Introduction
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.
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.
Problem
The topic of scrotal trauma includes the following 3 areas of discussion: scrotal injury avulsions, blunt and penetrating trauma, and 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). 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).
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).
Etiology
- Avulsions
- Animal attacks
- Motor vehicle accidents
- Assaults (sharp or high-velocity missiles)
- Self-mutilation
- Machinery-related (ie, industrial, agricultural) accidents
- Blunt injury
- Sports
- Motor vehicle accidents
- Assault
- Penetrating injury (low velocity)
- Assaults
- Animal attacks
- Motor vehicle accidents
- Self-mutilation
- Penetrating injury (high velocity) - Military casualties
Pathophysiology
Blunt and/or penetrating trauma to the scrotal area resulting in injury
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
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.
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.
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.
More on Scrotal Trauma |
 Overview: Scrotal Trauma |
| Workup: Scrotal Trauma |
| Treatment: Scrotal Trauma |
| Follow-up: Scrotal Trauma |
| Multimedia: Scrotal Trauma |
| References |
| Next Page » |
References
Whelan C, Stewart J, Schwartz BF. Mechanics of wound healing and importance of Vacuum Assisted Closure in urology. J Urol. May 2005;173(5):1463-70. [Medline].
Bandi G, Santucci RA. Controversies in the management of male external genitourinary trauma. J Trauma. Jun 2004;56(6):1362-70. [Medline].
Catalano O, Lobianco R, Sandomenico F, et al. Real-time, contrast-enhanced sonographic imaging in emergency radiology. Radiol Med (Torino). Nov-Dec 2004;108(5-6):454-69. [Medline].
Jankowski JT, Spirnak JP. Current recommendations for imaging in the management of urologic traumas. Urol Clin North Am. Aug 2006;33(3):365-76. [Medline].
Kerins M, Greene S, O'Connor N. A human bite to the scrotum: a case report and review of the literature. Eur J Emerg Med. Aug 2004;11(4):223-4. [Medline].
Ko SF, Ng SH, Wan YL, et al. Testicular dislocation: an uncommon and easily overlooked complication of blunt abdominal trauma. Ann Emerg Med. Mar 2004;43(3):371-5. [Medline].
Morey AF, Metro MJ, Carney KJ, et al. Consensus on genitourinary trauma: external genitalia. BJU Int. Sep 2004;94(4):507-15. [Medline].
Further Reading
Keywords
scrotal trauma, testis trauma, scrotal avulsion, blunt scrotal trauma, penetrating scrotal trauma, scrotal swelling, scrotal hematoma, scrotal wall ecchymosis, scrotal injury avulsion, scrotal injury, scrotum injury, scrotum trauma
