Testicular Rupture

Testicular rupture is a disruption of the tunica albuginea (the fibrous capsule of the testis) with extrusion of seminiferous tubules. Early diagnosis is essential: surgical exploration within 72 hours (ideally within 24 hours) leads to testicular salvage in about 90 percent, compared with 45 to 55 percent when delayed.

It results from blunt scrotal trauma, in which the testis is crushed against the pubic bone or thigh. A force of at least 50 kg is needed to rupture the tunica. Causes are sports injuries, kicks, straddle injuries, motor vehicle collisions, assault, and bicycle and motorcycle accidents. Penetrating trauma (gunshot, stab wounds) can also cause it.

It accounts for about 50 percent of cases of severe blunt testicular trauma. It occurs mostly in young males aged 10 to 30, and the left and right sides are equally affected.

Other conditions associated with scrotal injuries are haematocele, testicular dislocation, traumatic epididymitis, testicular torsion (traumatic), hydrocele, and penile and urethral injury. Delayed surgery carries higher rates of infection, atrophy and orchiectomy.

• Immediate severe scrotal pain after trauma, nausea, vomiting, and occasionally syncope.
• Scrotal swelling, ecchymosis and haematoma (a large tense haematocele), with tenderness, with a testis that is not palpable or has an indistinct outline.
• Pain radiating to the groin or lower abdomen; rarely, hypotension from blood loss.
• Examination may be difficult because of pain and swelling; transillumination is negative (blood).
• Associated injuries: epididymis, spermatic cord, urethra (blood at the meatus), penis, and pelvic fracture.
• Penetrating injuries show entry and exit wounds.

• Clinical assessment: history of mechanism, examination of scrotum, penis, urethra and perineum; analgesia.
• Scrotal ultrasound with colour Doppler is the diagnostic test of choice (sensitivity about 90 to 100 percent, specificity 65 to 100 percent). Findings:
  • Loss of the normal smooth contour of the tunica albuginea.
  • Heterogeneous testicular echotexture.
  • A discrete fracture line (hypoechoic or hyperechoic line).
  • Irregular testicular contour and extrusion of tubules.
  • Haematocele (complex fluid collection).
  • Loss of or decreased intratesticular blood flow.
  • Scrotal wall thickening.
• Ultrasound should not delay surgery when the clinical suspicion is high.
• MRI is accurate (sensitivity of 100 percent, disrupted tunica albuginea seen as low signal intensity) when ultrasound is equivocal; not usually necessary.
• Urinalysis, and urethrogram if there is blood at the meatus or a suspected urethral injury; full blood count; trauma imaging if other injuries are suspected.
• Differential diagnosis: testicular contusion, haematocele without rupture, traumatic epididymitis, testicular torsion (traumatic), testicular dislocation, and scrotal wall haematoma.

Surgical exploration is the standard of care when rupture is confirmed or suspected. Operate as early as possible, preferably within 72 hours (within hours when possible).

• Pre-operative: analgesia (intravenous morphine 2 to 5 mg or paracetamol 1 g), antiemetic, antibiotic prophylaxis (cefazolin 1 to 2 g intravenously, or ciprofloxacin 400 mg), scrotal elevation and ice.
• Tetanus prophylaxis: tetanus toxoid 0.5 mL intramuscular, with tetanus immunoglobulin 250 units for contaminated wounds.
• Scrotal exploration through a median raphe or transverse scrotal incision (hemiscrotal exploration). Evacuate the haematocele. Inspect the testis, tunica vaginalis, cord and epididymis.
• Testicular salvage: debride necrotic seminiferous tubules that have extruded (without tension), achieve haemostasis, and close the tunica albuginea with a running 4-0 or 5-0 absorbable suture (polyglactin or polydioxanone).
• If the defect is large, use a tunica vaginalis flap or graft to cover it (to avoid compression), without closing under tension. Place a closed suction drain or Penrose drain in the scrotum for 24 to 48 hours, and apply a scrotal support.
• Orchiectomy: only for non-viable testis, or severe destruction beyond repair (the extent of tubule loss over 50 percent, or devascularisation).
• The contralateral testis is not routinely fixed (orchiopexy), although some surgeons perform contralateral fixation to prevent torsion.
• Penetrating (gunshot) injuries: exploration, debridement and repair of the testis, and antibiotics. Look for associated injuries. Repair vasovenous injuries (spermatic cord) when possible.
• Postoperative: scrotal support, ice, analgesia, avoid strenuous activity and sports for 4 to 6 weeks. Give antibiotic prophylaxis (cefalexin 500 mg four times daily for 3 to 5 days) if there is infection risk.
• Follow up: ultrasound at 6 weeks to 3 months for testicular size and perfusion (atrophy occurs in about 10 to 20 percent despite repair).
• Semen analysis at 3 to 6 months for fertility. Fertility is affected in some patients, with 70 to 80 percent normal, and anti-sperm antibodies may form. Check testosterone levels if both testes are damaged.
• Complications: infection and abscess, atrophy, chronic pain, hydrocele, infertility, and hypogonadism (in bilateral trauma). Counsel on protective equipment in contact sports.
• Prognosis is good with early repair, and testicular salvage rates exceed 90 percent in the first 72 hours.