Testicular Trauma

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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:

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.

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).

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:

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.

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.

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] :

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]  

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).

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.

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.

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 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.

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.

These 3 vessels collateralize and anastomose in the spermatic cord and near the epididymis.

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.

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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: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Boston Scientific; UMarvl; MicroGen Dx<br/>Received research grant from: Boston Scientific; Department of Defense.

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, International Society of Urology, American Urological Association

Disclosure: Nothing to disclose.

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.

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, American Urological Association, Association of Military Osteopathic Physicians and Surgeons, Endourological Society, Society of Laparoendoscopic Surgeons, Society of University Urologists

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Cook Medical; Olympus.

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 College of Surgeons, American Urogynecologic Society, American Urological Association, International Continence Society, International Urogynaecology Association, Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Astellas<br/>Received research grant from: Uroplasty/Cogentix, Astellas, Allergen.

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.

Testicular Trauma

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