrast mode [ 12 ]. These microbubbles, with an average diameter of around 2.5 μm, act as a pure intra-vascular contrast agent, passing through capillaries, without penetrating the vascular endothelium [ 13 ]. The testicle is primarily supplied by the testicular artery, originating from the abdominal aorta and branching into various segments. Microbubbles allow visualization of normal parenchymal microcirculation, highlighting any intraparenchymal anomalies. Following contrast agent administration, rapid enhancement of the testicle and epididymis occurs, with progressive enhancement of the parenchyma within seconds, followed by signal decline and disappearance after about 3 min. The arterial and parenchymal phases should be captured using images and videos, which are then digitally archived (Fig. 5 ). Fig. 5. Open in a new tab Contrast Enhanced Ultrasound (CEUS) and B-mode view of a normal testis, longitudinal scan: ( a ) arterial phase; ( b ) homogeneous parenchymal enhancement 50 s after the injection of the intravenous contrast agent Establishing an imaging plane through a preliminary B-mode examination is crucial when studying a lesion, followed by analyzing the behavior from the appearance to the disappearance of the microbubbles. Maximum Intensity Projection (MIP) can enhance this process, providing a clearer visualization of the vascular network by summing frames over a short period, especially useful in trauma cases. CEUS studies involve both qualitative and quantitative assessments. Qualitative assessment relies on visual interpretation of enhancement patterns, while quantitative assessment involves specialized software analysis. Graphical representation shows in-tensity over time, with the peak indicating Peak Enhancement. This method allows us to measure contrast dynamics and compare them to healthy tissue. By placing Regions of Interest (ROI) on the lesion and healthy tissue, we can differentiate between neoplastic and non-neoplastic lesions [ 14 ]. Testicular diseases Multiparametric ultrasound is extremely useful in testicular pathologies as it allows for a detailed evaluation of various parameters, providing a comprehensive view of the testicle's condition (Table 2 ). Table 2. Multiparametric ultrasound in testicular evaluation Multiparametric US Diagnostic clue Acute scrotum Torsion Inflammation Trauma B-mode Parenchyma structure Inhomogeneous/time dependent Inhomogeneous/abscess Inhomogeneous/hematoma Elastosonography Consistency High High/Low (abscess) High/Low (hematoma degradation) Color-/Pulse- Doppler Vascularization/Type of flow (low resistance arterial flow) Absent/high-resistance arterial flows (partial torsion) Incremental/high-resistance arterial flows (edematous/exudative infiltration) Incremental/high-resistance arterial flows (hematic infiltration) Power Doppler/Microflow Imaging Slow blood flows magnification Absent Incremental Incremental CEUS Perfusion Absent Inhomogeneous/ischemic area/abscess Inhomogeneous/hematoma Open in a new tab Testicular torsion Testicular torsion is the primary cause of acute scrotum in adolescents and newborns, but it can affect individuals of all ages and may occur due to sports or physical trauma [ 5 ]. In testicular torsion, timely diagnosis is crucial. Saving the testicle is possible in 90–100% of cases if diagnosed correctly within 6 h, but the likelihood decreases significantly with time: 20–50% after 12–24 h and 0–10% after more than 24 h [ 15 ]. Sonographic findings in testicular torsion can vary significantly depending on the time of onset and the degree of twisting in the spermatic cord. Within the first 4 h, a homogeneous echostructure with regular testicular volume is often seen. After this initial period, vascular congestion may lead to volumetric enlargement and increased homogeneous hypoechoic appearance over the next two hours. However, after 12–24 h, a heterogeneous pattern may develop due to vascular congestion, hemorrhage, and infarction. Changes in tissue stiffness or elasticity due to impaired vascularization and ischemia can be detected using elastography. This can lead to increased stiffness in the affected testicle, although the extent of this change depends on the severity and duration of testicular torsion. The degree of torsion affects diagnostic accuracy. A high-grade torsion of approximately 360° is typically required for arterial flow disappearance. However, complete arterial flow disappearance may occur with less torsion if it is severe enough. Using the absence of intratesticular flow on color Doppler alone yields a sensitivity of 86–94%, indicating that 6–14% of patients may receive a false negative diagnosis [ 16 ]. In the majority of cases, the observed low-grade torsions involve compression of veins and lymphatics while maintaining the patency of the arterial flow signal [ 17 ]. The presence of testicular arterial flow signals can vary in location and waveform characteristics depending on the severity of torsion, sometimes appearing near the hilum or in a more peripheral distribution. Assessing asymmetry or differences in color Doppler flow signals between affected and contralateral testicles is crucial, but additional signs and spectral analysis may be necessary. In high-grade torsion, spectral Doppler typically shows absent flow or very high resistance in the spermatic artery above the torsion level. Low-grade torsion obstructs venous outflow, resulting in a high-resistance waveform. Ischemic signs include monophasic waveforms, increased resistance index, reversal of diastolic flow, and post-stenotic flow with the whirlpool sign [ 16 ] (Fig. 6 ). Fig. 6. Open in a new tab Different stages of testicular torsion. The importance of sampling and knowing how to analyze the flow pattern: a normal flow pattern compared to ( b ) abnormal flow, characterized by increase resistance with higher systolic peak and flow reversal during diastole. This flow pattern is due to partial torsion, involving the venous side due to the lower venous pressure; c recent high grade torsion, with absence of vascular signal ( d ) Ischemic-necrotic changes after persistent torsion Many cases of low-grade torsion necessitate a meticulous evaluation of the morphological characteristics of the spermatic cord for identification, especially in pediatric patients where Doppler assessment is challenging due to low flow velocity. Anomalies such as changes in the cord's course, size, and shape, or the presence of the Whirlpool sign [ 18 ], where funicular vessels encircle the central axis of the twisted spermatic cord, should be investigated. This sign is easily visible by maneuvering the probe along the cranio-caudal axis. B-MODE and Doppler ultrasound techniques are usually sufficient for diagnosis, with support from numerous studies, particularly in cases of high-grade torsions [ 19 – 23 ]. Although its role is not considered necessary for the diagnosis of testicular torsion, CEUS can still prove to be helpful for early diagnosis confirmation, particularly in uncertain cases with vascularization, by detecting contrast agent uptake differences between the testicles. It also helps assess complications like segmental infarctions, expediting treatments. However, the latest guidelines from EFSUMB indicate that there is currently insufficient evidence to recommend the routine use of CEUS in cases of spermatic cord torsion. Nevertheless, CEUS proves effective in demonstrating the absence of overall vascularity in such instances [ 12 ]. Indeed, testicular torsion can lead to infarction through both venous and arterial occlusion, resulting in parenchymal changes correlating with torsion duration and severity. Ischemic areas in torsion cases are typically concentrated in the central regions of the testicle and are clearly visualized with the use of a contrast agent. Appendix torsion Appendix torsion can mimic testicular torsion and is a common cause of acute scrotum. It is characterized by the presence of a rounded, nodular appendix with a diameter over 5–6 mm at the upper pole of the testicle. On SE, the round lesion identified on gray-scale ultrasound (US) exhibits increased tissue stiffness [ 24 ]. It lacks vascular signal and shows peripheral hyperemia on Doppler. Hydrocele and skin thickening may accompany it [ 5 ]. CEUS shows normal enhancement in both testicles, ruling out the diagnosis of testicular torsion, and confirms the lack of vascularization in the enlarged testicular appendix. Inflammatory pathology Testicular inflammatory pathology is extremely common, representing the most common cause of acute scrotal pain in post-pubertal individuals. These conditions are usually linked to infections originating from the lower urinary tract, spreading retrogradely, but can also arise from hematogenous routes or as post-traumatic complications. The primary pathogens responsible are Chlamyhdia trachomatis, Neisseria gonorrheae, E.coli, Pseudomonas, Klebsiella. The infection primarily targets the spermatic cord, causing funiculitis characterized by inguinal canal swelling and adipose tissue thickening, with hyperemia evident on Doppler and CEUS. Additionally, it can spread to the epididymis, affecting its tail, body, and head with epididymo-orchitis occurring in over 20% of cases [ 5 ]. Orchitis, primarily associated with viral infections like mumps, can manifest as isolated epididymis infection, often bilateral, particularly in children. In B-mode, the inflamed epididymis appears enlarged and heterogeneous (focally or diffusely) with varying degrees of echogenicity: hypoechoic com-pared to the testicle in case of edema, hyperechoic in case of hemorrhage, and with a striated pattern in case of post-inflammatory fibrosis; the latter case should be considered in the differential diagnosis with infiltrative processes such as lymphoma (markedly internal vascularization with absent elastic strain at SE and rapid wash-in and wash-out at CEUS) and leukemia (internal vascularization with intermediate/soft elastic strain at SE). It may present with or without reactive hydrocele (also septated or with sediment), along with thickening and hyperemia of the scrotal tunics [ 5 ] (Fig. 7 ). Fig. 7. Open in a new tab Findings of inflammatory involvement ( a ) diffuse increase of the vascularity at the color-Doppler evaluation of the testis in case of orchitis and ( b ) epididymo-orchitis; c presence of corpuscular hydrocele; d septated hydrocele, suggesting long-standing alterations In cases of epididymis involvement, ultrasound findings include marked vascularization observed on Doppler (Fig. 8 ). Fig. 8. Open in a new tab Findings of epididymitis, ( a ) usually starting at the tail of the epididymis, found at the inferior pole of the testis, ( b ), ( c ), ( d ) progressively involving the whole epididymis with increased volume and vascular flow at the color-Doppler evaluation Early stages may show reduced resistance indices before edema develops (IR < 0.5). The SE can reveal a heterogeneous pattern of firmness, which varies depending on the stage of the condition. Established epididymo-orchitis shows a firm texture, whereas abscesses are softer. Additionally, as an abscess matures, it may become stiffer around the edges with varying firmness at the center, indicating localized liquefaction [ 6 , 25 ]. CEUS reveals hyperemia in inflamed structures compared to surrounding or contra-lateral ones and can detect both abscess formation and infarction in cases of severe epi-didymo-orchitis, as recommended by EFSUMB (Recommendation 17) [ 12 ]. As inflammation progresses, microabscesses or true abscesses may develop within the epididymis, appearing as hypoanechoic or mixed echogenicity focal areas with irregular margins and rich peripheral vascularity. CEUS complements Doppler data, depicting areas devoid of central flow with peripheral rim enhancement. Abscesses may mimic neoplasms, but usually CEUS distinguishes them by showing rapid arterial wash-in in neoplasms, dis-tinct from peripheral abscess rim enhancement. Older abscesses can show echogenic septa radiating and dividing hypoechoic spaces. There may be increased enhancement around the abscess cavity, but central enhancement is absent [ 26 ]. The rupture of an abscess into the scrotal sac can result in the development of an endovaginal purulent collection known as a pyocele (Fig. 9 ). Fig. 9. Open in a new tab a CEUS may help in the evaluation of inhomogeneous hypo-anechoic areas within the testicular parenchyma, confirming the absence of enhancement in an area of complicated flogosis due to orchitis (abscess). Complication of inflammatory involvement of epididymis and testis; two different cases of abscessualization phenomena of the epididymis, b which is diffusely enlarged (caliper), characterized by inhomogeneous structure and hypo-anechoic areas in its context (arrow), c the vascularization increases, and fluid collection may develop (arrow) Ischemia and infarction Initially, infarction may be difficult to visualize on grayscale ultrasound, but later, hypoechoic areas may become apparent, often accompanied by hyperechoic patches in cases of hemorrhage. The tissue elastography method, particularly utilizing real-time wave elastography, has become widely utilized in recent years for diagnosing and differentially diagnosing cases of testicular infarction [ 27 ]. In elastography, segmental testicular infarction is characterized by a firm texture in the outer regions and a softer texture in the center, attributed to edema and bleeding [ 6 ]. Ischemic testicles feel hard and appear stiff in elastography, while soft areas signify ongoing necrosis and liquefaction [ 11 ]. Infarcted areas consistently show hypovascularity or avascularity on Doppler. Furthermore, SMI can be employed to confirm these findings, providing high-resolution visualization of microvascular flow and aiding in the accurate assessment of tissue vascularity. CEUS is crucial in assessing ischemia and infarction in scrotal pathology. These conditions can manifest as segmental infarction affecting parts of the testicle or complete infarction involving the entire didymo. CEUS confirms the lack of enhancement compared to normal tissue. Testicular infarction can occur idiopathically or as a result of various factors such as recent surgery, testicular torsion, inflammatory events, blood disorders like sickle cell dis-ease, polycythemia, or autoimmune diseases such as vasculitis, or systemic embolization. Testicular torsion can lead to infarction due to venous and arterial occlusion, with parenchymal changes reflecting the duration and severity of torsion. Peri-epididymal swelling in severe epididymitis can obstruct venous outflow, causing venous stasis, ischemia, or infarction. Grayscale imaging may demonstrate an enlarged, heterogeneous testicle with reduced or absent color flow and an adjacent anomalous epididymis. Epididymal hyperemia aids in distinguishing between testicular ischemia secondary to inflammation and that caused by torsion. High-resistance waveforms, along with reduced or reversed diastolic flow, may be observed on spectral Doppler tracing, suggesting venous infarction. If left untreated, this can lead to abscess formation. Ischemic areas tend to localize centrally in torsion cases but prefer peripheral regions in post-inflammatory ischemia (Fig. 10 ). Fig. 10. Open in a new tab Ischemic area. a The testis echotexture is non-homogeneous for the presence of a large slightly hypoechoic area with ill-defined margins (white circle), b characterized by absence of vascular flow at microflow and ( c ) color Doppler as well as ( d ) lack of contrast enhancement at CEUS. Complication of inflammatory involvement of epididymis and testis. e The epididymis is enlarged with non-homogeneous echotexture and increased vascularization at color Doppler. f The testis is diffusely hypo-echoic and the color Doppler does not reveal any vascular signal. g The CEUS confirms the absence of testis vascularization as absence of the enhancement in the whole testis due to venous flow impairment Ischemic lesions with rounded morphology and hypovascular appearance on Doppler present a challenge in distinguishing them from hypovascular tumor lesions. Neo-plastic lesions in elastography typically appear hard with low or absent elasticity, although the elastography features in ischemia can vary depending on the timing of the ultrasound examination. Initially, the abnormal area may exhibit soft characteristics due to swelling and increased water content, but as the lesion progresses, it may display hard features on the elastography color map [ 8 ]. CEUS facilitates the differentiation of segmental ischemic areas from hypovascular tumors. In some cases, small testicular tumors may not show flow on color Doppler and could be misinterpreted as benign lesions; however, CEUS can confirm tumor enhancement, except in cystic components and necrotic regions which will show no enhancement. Subacute segmental infarction typically shows perilesional rim enhancement that diminishes over time. Subsequently, the lesion decreases in size, assumes a wedge-shaped appearance, and eventually disappears, sometimes leaving a parenchymal scar. Follow-up is always necessary to document lesion evolution. Changes in lesion shape, vascular characteristics, and size reduction during follow-up confirm the diagnosis. Traumatic pathology Trauma represents the third most common cause of acute scrotum. Less than 1% of trauma injuries affect this anatomical area, both due to its location and its mobility [ 28 ]. Traumatic scrotal pathology typically arises from sports injuries, motorcycle accidents, and penetrating injuries. [ 29 ]. When assessing a patient with trauma, it's crucial to follow a checklist, examining: Scrotal wall (skin, abdominal wall fascia, extra-testicular tissues); Tunica vaginalis (presence of fluids such as hydrocele, more or less corpuscular, or hematocele). Tunica albuginea (fibrous, hyperechoic layer similar to a capsule); Epididymis and testicle. Scrotal injuries can involve structures inside or outside the testicle. They may include extratesticular conditions like hematomas, hydroceles, hematoceles, or epididymal lesions, and intratesticular issues such as hematomas, fractures, or ruptures. Trauma can lead to complications like testicular dislocation (usually into the inguinal canal), cord torsion, or pseudoaneurysm development. Severe cases may require surgical intervention, including orchiectomy. Surgery within 72 h significantly reduces the likelihood of orchiectomy, with a success rate of 90%, decreasing to 45% beyond this timeframe. Untreated testicular rupture or fracture can cause infertility within 72 h due to the release of spermatic antigens, triggering the immune system to produce antisperm antibodies. [ 30 ]. The gold standard for evaluating scrotal lesions involves B-MODE analysis with Doppler integration, further enhanced by CEUS evaluation. In cases of acute testicular trauma, CEUS allows for precise quantification of testicular perfusion and assessment of testicular vitality, aiding in testicular salvage management. However, it's crucial to note that if testicular trauma is accompanied by testicular torsion, no contrast enhancement will be detectable [ 31 ]. Extra-testicular hematoma The extra-testicular hematoma, originating from either the scrotum or the abdomen through a patent inguinal canal, can compromise testicular vascularization due to com-pression mechanisms [ 32 ]. The hematoma typically appears echogenic, which can hinder the evaluation of the tunica albuginea continuity and testicular contours, sometimes mimicking a neoplasm. However, CEUS can demonstrate the avascular nature of the hematoma, outline the testicular contour, and confirm regular perfusion of the testicular parenchyma [ 3 ]. Hematocele Hematocele refers to the collection of blood in the vaginal cavity, and its appearance can vary depending on the time of onset [ 3 ]. The acute hematoma typically appears uniformly echogenic, making it hard to differentiate from the tunica albuginea [ 3 ]. The chronic hematocele undergoes changes over time, including solid-cystic organization and the development of proteinaceous septa. Despite these changes, hematoceles typically decrease in size during follow-up. In some cases, fluid–fluid levels may develop due to blood stratification, resembling certain rare extra-testicular neoplasms; however, they can be distinguished by the absence of enhancement on contrast-enhanced ultrasound. Additionally, large hematoceles may lead to testicular displacement and compression [ 3 ]. Therefore, studying its perfusion with CEUS is crucial for identifying parenchymal borders and assessing the integrity of the tunica albuginea. Intra-testicular hematoma Intra-testicular hematomas may not cause symptoms and their appearance on ultra-sound depends on the time since their formation. Acute hematomas typically appear iso- or hyper-echoic with mild testicular heterogeneity and should be re-evaluated within 12–24 h [ 33 ]. Chronic hematomas in the testicle tend to organize into a complex cystic-solid appearance [ 5 ] and decrease in size over time until they resolve. Strain Elastography shows that intratesticular hematomas predominantly exhibit"soft"SE properties with intermediate to high elastic strain [ 34 ]. Stiffness levels in hematomas may vary during the healing process, similar to other testicular pathologies [ 35 ]. Doppler reveals no internal vascularization signal. CEUS detects hematomas as clearly outlined lesions without blood flow, facilitating accurate size assessment and longitudinal monitoring (Fig. 11 ). Fig. 11. Open in a new tab Post-traumatic alterations. a Note the inhomogeneous hypoechoic intraparenchimal area (arrow) characterized by absence of vascular flow, b increased stiffness ( c ) and lack of contrast enhancement, due to intraparenchymal hematoma It also highlights secondary ischemic areas and can diagnose active bleeding within the hematoma if vascular signals are present [ 25 ]. CEUS offers superior accuracy, also in identifying post-traumatic vascular lesions like pseudoaneurysms, characterized by anechoic appearance on B-mode, “Ying-Yang” appearance on ECD and “to-and-fro” pattern on spectral analysis. Follow-up is crucial due to the risk of infections and necrosis, which may necessitate surgery. Additionally, large intra-testicular hematomas should be drained to prevent in-creased pressure leading to necrosis, atrophy, and subsequent orchiectomy. Intra-testicular hematomas can have varied locations, being peripheral or central, depending on the cause of trauma. They often accompany penetrating injuries like biopsies, animal bites, or gunshot wounds, along with fractures and hematoceles. Detection can be complicated by foreign bodies or gas causing acoustic shadowing on B-mode ultrasound. Spontaneous hematomas can arise from arteriovenous malformations or undetected aneurysms. CEUS is essential for distinguishing them, particularly from hypovascular neoplasms. Follow-up is crucial to monitor rapid changes and confirm their nature. Despite hematomas typically lacking internal vascularization on ECD, infected ones may exhibit peripheral hyperemia. Septa, if present, are usually non-vascularized [ 22 ]. Occasionally, vascularized septa and mild perilesional enhancement, often of artifact origin, may be observed [ 3 ]. CEUS is crucial for differentiating between hematomas and neoplasms. Intralesional vascularization and lack of resolution during follow-up are suspicious signs (Fig. 12 ). Fig. 12. Open in a new tab a The testis echotexture is non-homogeneous for the presence of some little nodular hypoechoic areas with ill-defined margins, characterized by intra-lesional vascularization and ( b ) hard stiffness pattern at strain elastography. c After the intravenous injection of contrast medium, the area is hypovascularized and suspected for testicular neoplasm Testicular fracture Testicular fracture is the traumatic interruption of testicular parenchyma, which may occur independently of tunica albuginea destruction. Sometimes, the rupture of the tunica albuginea may be secondary to the intra-testicular pressure generated by the hematoma. Rapid diagnosis is crucial regardless of tunica albuginea integrity. On B-mode ultra-sound, it appears as a poorly defined linear hypoechoic band within the testicular parenchyma, often associated with intact tunica albuginea, smooth testicular contours, and sometimes an associated hematocele. Massive edema can impede visibility [ 36 ]. In Doppler ultrasound, no vascular signal is detected within the band, prompting the need to evaluate vascularization to determine the feasibility of partial orchiectomy. If in-tact blood flow and self-sufficient vital testicular tissue are present, testicular salvage is possible; otherwise, surgical intervention is necessary due to probable ischemia. CEUS provides a more accurate representation of vascularization and the fracture plane, which appears well-defined and avascular or hypovascular, easily distinguishable from adjacent normoperfused testicular parenchyma. In severe trauma cases with fracture, a weak homogeneous enhancement may be observed. CEUS plays a crucial role in preoperative planning by providing detailed information about the extent of vital testicular tissue. This assessment helps surgeons determine the best approach for surgical intervention, such as partial or total orchiectomy, and reduces the risk of false negatives and associated complications (Fig. 13 ). Fig. 13. Open in a new tab Post-traumatic injuries. a The testis echotexture is non-homogeneous for the presence of peripheral hypoechoic areas, characterized by hard stiffness pattern at strain elastography ( b ) and no enhancement after the intravenous administration of contrast medium at CEUS Testicular rupture Testicular rupture is a condition characterized by the loss of integrity of the tunica albuginea. Early diagnosis within 72 h of trauma is crucial, as it can save up to 80% of affected testicles. Ultrasound findings include a direct visualization of tunica albuginea disruption or irregularity, along with additional signs like distorted testicular contours, heterogeneous parenchyma, thickened scrotal wall, and the presence of a haematocele. On Doppler, reduced or absent vascularization may be observed, along with seg-mental ischemic areas related to tunica vasculosa lesion during tunica albuginea rupture. B-MODE analysis demonstrated a sensitivity of 100% and specificity of 93.5% for detecting tunica albuginea rupture when accompanied by heterogeneous echostructure and contour abnormalities [ 37 ]. On Doppler, reduced or absent vascularization may be observed, along with segmental ischemic areas related to tunica vasculosa lesion during tunica albuginea rupture. In challenging situations, particularly with significant scrotal hematomas or hematomas of the scrotal wall, evaluating the integrity of the tunica albuginea can be difficult. In such cases, abnormalities in the contours can suggest a possible rupture, indicating potential extrusion of parenchyma following the rupture of the tunica. CEUS, once again, provides a more precise distinction. It clearly defines the tunica rupture compared to B-MODE and accurately outlines the perfused and vital testicular tissue. Typically, focal or global ischemia with non-vascularized testicular regions and evidence of a rupture in the tunica albuginea can be observed. Furthermore, CEUS is essential for planning surgical procedures and monitoring traumatic injuries until they heal. Conclusions The acute scrotum requires accurate diagnosis, utilizing various imaging tools like B-MODE, elastography, CD-US, PD-US, and spectral analysis. CEUS integration is crucial in cases of doubt, trauma, suspected neoplastic lesions, and lesion follow-up, using full-dose contrast medium. CEUS proves essential in evaluating and monitoring scrotal lesions, offering detailed vascularization assessment for accurate diagnosis and timely intervention. Its ability to differentiate between pathological conditions guides clinical management, making it valuable for surgical planning and postoperative recovery monitoring, ultimately improving patient outcomes. Acknowledgments Thanks to Ciro Acampora for the teachings. Author contributions Conceptualization, M.L.S. and M.D.S.; methodology, M.L.S.; software, M.L.S.; validation, M.L.S., M.D.S., F.I. and M.C.; formal analysis, M.L.S., M.D.S., F.I. and M.C.; investigation, M.L.S., M.D.S., F.I., M.C., C.C., C.D., F.V., G.D.O., C.R., D.G., V.S., G.G., F.M; resources, M.L.S., M.D.S., F.I., M.C., C.C., C.D., F.V., G.D.O., C.R., D.G., V.S.; data curation, M.L.S., M.D.S., F.I. and M.C.; writing-original draft preparation, M.L.S.; writing, review and editing, M.L.S., M.D.S. and V.L.; visualization, E.S.; supervision, V.L.; project administration, M.L.S., V.L. Funding This research received no external funding. Data availability Data are not publicly available in order to protect patient privacy. Declarations Conflict of interest The authors declare no conflicts of interest. Informed consent Written informed consent has been obtained from the patients to publish this paper. 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