Testicular Trauma

Testicular trauma is relatively uncommon, despite the exposed position of the testicles in the male perineum. Testicular injuries can be divided into 3 broad categories based on the mechanism of injury. These categories include blunt trauma, penetrating trauma, and degloving trauma. Injuries typically occur in men aged 15-40 years.

A careful history and detailed physical examination are essential for an accurate diagnosis. Scrotal ultrasound with Doppler studies is particularly helpful in determining the nature and extent of injury. Penetrating testicular trauma usually requires scrotal exploration to determine the severity of testicular injury, to assess the structural integrity of the testis, and to control intrascrotal hemorrhage. If the tunica albuginea is violated, early surgical exploration, debridement, and closure of the tunica albuginea are necessary.

Problem: Testicular trauma is defined as any injury sustained by the testicle. Types of injuries include blunt, penetrating, or degloving.

Blunt trauma refers to injuries sustained from rounded objects applied with great force to the scrotum and testicles. Examples include a kick to the groin or a baseball injury.

Penetrating trauma refers to injuries sustained from sharp objects or high-velocity missiles. Examples include gunshot and stab wounds.

Degloving injuries (or avulsion injuries) are less common. With these, scrotal skin is sheared off, for example, when a testicle becomes trapped in heavy machinery.

Quite often, testicular injury is an associated complication of a larger trauma.

Testicular rupture or fractured testis refers to a rip or tear in the tunica albuginea resulting in extrusion of the testicular contents.

Frequency: Testicular trauma is relatively uncommon. Blunt trauma accounts for approximately 85% of cases, and penetrating trauma accounts for 15%. As many as 80% of hematoceles (blood in the tunica vaginalis) are associated with testicular rupture.

Blunt testicular injuries can be managed either medically or surgically, depending on the clinical presentation. Early surgical intervention for blunt trauma is associated with higher salvage rates (94% vs 79%).

Etiology: The most common cause of blunt testicular trauma is sports injuries. The second most common cause is kicks to the groin. Less common etiologies include motor vehicle accidents, falls, and straddle injuries.

The most common cause of penetrating testicular injuries is a gunshot wound to the genital area. Other causes include stab wounds, self-mutilation, and emasculation.

The most common cause of degloving testicular injuries is accidents while operating heavy machinery (eg, industrial accidents).

Pathophysiology: The testis is enveloped by layers of white fibrous connective tissue called the tunica vaginalis and the tunica albuginea. The tunica albuginea is the visceral layer that covers the testis, and the tunica vaginalis is the parietal layer that lines the hydrocele sac.

The tunica albuginea is the layer that is violated during a testicular rupture. Approximately 50 kg of force are required to rupture the testicle. A tear in the tunica albuginea leads to extrusion of the seminiferous tubules and intratesticular hemorrhage. This advances to bleeding and hematocele formation in the tunica vaginalis. Disruption of the tunica vaginalis or extension to the epididymis leads to bleeding into the scrotal wall, resulting in a scrotal hematoma.

Two factors allow testes to be protected from minor external trauma. First, a thin layer of serous fluid (ie, physiologic hydrocele) separates the tunica albuginea from the tunica vaginalis and allows the testis to slide freely within the scrotal sac. Second, the testes are suspended within the scrotum by the spermatic cord, allowing them to move freely within the genital area. In cases of penetrating trauma or severe blunt trauma, these protective features are insufficient to prevent injury to the testis proper.

Clinical: Patients typically present to the emergency department with a fairly straightforward history of injury (eg, sports injury, kick to the groin, gunshot wound) soon after the event occurs.

Patients who have sustained severe blunt trauma usually exhibit symptoms of severe scrotal pain, frequently associated with nausea and vomiting. When evaluating a patient with clinical history of minor trauma, do not overlook the possibility of testicular torsion and epididymitis. Physical examination reveals a swollen, severely tender testicle with visible hematoma. Scrotal or perineal ecchymosis may be present. Bilateral testicular examination and perineal examination should always be performed to rule out associated pathologies. However, because of the severe pain the patient experiences, performing a thorough examination often is difficult, and radiologic study or surgical exploration may be required.

The vast majority of blunt testicular injuries are solitary (and unilateral). The absence of scrotal swelling and hematoma may indicate a relatively benign injury. Additional imaging tests or scrotal exploration is required if testicular rupture is suggested based on clinical findings or when a patient experiences pain out of proportion to the physical findings. Blunt trauma to the testes may manifest as hematocele or a ruptured testis. The complete absence of pain in a patient with scrotal swelling and hematoma raises the possibility of testicular infarction or spermatic cord torsion.

For penetrating injuries, determine the entrance and exit sites of the wound. As many as 75% of men with penetrating injuries to the genitalia demonstrate additional associated injuries. Carefully examine the contralateral hemiscrotum and the perineal area. Rule out injuries to the contralateral testicle, bulbar urethra, femoral vessels, and rectum. Although uncommon, vascular injury leading to an ischemic testis has been reported.

Using universal precautions when evaluating these injuries is important. One review of 40 men with penetrating trauma revealed that 38% tested positive for hepatitis B, hepatitis C, or both. Furthermore, according to Cline et al in 1998, 60% of these patients were legally intoxicated at the time of injury.

Screening urinalysis is an important adjunct to the physical examination to rule out urinary tract infection or epididymo-orchitis.

Scrotal ultrasound imaging with Doppler studies is valuable for diagnosing and staging testicular injuries. The presence of a disrupted tunica albuginea is pathognomonic for testicular rupture. A scrotal hematoma often has associated scrotal skin thickening.

Perform Doppler studies during the scrotal ultrasound because they provide information on the vascular status of the testes. Blood flow to the testis indicates that the vascular pedicle is intact and torsion has not occurred. An absence of flow implies that a torsion or devascularizing injury has occurred to the spermatic cord.

Other imaging studies, such as nuclear imaging or MRI, may be used to obtain additional information in equivocal cases. However, the definitive diagnosis of testicular rupture is made in the operating room. Scrotal exploration is the best diagnostic tool for any equivocal testicular trauma.

Indications for scrotal exploration include the following:

Clinical hematoceles usually require scrotal exploration because noninvasive imaging techniques (eg, scrotal ultrasound, nuclear scanning, MRI) are often inaccurate.

If the testis is fractured, testicular debridement and surgical closure of the tunica albuginea are necessary.

The absence of blood flow indicates spermatic cord torsion, devascularization, or testicular infarction.

Penetrating testicular trauma usually requires exploration to ascertain the degree of injury, to assess the integrity of the testis, and to identify and control intratesticular hemorrhage.

Lab Studies:

Imaging Studies:

Medical therapy: Institute conservative treatment for patients with minor trauma in which the testes are unequivocally spared and the scrotum has not been violated. The usual treatment consists of scrotal support, nonsteroidal anti-inflammatory medications, ice packs, and bed rest for 24-48 hours.

Scrotal support prevents the scrotum from hitting the inner thigh and aggravating the injury. Anti-inflammatory medications decrease scrotal edema and provide nonsedating analgesia. Ice packs applied to the groin at least every 3-4 hours decrease swelling.

If associated epididymitis is suggested or if urinary tract infection is present, administer appropriate oral antibiotics.

Failure of medical therapy after an appropriate period of expectant management warrants imaging of the scrotum with ultrasound and Doppler studies.

Surgical therapy: With the possible exception of a superficial skin injury, explore penetrating testicular trauma in the operating room. Patients with a history of blunt trauma and associated hematoceles should undergo early surgical exploration.

Documented testicular injuries command immediate repair. Inappropriately protracted expectant management promotes testicular infection, atrophy, and necrosis. Delay in repair may herald the loss of spermatogenesis and hormonal functions.

Proper operative management is adequate debridement of necrotic or devitalized tissue, copious irrigation, meticulous attention to hemostasis, and closure of the tunica albuginea. A small, dependently placed drain and broad-spectrum antibiotic coverage are also indicated.

Injury to the vas deferens or epididymis may be repaired using microsurgical techniques. This is usually performed as a staged procedure several months later to avoid operating in a potentially contaminated field.

Orchiectomy is rarely indicated, unless the entire testis is completely infarcted or shattered because of extensive damage sustained in the injury. Testicular injuries may be associated with significant loss of scrotal covering. Loss of scrotal skin from degloving injuries most commonly is the result of industrial or large machinery accidents and may be treated in 1 of 3 ways, as follows:

Manage bilateral or unilateral testicular amputation with microvascular reimplantation techniques to achieve successful revascularization within 8 hours. Do not place a testicular prosthesis until complete healing has occurred.

Preoperative details: Begin broad-spectrum antibiotics preoperatively and continue postoperatively; gangrenous infection is the most feared complication of scrotal trauma.

Obtain proper informed consent. Risks specific to scrotal exploration include bleeding, infection, and loss of the testicle. During the consent process, discuss the possibility of partial or total orchiectomy. Loss of one testicle should not affect sexual function, libido, or fertility, assuming the contralateral testis is functioning properly. If the injured testis is repaired and left in situ, inform the patient of the possibility that it may undergo gradual atrophy as a result of the injury. Furthermore, violation of the blood-testis barrier as a result of the inciting trauma may increase the patient's risk for secondary infertility.

Intraoperative details: After inducing general anesthesia, position the patient in a supine fashion and meticulously examine the entire genital area. Examination under anesthesia may reveal findings that could not be ascertained earlier when the patient could not tolerate the genital examination.

Prepare the scrotum with povidone-iodine solution, and cover it with sterile draping. Incise the affected hemiscrotum transversely. Carry the incision down to the tunica vaginalis; incising the tunica vaginalis exposes the testis.

Evacuate blood (hematocele) and fluid. Deliver the testis onto the operative site. Copiously irrigate the testis, the spermatic cord, and the tunica vaginalis with normal saline, and remove any foreign bodies.

Examine the testis for spermatic cord injury or injury to the testis proper.

If vascular injury is considered, wrap the testis with warm sodium chloride gauze to improve blood flow. Sharply incise the tunica albuginea to assess the viability of the testis. Brisk red bleeding signifies adequate blood flow to the testis. Dark black secretion indicates testicular infarction. Testicular infarction suggests that the vascular pedicle has sustained significant injury and that the testis is no longer viable. Testicular infarction mandates orchiectomy.

If extrusion of testicular contents has occurred, remove contaminated seminiferous tubules. Sharp debridement of the seminiferous tubules involves resecting as little of the tubules as possible. Close the tunica albuginea with a running, fine, absorbable suture. Leave the tunica vaginalis open, and consider placing a small Penrose drain in situ, away from the closure site. The decision to leave a drain must be made on a case-by-case basis because the drain itself may become a source of retrograde wound infection. Close the dartos layer and then the scrotal skin using absorbable sutures.

Postoperative details: Continue intravenous antibiotics until patient discharge. When draining ceases, remove the Penrose. Drainage usually becomes minimal within the first 24 hours, and the Penrose may be removed the day after surgery. If the drainage is persistent, discharge the patient home with the drain in place.

If associated perineal or penile injury has been sustained, leaving an indwelling catheter is advisable to prevent soilage of the operative site by urine. Discharge the patient home with oral antibiotics and pain medications. Recommend scrotal support, ice packs to the groin area, and bed rest.

Follow-up care: Instruct the patient to return for a follow-up visit in 1 week. If drain removal is necessary, instruct the patient to return for a follow-up visit in 24 hours.

Inspect the scrotal area for incision integrity and the presence of infection. Expect the scrotum to be somewhat enlarged and edematous from postsurgical edema and hematoma. This swelling and ecchymosis gradually subside over the next 4 weeks.

The final office visit usually occurs in 1 month.

Complications associated with untreated testicular injuries are significant and include the following:

Complications associated with scrotal exploration and testicular salvage include the following:

Progressive testicular atrophy may occur in spite of a successful repair. Testicular atrophy is most likely the result of the original testicular trauma rather than efforts to salvage the testis.

Traumatic testicular injuries are relatively uncommon. When present, they are most often caused by blunt trauma. History, physical examination, and scrotal ultrasound with Doppler studies are important in diagnosing and staging these injuries.

Surgically explore all penetrating injuries and many blunt injuries because this has proven to increase testicular salvage rates and decrease morbidity. Early surgical intervention leads to higher salvage rates, shorter hospitalizations, and more rapid recuperation.