- Author: Ryan P Terlecki, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS more...
Despite the vulnerable position of the testicles, testicular trauma is relatively uncommon. The mobility of the scrotum may be one reason severe injury is rare. Given the importance of preserving fertility, traumatic injuries of the testicle deserve careful attention.
Testicular injuries can be divided into three broad categories based on the mechanism of injury: (1) blunt trauma, (2) penetrating trauma, and (3) degloving trauma. Such injuries are typically seen in males aged 15-40 years.
A thorough history and detailed physical examination are essential for an accurate diagnosis. Scrotal ultrasonography with Doppler flow evaluation is particularly helpful in determining the nature and extent of injury. This is especially true in blunt trauma cases, given the difficulty of scrotal examination and the repercussions of missing a testicular rupture. The sensitivity and specificity of ultrasonography in this situation has been reported to be 93.5% and 100%, respectively. However, in the setting of a clinically apparent hematocele, some authors question the value of a ultrasonographic examination and feel prompt exploration is more appropriate.
Penetrating testicular trauma usually requires scrotal exploration to determine the severity of testicular injury, to assess the structural integrity of the testis, and to control intrascrotal hemorrhage. If the tunica albuginea is violated, early surgical exploration, debridement, and closure of the tunica albuginea are necessary.
Blunt injuries are encountered more often than penetrating injuries and are usually unilateral, whereas penetrating injuries involve both testes in a third of cases. Most cases of blunt trauma to the testicles are minor and usually require only conservative therapy. However, in one study, Buckley and McAninch reported that 46% of patients presenting with blunt scrotal trauma underwent surgical exploration and were found to have rupture of the tunica albuginea. Operative indications for blunt trauma include suspicion of rupture, expanding hematomas, dislocation refractory to manual reduction, avulsion, and scrotal degloving.
However, a study by Chandra et al has suggested that conservative management is an option in blunt trauma patients when ultrasonography demonstrates absence of hematocele, obvious testicular fracture planes, or disruption of the tunica albuginea. In a study of nonoperative management in seven adolescent boys who presented with testicular rupture 1 to 5 days after sustaining blunt scrotal trauma, Cubillos et al reported that none of the patients required orchiectomy or developed atrophy at 6 months of follow-up. Further investigation is needed before such an approach can be recommended in children or adults.
Testicular trauma is defined as any injury sustained by the testicle. Types of injuries include blunt, penetrating, or degloving.
Blunt trauma refers to injuries sustained from objects applied with any significant force to the scrotum and testicles. This can occur with various types of activity. Examples include a kick to the groin or a baseball injury. One report even described testicular rupture from a paint ball injury. Also, one study reported an increased incidence of testicular calcifications in extreme mountain bikers over nonbikers, suggesting repeated testicular trauma in these individuals.
Penetrating trauma refers to injuries sustained from sharp objects or high-velocity missiles. Examples include gunshot and stab wounds.
Degloving injuries (or avulsion injuries) are less common. With these, scrotal skin is sheared off, for example, when a testicle becomes trapped in heavy machinery.
Testicular rupture or fractured testis refers to a rip or tear in the tunica albuginea resulting in extrusion of the testicular contents (see below).
Testicular dislocation is an uncommon and sometimes easily overlooked event that refers to a testis that has been relocated from its orthotopic position to another location secondary to blunt trauma. Indirect inguinal hernias and atrophic testicles may be predisposing factors. Most cases of testicular dislocation are the result of motorcycle crashes, and one third involve both testicles. This is related to impact with the fuel tank, and the inguinal region is the most frequent site of displacement. Additional routes include pubic, preputial, acetabular, canalicular, penile, intra-abdominal, retrovesical, perineal, and crural dislocations. Diagnosis should be followed by early treatment in the form of manual closed reduction and surgical fixation if closed reduction is unsuccessful.
Genital self-mutilation is another potential source of testicular trauma. The offending patient is often psychotic, although nonpsychotic patients practicing autoeroticism and motivated yet desperate transsexuals may find themselves requiring an urgent urologic consultation. Most cases of genital self-mutilation involve men castrating themselves. If the patients seek care promptly and the testicles are vital, reimplantation may be considered.
Testicular trauma is relatively uncommon. Blunt trauma accounts for approximately 85% of cases, and penetrating trauma accounts for 15%. As many as 80% of hematoceles (blood in the tunica vaginalis) are associated with testicular rupture. The image below depicts hematoma in testicular fracture.
In a survey of 731 male high school and college athletes, 18% reported having had a testicular injury during sports and 36.4% had observed injuries in other team members. Only 12.9% of respondents reported use of athletic cups. Prevalence rates of reported testicular injuries were as follows: lacrosse, 48.5%; wrestling, 32.8%; baseball 21%; and football, 17.8%.
Blunt testicular injuries can be managed either medically or surgically, depending on the clinical presentation. Early surgical intervention for blunt trauma is associated with higher salvage rates (94% vs 79%).
Testicular dislocation is seen in less than 0.5% of cases of abdominal trauma. One retrospective review of emergency department records found that all instances were missed initially, even with CT scanning demonstrating an empty scrotum and displaced testis. The average delay in diagnosis was 19 days.
The most common cause of blunt testicular trauma is sports injuries. For example, a study of rugby players in Australia and New South Wales from 1980 to 1993 revealed 14 players with testicular injuries, with the most unfortunate losing both testicles. However, the risk of sports-related testicular injury in American children is likely less than previously suspected. Wan et al (2003) reviewed the National Pediatric Trauma Registry for all 50 states and referenced commonly played contact sports. Of 5,439 reported sports injuries, there were no reported testicular injuries. The American Academy of Pediatrics Committee on Sports Medicine and Fitness gives an "unqualified yes" to the question of whether or not a boy with only one testicle can play sports. Protective cups may be required in some instances.
The second most common cause of testicular trauma is a kick to the groin. Less common etiologies include motor vehicle accidents, falls, and straddle injuries.
The most common cause of penetrating testicular injuries is a gunshot wound to the genital area. Other causes include stab wounds, self-mutilation, animal bites (usually dog), and emasculation.
The most common cause of degloving testicular injuries is accidents incurred while operating heavy machinery (eg, industrial or farming accidents).
The testis is enveloped by layers of white fibrous connective tissue called the tunica vaginalis and the tunica albuginea. The tunica albuginea is the visceral layer that covers the testis, and the tunica vaginalis is the parietal layer that lines the hydrocele sac. The image below depicts a healthy testis.
The tunica albuginea is the layer that is violated during a testicular rupture. Approximately 50 kg of force is required to rupture the testicle. A tear in the tunica albuginea leads to extrusion of the seminiferous tubules and allows an intratesticular hemorrhage to escape into the tunica vaginalis. This is referred to as a hematocele. Disruption of the tunica vaginalis or extension to the epididymis leads to bleeding into the scrotal wall, resulting in a scrotal hematoma.
Two factors protect the testes minor external trauma. First, a thin layer of serous fluid (ie, physiologic hydrocele) separates the tunica albuginea from the tunica vaginalis and allows the testis to slide freely within the scrotal sac. Second, the testes are suspended within the scrotum by the spermatic cord, allowing them to move freely within the genital area. In cases of penetrating trauma or severe blunt trauma, these protective features are insufficient to prevent injury to the testis proper.
Patients with testicular trauma typically present to the emergency department with a straightforward history of injury (eg, sports injury, kick to the groin, gunshot wound) soon after the event occurs.
Patients who have sustained severe blunt trauma usually exhibit symptoms of extreme scrotal pain, frequently associated with nausea and vomiting. When evaluating a patient with a clinical history of only minor trauma, do not overlook the possibility of testicular torsion or epididymitis. Physical examination often reveals a swollen, severely tender testicle with a visible hematoma. Scrotal or perineal ecchymosis may be present. Bilateral testicular examination and perineal examination should always be performed to rule out associated pathologies. However, because of the severe pain the patient experiences, performing a thorough examination is often difficult, and radiologic evaluation or surgical exploration may be required.
Most blunt testicular injuries are unilateral and isolated (ie, without other associated injuries). The absence of scrotal swelling and hematoma may indicate a relatively benign injury. Additional imaging tests or scrotal exploration is required if testicular rupture is suggested because of clinical findings or when a patient experiences pain out of proportion to the physical examination findings. Blunt trauma to the testes may manifest as a hematocele or a ruptured testis. The complete absence of pain in a patient with scrotal swelling and hematoma raises the possibility of testicular infarction or spermatic cord torsion.
For penetrating injuries, determine the entrance and exit sites of the wound. Up to 75% of men with penetrating injuries to the genitalia demonstrate additional associated injuries. Carefully examine the contralateral hemiscrotum and the perineal area. Rule out injuries to the contralateral testicle, bulbar urethra, and rectum. Also evaluate the femoral vessels, as major vascular insult in the thigh region is the most commonly reported associated injury. Although uncommon, vascular injury subsequently leading to an ischemic testis has been reported.
Using universal precautions when evaluating these injuries is important. One review of 40 men with penetrating trauma revealed that 38% tested positive for hepatitis B, hepatitis C, or both. Furthermore, according to Cline et al in 1998, 60% of these patients were legally intoxicated at the time of injury.
Screening urinalysis is an important adjunct to the physical examination to rule out urinary tract infection or epididymo-orchitis.
Scrotal ultrasonography with Doppler studies is valuable for diagnosing and staging testicular injuries. The presence of a disrupted tunica albuginea is pathognomonic for testicular rupture. A scrotal hematoma often has associated scrotal skin thickening.
Perform Doppler studies during the scrotal ultrasonography because they provide information on the vascular status of the testes. Blood flow to the testis indicates that the vascular pedicle is intact. An absence of flow implies that a torsion or devascularizing injury has occurred to the spermatic cord.
Other imaging studies, such as nuclear imaging or MRI, may be used to obtain additional information in equivocal cases. However, the definitive diagnosis of testicular rupture is made in the operating room, and time is a factor in testicular preservation. Scrotal exploration is truly the best diagnostic tool for any equivocal testicular trauma.
Indications for scrotal exploration include the following:
Uncertainty in diagnosis after appropriate clinical and radiographic evaluations
Clinical findings consistent with testicular injury
Disruption of the tunica albuginea
Absence of blood flow on sonograms with Doppler studies
Clinical hematoceles that are expanding or of considerable size (eg, ≥5 cm) should be explored. Collections of smaller size are also often explored, because it has been shown that such practice allows for more optimal pain control and shorter hospital stays.
If the testis is fractured, testicular debridement and surgical closure of the tunica albuginea are necessary.
Penetrating testicular trauma usually requires exploration to ascertain the degree of injury, to assess the integrity of the testis, and to identify and control intratesticular hemorrhage.
Degloving injuries are another indication for operative evaluation and often require debridement. Skin closure may or may not be possible in the acute setting.
The absence of blood flow on ultrasonography may represent spermatic cord torsion, avulsion, or infarction.
To properly evaluate and treat testicular injuries, a thorough knowledge of scrotal and testicular anatomy is required.
The outermost layer of the scrotum is the scrotal skin. The next most superficial layer is the dartos muscle/fascia, which is contiguous with the Scarpa fascia of the abdomen, the Colles fascia of the perineum, and the dartos fascia of the penis. The dartos layer is followed by the external, middle, and internal spermatic fasciae, which are contiguous with the external oblique, internal oblique, and transversalis fasciae, respectively. The middle spermatic fascia forms the cremasteric muscle of the spermatic cord. In most cases, the testicle is tethered to the scrotum inferiorly by the gubernaculum.
The next layer is the tunica vaginalis, which is composed of an outer (parietal) layer and an inner (visceral) layer. The tunica albuginea is a tough, white, fibrous, capsulelike layer surrounding the seminiferous tubules of the testis. The visceral layer of the tunica vaginalis adheres to this layer.
Immediately beneath the tunica albuginea is the final layer, the tunica vascularis, which contains the arterial blood supply to the seminiferous tubules. The tunica albuginea extends inward posteriorly to form the mediastinum testis, the point where vessels and ducts traverse the testicular capsule. The epididymis attaches posterolaterally.
Blood supply to the testes is threefold.
The testicular artery is the principal artery, rising from the aorta, just below the renal artery.
The cremasteric artery is a branch of the inferior epigastric artery.
The deferential artery is a branch of the superior vesical artery.
These 3 vessels collateralize and anastomose in the spermatic cord and near the epididymis.
Surgical therapy is unnecessary in cases of minor trauma in which the testes are unequivocally spared and the scrotum has not been violated.
Documented testicular injuries necessitate immediate repair. Inappropriately protracted expectant management promotes testicular infection, atrophy, and necrosis. Delay in repair may herald the loss of spermatogenesis and hormonal functions.
Chandra RV, Dowling RJ, Ulubasoglu M, Haxhimolla H, Costello AJ. Rational approach to diagnosis and management of blunt scrotal trauma. Urology. 2007 Aug. 70(2):230-4. [Medline].
Buckley JC, McAninch JW. Use of ultrasonography for the diagnosis of testicular injuries in blunt scrotal trauma. J Urol. 2006 Jan. 175(1):175-8. [Medline].
Cubillos J, Reda EF, Gitlin J, Zelkovic P, Palmer LS. A conservative approach to testicular rupture in adolescent boys. J Urol. 2010 Oct. 184(4 Suppl):1733-8. [Medline].
Freehill MT, Gorbachinsky I, Lavender JD, Davis RL 3rd, Mannava S. Presumed testicular rupture during a college baseball game: a case report and review of the literature for on-field recognition and management. Sports Health. 2015 Mar. 7 (2):177-80. [Medline].
Joudi FN, Lux MM, Sandlow JI. Testicular rupture secondary to paint ball injury. J Urol. 2004 Feb. 171(2 Pt 1):797. [Medline].
Frauscher F, Klauser A, Stenzl A, Helweg G, Amort B, zur Nedden D. US findings in the scrotum of extreme mountain bikers. Radiology. 2001 May. 219(2):427-31. [Medline].
Jecmenica DS, Alempijevic DM, Pavlekic S, Aleksandric BV. Traumatic testicular displacement in motorcycle drivers. J Forensic Sci. 2011 Mar. 56(2):541-3. [Medline].
Bieniek JM, Sumfest JM. Sports-related testicular injuries and the use of protective equipment among young male athletes. Urology. 2014 Dec. 84 (6):1485-9. [Medline].
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].
Wan J, Corvino TF, Greenfield SP, DiScala C. Kidney and testicle injuries in team and individual sports: data from the national pediatric trauma registry. J Urol. 2003 Oct. 170(4 Pt 2):1528-3; discussion 1531-2. [Medline].
Bjurlin MA, Kim DY, Zhao LC, Palmer CJ, Cohn MR, Vidal PP, et al. Clinical characteristics and surgical outcomes of penetrating external genital injuries. J Trauma Acute Care Surg. 2013 Mar. 74 (3):839-44. [Medline].
Cline KJ, Mata JA, Venable DD, Eastham JA. Penetrating trauma to the male external genitalia. J Trauma. 1998 Mar. 44(3):492-4. [Medline].
Valentino M, Bertolotto M, Derchi L, Bertaccini A, Pavlica P, Martorana G, et al. Role of contrast enhanced ultrasound in acute scrotal diseases. Eur Radiol. 2011 Jun 2. [Medline].
Srinivas M, Degaonkar M, Chandrasekharam VV, Gupta DK, Hemal AK, Shariff A. Potential of MRI and 31P MRS in the evaluation of experimental testicular trauma. Urology. 2002 Jun. 59(6):969-72. [Medline].
Lee SH, Bak CW, Choi MH, Lee HS, Lee MS, Yoon SJ. Trauma to male genital organs: a 10-year review of 156 patients, including 118 treated by surgery. BJU Int. 2008 Jan. 101(2):211-5. [Medline].
Phonsombat S, Master VA, McAninch JW. Penetrating external genital trauma: a 30-year single institution experience. J Urol. 2008 Jul. 180(1):192-5; discussion 195-6. [Medline].
Yap SA, DeLair SM, Ellison LM. Novel technique for testicular salvage after combat-related genitourinary injury. Urology. 2006 Oct. 68(4):890.e11-2. [Medline].
Ramdas S, Thomas A, Arun Kumar S. Temporary ectopic testicular replantation, refabrication and orthotopic transfer. J Plast Reconstr Aesthet Surg. 2007. 60(7):700-3. [Medline].
A Ward M, L Burgess P, H Williams D, E Herrforth C, L Bentz M, D Faucher L. Threatened fertility and gonadal function after a polytraumatic, life-threatening injury. J Emerg Trauma Shock. 2010 Apr. 3(2):199-203. [Medline]. [Full Text].
Molokwu CN, Doull RI, Townell NH. A novel technique for repair of testicular rupture after blunt trauma. Urology. 2010 Oct. 76(4):1002-3. [Medline].
Yoshimura K, Okubo K, Ichioka K, Terada N, Matsuta Y, Arai Y. Restoration of spermatogenesis by orchiopexy 13 years after bilateral traumatic testicular dislocation. J Urol. 2002 Feb. 167(2 Pt 1):649-50. [Medline].
Lysiak JJ, Nguyen QA, Kirby JL, Turner TT. Ischemia-reperfusion of the murine testis stimulates the expression of proinflammatory cytokines and activation of c-jun N-terminal kinase in a pathway to E-selectin expression. Biol Reprod. 2003 Jul. 69(1):202-10. [Medline].
Cross JJ, Berman LH, Elliott PG, Irving S. Scrotal trauma: a cause of testicular atrophy. Clin Radiol. 1999 May. 54(5):317-20. [Medline].
Baskin LS, McAninch JW. Reconstruction of testicular rupture. McAninch JW, ed. Traumatic and Reconstructive Urology. Philadelphia: WB Saunders; 1996. 733-6.
Bedir S, Yildirim I, Sümer F, Tahmaz L, Dayanç M, Peker AF. Testicular dislocation as a delayed presentation of scrotal trauma. J Trauma. 2005 Feb. 58(2):404-5. [Medline].
Bromberg W, Wong C, Kurek S, Salim A. Traumatic bilateral testicular dislocation. J Trauma. 2003 May. 54(5):1009-11. [Medline].
Cass AS, Luxenberg M. Testicular injuries. Urology. 1991 Jun. 37(6):528-30. [Medline].
Hendry WF. Testicular, epididymal and vasal injuries. BJU Int. 2000 Aug. 86(3):344-8. [Medline].
Lrhorfi H, Manunta A, Rodriguez A, Lobel B. Trauma induced testicular torsion. J Urol. 2002 Dec. 168(6):2548. [Medline].
Mohr AM, Pham AM, Lavery RF, Sifri Z, Bargman V, Livingston DH. Management of trauma to the male external genitalia: the usefulness of American Association for the Surgery of Trauma organ injury scales. J Urol. 2003 Dec. 170(6 Pt 1):2311-5. [Medline].
O'Brien MF, Collins DA, McElwain JP, Akhtar M, Thornhill JA. Traumatic retrovesical testicular dislocation. J Urol. 2004 Feb. 171(2 Pt 1):798. [Medline].
van der Horst C, Martinez Portillo FJ, Seif C, Groth W, Jünemann KP. Male genital injury: diagnostics and treatment. BJU Int. 2004 May. 93(7):927-30. [Medline].