Testicular Trauma

Testicular trauma is injury to the testis, most often blunt (about 85% of cases), from sports, assault, road collisions and falls. Penetrating injury follows gunshot, stab, bites and industrial accidents.

Blunt force can rupture the tunica albuginea, haematoma can compromise blood flow, and the cord can twist. Early repair saves the testis: salvage is about 90% when surgery is done within 72 hours, and falls to about 45 to 55% afterwards.

Pathophysiology. The testis is crushed against the pubic bone. When the tunica albuginea ruptures, seminiferous tubules extrude, and bleeding collects in the tunica vaginalis (haematocele) or in the parenchyma (haematoma).

Grades of injury:

• Grade I: contusion or haematoma.
• Grade II: subclinical laceration of the tunica albuginea.
• Grade III: laceration with under 50% parenchymal loss.
• Grade IV: major laceration with 50% or more parenchymal loss.
• Grade V: total destruction or avulsion.

Associated injuries include epididymal and cord injury, post-traumatic torsion, dislocation of the testis, urethral or penile injury, and pelvic fracture.

Pain, nausea and vomiting, scrotal swelling and bruising, and sometimes a vasovagal response. The testis is tender and enlarged, and may not be palpable because of haematocele. Penetrating wounds need inspection for the track. Check for blood at the meatus, perineal bruising and pelvic injury.

A rapidly expanding scrotum, loss of testicular contour, absent flow, or a testis lying outside the scrotum needs emergency exploration.

• Resuscitation and trauma assessment first.
• High frequency Doppler ultrasound: loss of continuity of the tunica albuginea, irregular contour, heterogeneous parenchyma, haematocele and reduced flow. Sensitivity for rupture is over 90%.
• MRI of the scrotum when ultrasound is equivocal and the patient is stable.
• Urinalysis. Retrograde urethrography when there is blood at the meatus. CT of the pelvis in major trauma.
• Haemoglobin, coagulation screen and tetanus status.

Differential diagnosis.

• Testicular torsion (including post-traumatic)
• Epididymitis
• Haematocele or haematoma alone
• Tumour with bleeding after minor trauma
• Inguinal hernia
• Spermatic cord injury

• Analgesia: paracetamol 1 g orally every 6 hours (maximum 4 g daily), ibuprofen 400 mg every 8 hours with food, and morphine 2 to 5 mg intravenously, titrated, for severe pain. Ice, scrotal elevation and support.
• Tetanus prone wounds: tetanus toxoid 0.5 mL intramuscularly if vaccination is incomplete or the last dose was over 5 years ago, and immunoglobulin 250 IU intramuscularly (500 IU if over 24 hours since injury or heavy contamination) when status is unknown or incomplete.
• Contusion or small intratesticular haematoma with intact tunica and normal flow: conservative care, with review at 48 hours and ultrasound at 2 to 4 weeks.
• Exploration within 72 hours, ideally as early as possible, for rupture, large or expanding haematocele (over about 5 cm), expanding haematoma, dislocation, penetrating injury, absent flow or doubt:
  • Evacuate clot, debride non-viable seminiferous tubules, close the tunica albuginea with running absorbable 4/0 suture, and use a tunica vaginalis flap for defects.
  • Orchidectomy only when the testis is not salvageable.
  • Dislocation: reduce manually or surgically and fix the testis.
  • Perioperative cefazolin 2 g intravenously (3 g if over 120 kg) as a single dose.
• Penetrating wounds: debride, explore for cord, urethral, penile and vascular injury, and repair. Bite wounds: amoxicillin-clavulanate 625 mg orally three times daily for 5 to 7 days, with tetanus prophylaxis and assessment for rabies exposure.
• Aftercare: scrotal support, rest for 24 to 48 hours, and no contact sport for 6 to 8 weeks. Advise a protective cup for later sport.
• Complications: atrophy, infection, chronic pain, hypogonadism and infertility, and antisperm antibodies.

Special groups. Boys have the same indications for early exploration. Sickle cell disease needs extra attention to haematoma.

Monitoring. Review at 1 to 2 weeks, ultrasound at 6 to 12 weeks, and semen analysis and testosterone at 3 to 6 months.

Referral and escalation. Urgent urology referral for suspected rupture, haematocele, penetrating wounds or absent flow. Refer to trauma teams for associated injuries.