Testicular Trauma 

Updated: Jun 26, 2017
Author: Ryan P Terlecki, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS 

Overview

Background

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.[1]

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.[2] Operative indications for blunt trauma are as follows:

  • Suspicion of rupture
  • Expanding hematomas
  • Dislocation refractory to manual reduction
  • Avulsion
  • 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.[1] 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.[3] Further investigation is needed before such an approach can be recommended in children or adults.

Problem

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.[4] One report even described testicular rupture from a paint ball injury.[5] Also, one study reported an increased incidence of testicular calcifications in extreme mountain bikers over nonbikers, suggesting repeated testicular trauma in these individuals.[6]

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 the image below).

This scrotal sonogram shows a fractured testis wit This scrotal sonogram shows a fractured testis with a disrupted tunica albuginea and testicular contents surrounded by tunica vaginalis.

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.[7] Additional dislocation routes include the following:

  • Pubic
  • Preputial
  • Acetabular
  • Canalicular
  • Penile
  • Intra-abdominal
  • Retrovesical
  • Perineal
  • Crural

Diagnosis of testicular dislocation should be followed by early treatment in the form of manual closed reduction. Surgical fixation is used 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.

Epidemiology

Frequency

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.

This scrotal sonogram shows intratesticular hemato This scrotal sonogram shows intratesticular hematoma in a fractured testis.

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[8] :

  • Lacrosse, 48.5%
  • Wrestling, 32.8%
  • Baseball, 21%
  • 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.[9]

In combat operations, wounds to the genitourinary (GU) structures have historically been less common than extremity and penetrating abdominal trauma. However, the use of improvised explosive devices (IEDs) has resulted in a significant increase in GU wounds since 2001. Studies report that 33-36% of GU injuries involved the testes.[10, 11]  

Etiology

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 US 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, none were testicular injuries.[12] 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.[13] Other causes include stab wounds, self-mutilation, animal bites (usually dog), and emasculation.

Degloving testicular injuries most commonly result from accidents incurred while operating heavy machinery (eg, industrial or farming accidents).

Pathophysiology

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.

This scrotal sonogram shows a healthy testis. This scrotal sonogram shows 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 from 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.

Presentation

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.[14]

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

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 that has been shown to allow 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, assess the integrity of the testis, and 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.

Relevant Anatomy

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, arising 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.

Contraindications

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.

 

Workup

Laboratory Studies

Obtain a urinalysis to rule out urinary tract infection or epididymo-orchitis.

Imaging Studies

Scrotal ultrasonography with Doppler studies (performed by an experienced ultrasonographer or radiologist) is valuable for diagnosing and staging testicular injuries. A normal parenchymal echo pattern, with normal blood flow in cases of blunt trauma, can safely exclude significant injury. Acute bleeding or contusion of the testicular parenchyma typically appears as a hyperechoic area, whereas old blood appears as a hypoechoic lesion.

Acute and chronic hematoceles are observed as mixed hypoechoic and hyperechoic areas confined by the tunica vaginalis. The most specific finding for testicular rupture is a discrete fracture plane, but this is seen in only 17% of cases. Characterization seems to be further improved by the use of contrast-enhanced ultrasound, which may allow for more informed surgical decision-making.[15]

Perform Doppler studies during the scrotal ultrasonography. Doppler studies provide information on the vascular status of the testes. Blood flow to the testis indicates that the vascular pedicle is intact. Absence of flow implies that a torsion or devascularizing injury has occurred to the spermatic cord.

Other imaging studies, such as nuclear imaging or magnetic resonance imaging (MRI), have been used to obtain additional information in equivocal cases. An animal-based study by Srinivas et al demonstrated that MRI after blunt testicular trauma could assist in stratifying the extent of injury and provide information regarding prognosis.[16]

 

 

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 the following:

  • Scrotal support
  • Nonsteroidal anti-inflammatory drugs
  • Ice packs
  • 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 determine whether nonoperative management is appropriate in certain cases of testicular trauma. However, prospective validation and long-term outcome data are lacking.

Surgical Therapy

Penetrating testicular trauma (with the possible exception of a superficial skin injury) should be explored 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 small (<5 cm) nonexpanding hematoceles following blunt trauma.

Documented testicular injuries mandate 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 reported that 20% of patients with a conservatively managed testicular rupture had atrophic changes on follow-up ultrasonography and consequently underwent delayed orchiectomy.[17]

Proper operative management includes 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.[18] In bilateral testicular injury with significant reduction in viable tunica albuginea, Yap et al reported successful salvage via merging of the remaining tissue into a single midline testis.[19] 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) 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.[20]

  • 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.[21] 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.

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.

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.[22]

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.

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. 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.

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.[23]

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.[24]

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.[25]

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.

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.[18]

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.