Scrotal Trauma Treatment & Management
- Author: Robert A Mevorach, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS more...
The following two specific scenarios warrant initiation of antibiotics prior to return of culture findings:
Partial loss of the scrotum is managed by debridement, excision of any islands of remnant full-thickness scrotal wall, and primary closure with absorbable sutures. The vascularity of the dartos layer and its significant compliance and elasticity allow scrotal flaps to be used to cover substantial areas of loss.
Complete scrotal loss requires skin grafting. Split-thickness grafting (0.008-0.014 in) that is meshed to allow fluid to drain is ideal for scrotal coverage because it does not result in hair growth. Testicles should be pexed together and dependently to minimize motion and maximize graft take. Although thigh pouches may be necessary with infected wounds until they are managed adequately to allow grafting, acute trauma without infection can be managed simply with wet-to-dry dressings until the patient is available for definitive graft placement.
This injury rarely results in scrotal necrosis, and surgical management is based upon testicular integrity. When explored emergently, salvage of a ruptured testis through debridement and primary closure of the tunica albuginea occurs in 80% of cases. Epididymal avulsion or rupture often requires epididymectomy with surgical attention to preserving the internal spermatic artery because the vasal artery is obligated to ligation. Testis torsion as a result of minor trauma should be managed by orchidopexy.
Dislocation of the testis can occur in blunt trauma and should be approached inguinally to minimize blind manipulation of cord structures as occurs during an orchidopexy.
Massive hemorrhage after minor injuries should dictate a close evaluation of the preoperative ultrasound because testis tumors can present in this fashion. When uncertain, inguinal exploration with early securing of the cord structures is a reasonable technique.
Low-velocity missiles and stab wounds require exploration above and below any sign of injury and often necessitate a combined inguinal and scrotal approach. Bleeding is controlled with testis salvage in mind. In the case of complete vascular transection with immediate exploration, a microvascular reanastomosis can be performed with cold ischemia of over 24 hours. If the native cord vessels have been thrombosed, microreimplantation using the inferior epigastric vessels is possible, but warm ischemia beyond 30 minutes should discourage such efforts, particularly if the contralateral gonad is unharmed.
High-velocity missile injury carries a higher incidence of subsequent vascular thrombosis and increased tissue loss. Skin should be debrided to bleeding edges to limit the need for reoperation. The use of drains is mandatory as the demarcation of injury may be underestimated, and guarded optimism is warranted when discussing outcome with patients and family members.
Stabilization of the trauma patient often delays care of scrotal trauma. Wet-to-dry saline dressings, appropriate wound cultures, and tetanus prophylaxis are indicated prior to definitive therapy.
See Surgical therapy.
Immobilize the site for graft take; in cases of testis replantation for organ survival, maintain immobilization for 5 days. All manner of creative dressings have been used; however, during bedrest periods, exercise prophylaxis for deep vein thrombosis. Pneumatic compression stockings are essential during surgery and initially postoperatively. Administration of low-dose heparin and other anticoagulant agents still is under some debate.
As in all cosmetic interventions, the initial care is followed by prolonged observation to manage wound infections, seromas, and scar formation.
Infection and necrotic tissue necessitates repeat debridement if progressive on antibiotics. Crepitus signals Fournier gangrene. This synergistic infection of gram-negative and gram-positive anaerobes and aerobes requires aggressive debridement to prevent death, which occurs in 30% of patients.
Testicular atrophy may follow testicular rupture or torsion but requires no additional treatment.
Outcome is highly dependent upon the specifics of the injury and, as in all traumas affecting nonvital organ systems, often relates to the emotionally charged nature of the anatomy.
Outcome and Prognosis
Long-term success with skin grafting for scrotal injury is excellent. Only 20% of patients require significant revisions or reconstructions, and these are routinely outpatient procedures.
Testis viability is highly variable and is largely dependent on the extent of tissue devascularization. Statistical analysis is not pertinent and must be individualized.
Future and Controversies
Areas of research that eventually may impact scrotal trauma include tissue engineering and the biochemical modifiers for ischemic tissue damage.
Tissue engineering has already produced acceptable skin for grafting, but even more interesting would be a reconstruction of the scrotal wall, detrusor included, that could be grafted to a clean wound bed. This would obviate the need for mere skin coverage of the scrotum, which is never a true cosmetic success.
Modifiers of free-radical injury (eg, allopurinol) may be useful adjuncts to surgical intervention in patients who may have a borderline viability of the testis or who are considered for revascularization.
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