Introduction
Background
Testicular trauma is uncommon because of its anatomic location and the mobility of testes within the scrotum. Most testicular trauma occurrences are related to sports injuries. Other causes include direct trauma, motor vehicle accidents, and straddle injuries. Patients present with an acute scrotum and history of trauma. Diagnosis is made in combination with clinical history and physical and ultrasound (US) findings. Testicular rupture is a urologic emergency, and more than 80% of ruptured testes can be saved if surgery is performed within 72 hours.
Pathophysiology
Trauma to a testis is uncommon because of its mobility and position. Trauma can be penetrating or blunt (more common). Impingement of the testis against the symphysis pubis or ischial ramus is the most common mechanism of injury resulting from blunt trauma.
Frequency
United States
More than 50% of testicular ruptures occur during sporting events. Motor vehicle accidents account for 9-17% of testicular injuries.
International
The international incidence is the same as in the US.
Mortality/Morbidity
Testicular rupture is a urologic emergency, and more than 80% of ruptured testes can be saved if surgery is performed within 72 hours.
Sex
The condition is observed only in men.
Age
The age at which testicular trauma occurs most commonly is 16-20 years; however, it can occur at any age.
Anatomy
A normal testis develops in the celomic cavity and begins to descend into the scrotum at 36 weeks, guided by the contractile cordlike structure termed the gubernaculum testis. Testicular size depends on age and stage of sexual development. Before age 12 years, testicular volume is 1-2 mL. Mean testicular volume at 16 years is 14 mL. Prepubertal testes are of low-to-medium level echogenicity.
US is the most common imaging study used to evaluate the testes. On US, a normal adult testis has medium-level echoes and measures approximately 5 X 3 X 2 cm. The tunica albuginea is the fibrous covering of the testicle. Capsular arteries (division of testicular artery) run under the tunica albuginea, forming the tunica vasculosa. Septa extend from the tunica albuginea into the testicle, dividing the testes into lobules.
The posterior surface of the tunica albuginea is reflected into the interior of the gland, forming the incomplete septum termed the mediastinum of the testis. Sonographically, this appears as an echogenic band running across the testis. Each lobule is composed of multiple seminiferous tubules that open via tubules (tubuli recti) into dilated spaces termed the rete testes within the mediastinum. These in turn communicate via efferent ductules in the epididymal head. The epididymis is composed of a head, body, and tail, the ducts of which continue as the vas deferens in the spermatic cord.
Presentation
Patients present with symptoms of an acute scrotum and history of trauma. Physical examination reveals scrotal edema and ecchymosis of the scrotal skin. The scrotum is tender to the touch, and discrete testis may be difficult to palpate because of surrounding edema and/or hematoma.
Preferred Examination
US is the imaging modality of choice. If US fails to reveal contusion, hematoma, or testicular rupture, perform surgical exploration.
Limitations of Techniques
US detects testicular contusion, hematoma, or rupture well. US is 80% specific for detecting tunica albuginea fracture.
Differential Diagnoses
Epididymitis
Testicle, Malignant Tumors
Testicle, Trauma
Testicular Torsion
Other Problems to Be Considered
Hematocele (may be secondary to extratesticular causes or testicular trauma, despite lack of definite US evidence of testicular rupture)
Testicular tumors (10-15% first present after scrotal trauma; therefore, follow intratesticular abnormalities if surgical intervention is not performed immediately)
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| References |
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References
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Further Reading
Keywords
testicular fracture, testicular rupture, testicular contusion, testicular hematoma, celomic, coelomic
