Scrotal Trauma Treatment & Management

Patients with trauma to the abdomen, pelvis, or lower extremity often have associated trauma to the scrotum and are managed per advanced trauma life support (ATLS) prioritization. In addition, isolated scrotal injuries, at times self-inflicted, are an indication for surgical intervention.

Aside from injuries to the scrotal contents that may pose a significant source of hemorrhage, spasm within the dartos muscle layer often provides effective hemostasis for even near-total scrotal avulsion. Associated injuries set the priority for surgical intervention, and scrotal injuries may be managed in a delayed fashion (with saline dressings and general wound care) if they occur in the setting of life-threatening trauma.

Extensive skin loss (eg, burn victims) may delay grafting until more vital coverage has been addressed and remains one of the best indications for placing testes within a thigh pouch in total scrotal avulsion.

In self-inflicted injuries, cosmetic interventions should be pursued only when the patient has been stabilized both medically and from a psychiatric standpoint to ensure compliance.

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.

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.

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).

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.

Postoperative Care

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. ^[9]

The successful use of Integra bilayer matrix wound dressing and a subsequent split-thickness skin graft for reconstruction of the anterior scrotum and coverage of the exposed testes caused by Fournier gangrene has been reported. Stable testicular coverage was achieved with closely matched skin and minimal donor-site morbidity. ^[10]

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.

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