Focal intratesticular lesions including spontaneous hematomas in the acute scrotum: the pivotal role of ultrasound and MRI in diagnosis and management—a pictorial review

An acute scrotum with a focal intratesticular lesion represents a diagnostic challenge and may lead to misdiagnosis and inappropriate management, such as unnecessary orchidectomy or empirical antibiotic therapy. In an emergency setting of acute scrotal pain, a wide spectrum of underlying conditions may be encountered, including testicular tumors with necrotic changes, abscesses, infarctions, and spontaneous hematomas. The latter are uncommon and frequently underrecognized entities, carrying a significant risk of mismanagement; therefore, particular emphasis is placed on their imaging features. Multiparametric ultrasound (US), including contrast-enhanced ultrasound and shear wave elastography (SWE), combined with multiparametric enhanced magnetic resonance imaging (MRI), plays a pivotal role in establishing an accurate diagnosis and guiding appropriate treatment decisions. This pictorial review illustrates the broad spectrum of focal intratesticular lesions presenting in the context of acute scrotum, emphasizing the role of imaging in differentiating benign conditions-such as spontaneous hematomas, which can be managed conservatively-from malignant tumors requiring prompt surgery. CRITICAL RELEVANCE STATEMENT: Multiparametric ultrasound and MRI improve the diagnostic accuracy of focal intratesticular lesions in acute scrotum, particularly spontaneous hematomas, helping avoid misdiagnosis and unnecessary surgical intervention. KEY POINTS: Acute scrotum associated with a focal intratesticular lesion is a diagnostic pitfall that may lead to inappropriate management, including unnecessary surgery. Multiparametric ultrasound (including CEUS and elastography) and MRI are complementary for distinguishing benign from malignant lesions and guiding management. Spontaneous testicular hematomas are rare benign entities characterized by T1-weighted image hyperintensity with a hypointense core and no enhancement on subtraction imaging, supporting conservative treatment. Lack of internal enhancement and geographic margins are keys for diagnosing segmental infarction, whereas enhancing thickened or nodular walls and increased stiffness suggest necrotic or hemorrhagic tumors; abscesses typically show dominant inflammatory changes with extra-testicular involvement.