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Testicular Trauma Treatment & Management

  • Author: Ryan P Terlecki, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
 
Updated: Oct 23, 2015
 

Medical Therapy

Institute conservative treatment for patients with minor trauma in which the testes are unequivocally spared and the scrotum has not been violated. The usual treatment consists of scrotal support, nonsteroidal anti-inflammatory medications, ice packs, and bed rest for 24-48 hours.

Scrotal support decreases scrotal mobility and the likelihood of aggravating the injury. Anti-inflammatory medications decrease scrotal edema and provide nonsedating analgesia. Ice packs applied to the groin at least every 3-4 hours decrease swelling in the acute phase.

If associated epididymitis is suggested or if urinary tract infection is present, administer appropriate antibiotic therapy.

Failure of medical management after an appropriate period of observation warrants imaging of the scrotum with ultrasonography and Doppler studies.

In the case of testicular dislocation, manual reduction has been used successfully in 15% of cases. Future elective orchiopexy should still be performed to minimize the risk of torsion.

Attempts have been made to apply injury severity scales, such as that of the American Association for the Surgery of Trauma (AAST), to dictate if nonoperative management is appropriate in certain cases of testicular trauma. However, prospective validation and long-term outcome data are lacking.

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Surgical Therapy

With the possible exception of a superficial skin injury, explore penetrating testicular trauma in the operating room. Patients with a history of blunt trauma and associated hematoceles often undergo surgical exploration for earlier resolution of pain and shorter convalescence. However, some institutions defer surgical exploration of nonexpanding hematoceles following blunt trauma if they are smaller than 5 cm.

Documented testicular injuries command immediate repair. Inappropriately protracted expectant management promotes testicular infection, atrophy, and necrosis. Delay in repair may herald the loss of spermatogenesis and hormonal functions. Lee et al (2008) reported that 20% of patients with a conservatively managed testicular rupture had atrophic changes on follow-up ultrasonography and consequently underwent delayed orchiectomy.[15]

Proper operative management is adequate debridement of necrotic or devitalized tissue, copious irrigation, meticulous attention to hemostasis, and closure of the tunica albuginea. This is true even if 50% of the parenchyma is destroyed. Conservative debridement is critical to tissue preservation.[16] Yap et al (2006) reported that, in bilateral testicular injury with significant reduction in viable tunica albuginea, salvage via merging the remaining tissue into a single midline testis was successful.[17] A small, dependently placed drain and broad-spectrum antibiotic coverage are also indicated.

Injury to the vas deferens or epididymis may be repaired using microsurgical techniques. This is usually performed as a staged procedure several months later to avoid operating in a potentially contaminated field.

Orchiectomy is rarely indicated, unless the testis is completely infarcted or shattered. Testicular injuries may be associated with significant loss of scrotal covering. Loss of scrotal skin from degloving injuries is most commonly the result of industrial or large machinery accidents and may be treated in 1 of 3 ways, as follows:

  • The preferred method is primary closure of the testis using the remaining scrotal skin. A minimum of 20% of the original scrotal skin provides adequate coverage of the scrotal contents. Adequate debridement and copious irrigation are required before attempting primary closure.
  • If the amount of remaining scrotal skin is insufficient, mobilize the testis to adjacent areas to obtain coverage. The optimal locations are subcutaneous thigh pouches, with delayed scrotal reconstruction in 4-6 weeks. The temperature of the thigh is approximately 10° lower than core body temperature, favoring spermatogenesis. Ramdas et al (2007) have reported a novel technique of temporary grafting of an avulsed testis to the forearm with successful staged microsurgical transfer to an orthotopic position at a more appropriate time. [18]
  • As a last resort, allow the testicles to remain exposed and apply daily moist-to-dry normal saline dressings until adequate granulation tissue forms. Within 1 week, follow this with a split-thickness skin graft, preferably harvested from the inner thigh.

Bilateral or unilateral testicular amputation treated within 8 hours with microvascular reimplantation techniques may allow successful revascularization. Thus, early involvement of appropriate specialists should be considered, even in the polytrauma patient.[19] Sperm extraction for cryopreservation should be considered at this time. Do not place a testicular prosthesis until complete healing has occurred. If reimplantation is not possible, the ductus deferens should be cleaned and ligated, with subsequent primary closure. It is important to note that in the case of psychotic and transsexual men, 20-25% reattempt autoemasculation following reconstruction after genital self-mutilation.

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Preoperative Details

Begin broad-spectrum antibiotics preoperatively and continue postoperatively; gangrenous infection is the most feared complication of scrotal trauma.

Obtain proper informed consent. Risks specific to scrotal exploration include bleeding, infection, and loss of the testicle. During the consent process, discuss the possibility of partial or total orchiectomy. Loss of one testicle should not affect sexual function, libido, or fertility, assuming the contralateral testis is functioning properly. If the injured testis is repaired and left in situ, inform the patient of the possibility that it may undergo gradual atrophy as a result of the injury. Furthermore, violation of the blood-testis barrier as a result of the inciting trauma may increase the patient's risk for secondary infertility.

In cases of avulsion, the testicle(s) should be wrapped in moist gauze and placed on ice, but without direct contact to the ice itself.

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Intraoperative Details

After inducing general anesthesia, position the patient in a supine fashion and meticulously examine the entire genital area. Examination under anesthesia may allow for a more complete and possibly more informative assessment.

Prepare the scrotum with povidone-iodine solution, and drape in sterile fashion. Incise the affected hemiscrotum transversely. Carry the incision down to the tunica vaginalis; incising the tunica vaginalis exposes the testis.

Evacuate any associated hematocele. Deliver the testis into the operative field. Copiously irrigate the testis, the spermatic cord, and the tunica vaginalis with normal saline, and remove any foreign bodies. Carefully inspect for spermatic cord injury or injury to the testis proper.

If vascular injury is considered, wrap the testis with warm saline-soaked gauze to improve blood flow. Sharply incise the tunica albuginea to assess the viability of the testis. Brisk red bleeding signifies adequate blood flow to the testis. Return of dark black fluid is indicative of testicular infarction. Testicular infarction suggests that the vascular pedicle has sustained significant injury and that the testis is no longer viable. In this situation, orchiectomy is mandatory. If bilateral orchiectomy is required, sperm-preserving measures (eg, microsurgical sperm extraction or milking of the ductus) must be considered.

If extrusion of testicular contents has occurred, remove contaminated seminiferous tubules. Sharp debridement of the seminiferous tubules involves resecting as little of the tubules as possible. Traditionally, tubule debridement has been carried out until the tunica albuginea can be reapproximated with minimal tension. An alternative to debridement of viable seminiferous tubules is to suture a covering of tunica vaginalis over the defect.[20] Close the tunica albuginea with a running, fine, absorbable suture. Leave the remaining tunica vaginalis open, and consider placing a small Penrose drain in situ, away from the suture line. The decision to leave a drain must be made on a case-by-case basis because the drain itself may become a source of infection. Close the dartos layer and scrotal skin using absorbable sutures.

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Postoperative Details

Continue intravenous antibiotics until patient discharge. Drainage usually becomes minimal within the first 24 hours, and the Penrose drain may be removed the day after surgery. If the drainage is persistent, discharge the patient home with the drain in place.

If associated perineal or penile injury has been sustained, leaving an indwelling catheter is advisable to prevent soilage of the operative site by urine. Discharge medications should include oral antibiotics and analgesics. Recommend scrotal support, ice packs to the groin area, and bed rest.

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Follow-up

Instruct the patient to return for a follow-up visit in 1 week. If drain removal is necessary, instruct the patient to return for a follow-up visit in 24 hours.

Inspect the scrotal area for incision integrity and the presence of infection. Expect the scrotum to be somewhat enlarged and edematous from postsurgical edema and hematoma. This swelling and ecchymosis gradually subside over the next 4 weeks.

The final office visit usually occurs in 1 month. All athletes should be educated on the need for appropriate protective equipment.

For patient education resources, see the Men's Health Center, as well as Testicular Pain.

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Complications

Complications associated with untreated testicular injuries are significant and include the following:

  • Testicular infarction
  • Testicular torsion
  • Testicular or epididymal abscess
  • Testicular necrosis
  • Testicular atrophy

Complications associated with scrotal exploration and testicular salvage include the following:

  • Bleeding
  • Infection
  • Loss of testis

Nearly all of the aforementioned complications are irreversible. However, Yoshimura et al (2002) reported restoration of spermatogenesis in a patient by orchiopexy 13 years after bilateral traumatic testicular dislocation. Although the patient was azoospermic before surgery and was found to have atrophic testicles rotated 180° intraoperatively, he was able to father a child 10 months later.[21]

Animal-based research has found that grade I unilateral blunt testicular trauma, defined as intratesticular hemorrhage with an intact tunica albuginea, significantly affects germ cell maturation bilaterally and alters the sex hormone profile. Ischemia-reperfusion of the testis, which is possible in a trauma patient, has been shown to cause germ cell–specific apoptosis and subsequent aspermatogenesis. Lysiak et al (2003) suggested that this may be due to a cytokine–stress-related kinase pathway.[22]

Progressive testicular atrophy may occur in spite of a successful repair. Testicular atrophy is most likely the result of the original testicular trauma rather than efforts to salvage the testis. Cross and colleagues (1999) performed a follow-up ultrasonographic study of unilateral testicular trauma patients. Half of the patients in that study were found to have atrophy of the injured side, defined as a reduction in volume of more than 50%, as compared with the unaffected side.[23]

Trauma-related torsion was described as early as the 19th century by Mikulicz and Gervais, and recent data suggest that trauma may account for 5%-6% of torsion cases.

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Outcome and Prognosis

Traumatic testicular injuries are relatively uncommon. When present, they are most often caused by blunt trauma. History, physical examination, and scrotal ultrasonography with Doppler studies are important in diagnosing and staging these injuries.

Surgical exploration of all testicular penetrating injuries and many blunt injuries has proven to increase testicular salvage rates and decrease morbidity. Early surgical intervention leads to higher salvage rates, shorter hospitalizations, and a more rapid return to baseline activity. Phonsombat et al (2008) found that testicular salvage rates are significantly higher with gunshot wound injuries than with stab wounds and lacerations, as gunshot wounds less commonly involve the spermatic cord.[16]

Following repair of penetrating testicular trauma caused by conventional bullet wounds, fertility results are approximately 62%. If the wound sustained was the product of high-velocity ammunition, fertility rates are much lower.

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Contributor Information and Disclosures
Author

Ryan P Terlecki, MD Director, Men's Health Clinic, Director, Fellowship in Urologic Reconstruction, Prosthetic Urology, and Infertility, Director, Medical Student Education, Associate Professor of Urology, Wake Forest Baptist Health

Ryan P Terlecki, MD is a member of the following medical societies: American Medical Association, American Urological Association, Phi Beta Kappa

Disclosure: Nothing to disclose.

Coauthor(s)

Richard A Santucci, MD, FACS Specialist-in-Chief, Department of Urology, Detroit Medical Center; Chief of Urology, Detroit Receiving Hospital; Director, The Center for Urologic Reconstruction; Clinical Professor of Urology, Michigan State University College of Medicine

Richard A Santucci, MD, FACS is a member of the following medical societies: American College of Surgeons, Societe Internationale d'Urologie (International Society of Urology), 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.

Shlomo Raz, MD Professor, Department of Surgery, Division of Urology, University of California, Los Angeles, David Geffen School of Medicine

Shlomo Raz, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Urological Association, California Medical Association

Disclosure: Nothing to disclose.

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

Gamal Mostafa Ghoniem, MD, FACS Professor and Vice Chair of Urology, Chief, Division of Female Urology, Pelvic Reconstructive Surgery, and Voiding Dysfunction, Department of Urology, University of California, Irvine, School of Medicine

Gamal Mostafa Ghoniem, MD, FACS is a member of the following medical societies: American Urogynecologic Society, International Continence Society, International Urogynaecology Association, Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction, American College of Surgeons, American Urological Association

Disclosure: Received honoraria from Astellas for speaking and teaching; Received grant/research funds from Uroplasty for none; Partner received honoraria from Allergan for speaking and teaching.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author, Jong M Choe, MD, FACS, and previous coauthor, Benjamin S Battino, MD, to the development and writing of this article.

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This scrotal sonogram shows a healthy testis.
This scrotal sonogram shows a fractured testis with a disrupted tunica albuginea and testicular contents surrounded by tunica vaginalis.
This scrotal sonogram shows intratesticular hematoma in a fractured testis.
 
 
 
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