Scrotal Trauma

Updated: Nov 21, 2015
  • Author: Robert A Mevorach, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
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Overview

Background

A wide variety of traumatic mechanisms have been reported to result in scrotal trauma, with a common endpoint of blunt and/or penetrating trauma to the scrotal area. In all cases but avulsion, this trauma manifests as scrotal swelling with intratesticular and scrotal hematoma and various degrees of scrotal wall ecchymosis. Immediate presentation is the standard for penetrating wounds, but blunt force trauma frequently has a delayed presentation if it is not associated with testicular dislocation or multisystem injury.

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History of the Procedure

Surgical care of scrotal trauma has evolved minimally since the early descriptions by Galen. The only significant shift in surgical care has been the use of early skin grafting (reducing the duration of thigh pouches for testicles) in association with complete avulsion injuries. The latter trend has gained universal acceptance only within the last 10 years.

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Problem

The topic of scrotal trauma includes the following three areas of discussion:

  • Scrotal injury avulsions
  • Blunt and penetrating trauma
  • Injury to scrotal contents (ie, testes, epididymis, spermatic cord contents, urethra)

Minor injuries that result in extensive scrotal pain, swelling, or ecchymosis must be considered for secondary testis torsion and managed per that algorithm (see Testicular Torsion). [1, 2] Painless hematoceles, especially in the pediatric population, can occur with abdominal injury (splenic laceration) and a persistent patent processus vaginalis (ie, indirect inguinal hernia) (see Abdominal Hernia).

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Epidemiology

Frequency

Scrotal trauma accounts for less than 1% of all traumas in the United States annually. The peak age range for this injury is 10-30 years. The right testis is injured more often than the left because of the greater possibility of trapping it against the pubis (70% higher riding).

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Etiology

Avulsions may result from the following:

  • Animal attacks
  • Motor vehicle accidents
  • Assaults (sharp or high-velocity missiles)
  • Self-mutilation
  • Machinery-related (ie, industrial, agricultural) accidents

Blunt injury may result from the following:

  • Sports
  • Motor vehicle accidents
  • Assault

Penetrating injury (low velocity) may result from the following:

  • Assaults
  • Animal attacks
  • Motor vehicle accidents
  • Self-mutilation

High-velocity penetrating injury is most often the etiology in military casualties.

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Presentation

Acute scrotal pain, swelling, bruising, and any associated skin loss from injury are the primary clinical findings. Even in isolated injuries, abdominal pain, nausea, emesis, and difficulty with voiding may occur. Embarrassment associated with the site, mechanism, or circumstance of injury often results in delayed presentation and may complicate diagnostic evaluation.

Physical examination includes a general survey, with particular attention to abdominal and pelvic injuries and areas of bruising inferior to the area caudal to the anterior superior iliac spine.

Penile examination should assess corporal integrity and should include inspection of the urethral meatus for blood that may indicate urethral injury.

Scrotal examination must document all of the following elements:

  • Location of swelling
  • Skin ecchymosis - Extent and location
  • Skin loss - Percent and integrity of remaining tunics
  • Exit and entry wounds
  • Testes/epididymides - Location, integrity, pain to palpation, and response to cremasteric reflex (stroking inner thigh)
  • Transillumination in instances without hematocele in which the testis is impalpable
  • An assessment for inguinal herniae
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Indications

Patients with trauma to the abdomen, pelvis, or lower extremity often have associated trauma to the scrotum and are managed per advanced trauma life support (ATLS) prioritization. In addition, isolated scrotal injuries, at times self-inflicted, are an indication for surgical intervention.

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Relevant Anatomy

The scrotal skin is supplied by branches of the external pudendal artery and inconsistent branches of the circumflex iliac artery. The dartos layer of muscle, which subtends the epithelial layer, is contiguous with Colles fascia and demonstrates a rich plexus of fascial perforating vessels. The dartos layer forms a septum beneath the median raphe of the scrotum that divides the sac into right and left compartments.

The testis, epididymis, and spermatic cord contents (ie, vas deferens, internal spermatic artery, veins) occupy each hemiscrotum and are contained within the tunica vaginalis. The bulbous urethra and proximal corpora cavernosa occupy a midline position deep to the septum and beneath the Buck fascia.

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Contraindications

Aside from injuries to the scrotal contents that may pose a significant source of hemorrhage, spasm within the dartos muscle layer often provides effective hemostasis for even near-total scrotal avulsion. Associated injuries set the priority for surgical intervention, and scrotal injuries may be managed in a delayed fashion (with saline dressings and general wound care) if they occur in the setting of life-threatening trauma.

Extensive skin loss (eg, burn victims) may delay grafting until more vital coverage has been addressed and remains one of the best indications for placing testes within a thigh pouch in total scrotal avulsion.

In self-inflicted injuries, cosmetic interventions should be pursued only when the patient has been stabilized both medically and from a psychiatric standpoint to ensure compliance.

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