Treatment
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.
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.9
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.10 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.11 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.12
- 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. 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% will reattempt autoemasculation following reconstruction after genital self-mutilation.
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.
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. Close the tunica albuginea with a running, fine, absorbable suture. Leave the 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.
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.
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.
For excellent patient education resources, visit eMedicine's Men's Health Center. Also, see eMedicine's patient education article Testicular Pain.
Complications
Complications associated with untreated testicular injuries are significant and include the following:
- Testicular infarction
- Testicular torsion
- Testicular or epididymal abscess
- Infertility
- 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.13
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.14
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.15
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.
More on Testicular Trauma |
| Overview: Testicular Trauma |
| Workup: Testicular Trauma |
 Treatment: Testicular Trauma |
| Follow-up: Testicular Trauma |
| Multimedia: Testicular Trauma |
| References |
| « Previous Page | Next Page » |
References
Chandra RV, Dowling RJ, Ulubasoglu M, Haxhimolla H, Costello AJ. Rational approach to diagnosis and management of blunt scrotal trauma. Urology. Aug 2007;70(2):230-4. [Medline].
Buckley JC, McAninch JW. Use of ultrasonography for the diagnosis of testicular injuries in blunt scrotal trauma. J Urol. Jan 2006;175(1):175-8. [Medline].
Joudi FN, Lux MM, Sandlow JI. Testicular rupture secondary to paint ball injury. J Urol. Feb 2004;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. May 2001;219(2):427-31. [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].
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. Oct 2003;170(4 Pt 2):1528-3; discussion 1531-2. [Medline].
Cline KJ, Mata JA, Venable DD, Eastham JA. Penetrating trauma to the male external genitalia. J Trauma. Mar 1998;44(3):492-4. [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. Jun 2002;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. Jan 2008;101(2):211-5. [Medline].
Phonsombat S, Master VA, McAninch JW. Penetrating external genital trauma: a 30-year single institution experience. J Urol. Jul 2008;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. Oct 2006;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].
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. Feb 2002;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. Jul 2003;69(1):202-10. [Medline].
Cross JJ, Berman LH, Elliott PG, Irving S. Scrotal trauma: a cause of testicular atrophy. Clin Radiol. May 1999;54(5):317-20. [Medline].
Baskin LS, McAninch JW. Reconstruction of testicular rupture. In: 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. Feb 2005;58(2):404-5. [Medline].
Bromberg W, Wong C, Kurek S, Salim A. Traumatic bilateral testicular dislocation. J Trauma. May 2003;54(5):1009-11. [Medline].
Brown SL, Dinchman KH. Testicular trauma. In: Atlas of the Urologic Clinics of North America. Vol 6. Philadelphia: WB Saunders; 1998:119-25.
Cass AS. Testicular trauma. J Urol. Feb 1983;129(2):299-300. [Medline].
Cass AS, Luxenberg M. Testicular injuries. Urology. Jun 1991;37(6):528-30. [Medline].
Fournier GR, McAninch JW. Sonography in the staging of testicular trauma. In: McAninch JW, ed. Traumatic and Reconstructive Urology. Philadelphia: WB Saunders; 1996:727-32.
Hendry WF. Testicular, epididymal and vasal injuries. BJU Int. Aug 2000;86(3):344-8. [Medline].
Lrhorfi H, Manunta A, Rodriguez A, Lobel B. Trauma induced testicular torsion. J Urol. Dec 2002;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. Dec 2003;170(6 Pt 1):2311-5. [Medline].
Muttarak M, Lojanapiwat B. The painful scrotum: an ultrasonographical approach to diagnosis. Singapore Med J. Jul 2005;46(7):352-7; quiz 358. [Medline].
O'Brien MF, Collins DA, McElwain JP, Akhtar M, Thornhill JA. Traumatic retrovesical testicular dislocation. J Urol. Feb 2004;171(2 Pt 1):798. [Medline].
Sagalowsky AI, Peters PC. Genitourinary trauma. In: Walsh PC, Retik AB, eds. Campbell's Urology. 7th ed. Philadelphia: WB Saunders; 1998:3116-7.
Srinivas M, Chandrasekharam VV, Degaonkar M, Gupta DK, Jha P, Jagannathan NR. Effects of unilateral grade I testicular injury in rat. Urology. Sep 2002;60(3):548-51. [Medline].
van der Horst C, Martinez Portillo FJ, Seif C, Groth W, Jünemann KP. Male genital injury: diagnostics and treatment. BJU Int. May 2004;93(7):927-30. [Medline].
Further Reading
Keywords
testicular trauma, testicle trauma, scrotal trauma, penile injury, testicular rupture, ruptured testicle, ruptured testis, scrotal hematoma, testicular hematoma, blunt testicular trauma, penetrating testicular trauma, degloving testicular trauma, fractured testis, testicular fracture, tunica albuginea, tunica vaginalis, scrotal pain, scrotum, testicle, testicles, testis, testes, testicular dislocation, genital mutilation, spermatogenesis, penetrating testicular injury, blunt testicular injury, hematocele, epididymitis, orchiopexy, orchiotomy, orchiectomy, testicular torsion, testicular atrophy
