Testicular Trauma Treatment & Management

Surgical therapy is unnecessary in cases of minor trauma in which the testes are unequivocally spared and the scrotum has not been violated. 

Blunt testicular injuries can be managed either medically or surgically, depending on the clinical presentation. However, early surgical intervention for blunt trauma is associated with higher salvage rates (94% vs 79%).

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.

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

The American Urological Association recommends early scrotal exploration in all patients suspected of testicular rupture to prevent testicular loss, infection, chronic pain, infertility, and altered self-image. ^[24]

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.

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.

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. ^[25]

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. ^[17] 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. ^[26] 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. ^[27]

• 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. ^[28] 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.

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 with the ice itself.

After inducing general anesthesia, place the patient in supine position 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. ^[29]

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.

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 Foley 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.

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.