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Scrotal Trauma Treatment & Management

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

Medical Therapy

The following two specific scenarios warrant initiation of antibiotics prior to return of culture findings:

  • First, field-related avulsions or penetrations (eg, farming, hunting, military) must be treated with clindamycin (900 mg IV/IM q8 h) and high-dose penicillin ( nafcillin, 1-2 gm IV q4 h) to cover Clostridium perfringens and tetanus.
  • Second, treatment of animal bites should cover Streptococcus species and Pasteurella multocida. The antibiotic of choice is amoxicillin-clavulanate (500-875 mg PO bid).
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Surgical Therapy

Scrotal avulsion

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.

Blunt trauma

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.

Penetrating trauma

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.

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Preoperative Details

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.

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Intraoperative Details

See Surgical therapy.

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Postoperative Details

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.

In cases of Fournier gangrene or primary wound-closure separation, vacuum-assisted dressings have substantially enhanced healing.[4]

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Follow-up

As in all cosmetic interventions, the initial care is followed by prolonged observation to manage wound infections, seromas, and scar formation.

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Complications

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.

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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.

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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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Contributor Information and Disclosures
Author

Robert A Mevorach, MD Associate Professor, Departments of Urology and Pediatrics, University of Rochester School of Medicine

Robert A Mevorach, MD is a member of the following medical societies: American Academy of Pediatrics, American Urological Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Bradley Fields Schwartz, DO, FACS Professor of Urology, Director, Center for Laparoscopy and Endourology, Department of Surgery, Southern Illinois University School of Medicine

Bradley Fields Schwartz, DO, FACS is a member of the following medical societies: American College of Surgeons, Society of Laparoendoscopic Surgeons, Society of University Urologists, Association of Military Osteopathic Physicians and Surgeons, American Urological Association, Endourological Society

Disclosure: Nothing to disclose.

Additional Contributors

Edmund S Sabanegh, Jr, MD Chairman, Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation

Edmund S Sabanegh, Jr, MD is a member of the following medical societies: American Medical Association, American Society of Andrology, Society of Reproductive Surgeons, Society for the Study of Male Reproduction, American Society for Reproductive Medicine, American Urological Association, SWOG

Disclosure: Nothing to disclose.

References
  1. Güneş M, Umul M, Altok M, Akyüz M, İşoğlu CS, Uruç F, et al. Is it possible to distinguish testicular torsion from other causes of acute scrotum in patients who underwent scrotal exploration? A multi-center clinical trial. Cent European J Urol. 2015. 68 (2):252-6. [Medline].

  2. Dagrosa LM, McMenaman KS, Pais VM Jr. Tension Hydrocele: An Unusual Cause of Acute Scrotal Pain. Pediatr Emerg Care. 2015 Aug. 31 (8):584-5. [Medline].

  3. Mohammed WM, Davis NF, O'Connor KM, Kiely EA. Re-evaluating the role of Doppler ultrasonography in patients presenting with scrotal pain. Ir J Med Sci. 2015 Aug 7. [Medline].

  4. Whelan C, Stewart J, Schwartz BF. Mechanics of wound healing and importance of Vacuum Assisted Closure in urology. J Urol. 2005 May. 173(5):1463-70. [Medline].

  5. Bandi G, Santucci RA. Controversies in the management of male external genitourinary trauma. J Trauma. 2004 Jun. 56(6):1362-70. [Medline].

  6. Catalano O, Lobianco R, Sandomenico F, et al. Real-time, contrast-enhanced sonographic imaging in emergency radiology. Radiol Med (Torino). 2004 Nov-Dec. 108(5-6):454-69. [Medline].

  7. Jankowski JT, Spirnak JP. Current recommendations for imaging in the management of urologic traumas. Urol Clin North Am. 2006 Aug. 33(3):365-76. [Medline].

  8. 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. 2004 Aug. 11(4):223-4. [Medline].

  9. Ko SF, Ng SH, Wan YL, et al. Testicular dislocation: an uncommon and easily overlooked complication of blunt abdominal trauma. Ann Emerg Med. 2004 Mar. 43(3):371-5. [Medline].

  10. Morey AF, Metro MJ, Carney KJ, et al. Consensus on genitourinary trauma: external genitalia. BJU Int. 2004 Sep. 94(4):507-15. [Medline].

 
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Transverse scrotal ultrasound image shows left intratesticular hematoma and hematocele consistent with testis rupture. Increased testis size on left is a soft sign, as hematoma alone could result in this finding.
Longitudinal image of left testis showing discontinuity of tunica albuginea. This finding mandates scrotal exploration.
This longitudinal Doppler image shows perfused testicular tissue exuding through disrupted tunica albuginea, eliminating any doubt regarding the diagnosis of testicular rupture.
 
 
 
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