Closed injuries and trauma to the scrotum and testicle

In peacetime, closed injuries and trauma to the scrotum and testicle predominate, accounting for 9-13% of all injuries to the genitourinary organs. Closed injuries to the scrotum and testicle in peacetime are more common (up to 80%) than open (19.4%), spontaneous (0.5%) and dislocating injuries (testicular dislocations - 0.1%). Closed injuries and trauma to the scrotum and testicle due to thermal, radiation, chemical, electrical injuries are quite rare.

[ 1 ], [ 2 ], [ 3 ]

What causes closed injuries and trauma to the scrotum and testicle?

In scrotal trauma, its organs are damaged less frequently than the scrotum itself (in 25-50% of cases), since it is believed that at the moment of injury, a reflex contraction of the muscles that lift the testicles occurs, and the latter usually migrate from the zone of impact of the traumatic force. Closed trauma leads to rupture of the testicle in cases where a strong blow falls on the testicle located directly at the pubic bone. In some cases, a suddenly applied force can push the testicle upward towards the inguinal canal or even through it into the abdominal cavity. Such injuries are more common in traffic accidents among motorcycle drivers due to a sharp and sudden impact with a wide gas tank. Such a dislocating injury, called a testicular dislocation, is very rare. The dislocation can be unilateral or bilateral, and the dislocated testicle is most often not damaged.

A. Ya. Pytel (1941) divided closed testicular dislocations into two groups: external (subcutaneous) and internal. The former include inguinal, pubic, femoral, perineal, as well as subcutaneous dislocation of the penis, the latter include dislocations into the inguinal and femoral canals, intra-abdominal and acetabular. Inguinal and pubic dislocations of the testicle develop most often.

Scrotum and testicle trauma is recorded in all age groups, but it is most common in adolescents and men aged 15 to 40 years. 5% of patients with scrotum and testicle trauma are children under 10 years of age. The literature also describes testicular injuries in newborns with breech presentation. Closed scrotum and testicle trauma is usually an isolated injury, but if it is caused by a penetrating object, the contralateral testicle, penis and/or urethra may be involved. In trauma to the external male genitalia, most often both the scrotum and testicles are involved on both sides. Unilateral injury occurs much less frequently (1-5% of cases).

Symptoms of Scrotal and Testicular Injury

In case of closed injuries (bruises, strangulations) of the scrotum, due to its abundant vascularization and loose connective tissue, superficial hemorrhages very often form in the form of massive bruises and hemorrhagic infiltration, often spreading to the penis, perineum, inner thighs, and anterior abdominal wall.

In this case, the spilled blood accumulates in the wall of the scrotum, without penetrating deeper than the external spermatic fascia. Pain in a closed injury is usually not intense and soon gives way to a feeling of heaviness and tension in the scrotum. Due to the hemorrhage, the skin of the scrotum acquires a purple-blue, sometimes almost black color. When palpating the scrotum, moderate pain is determined, the tissues infiltrated with blood have a doughy consistency. However, through the wall of the scrotum, it is often possible to palpate the testicle, its appendage, and the spermatic cord.

Along with the scrotum, its organs can be damaged on one side, less often on both sides. In this case, closed (subcutaneous) contusions and ruptures of the testicle, its appendage, spermatic cord and membranes of these organs are possible. Such injuries are accompanied by the formation of deep hemorrhages (hematomas), which are divided into extravaginal and intravaginal.

In extravaginal hemorrhages, the blood that has spilled does not penetrate deeper than the vaginal membrane of the testicle. The size of the hematoma may vary, and it usually does not have clear boundaries. In some cases, the hemorrhage is small and can be felt in a limited area of the spermatic cord, in others, hemorrhagic infiltration extends from the testicle to the external opening of the inguinal canal. Such hemorrhages occur when elements of the spermatic cord and the testicular membranes located outside the vaginal membrane are damaged. With these hemorrhages, the testicle can be felt.

Intravaginal hemorrhages (hematomas) are called traumatic hematocele. This type of hemorrhage occurs when the testicle or its vaginal membrane is damaged. When examined and palpated, such hemorrhage can be mistaken for hydrocele of the testicular membranes. A typical hematocele occurs as a result of a rupture of the testicular membranes during hydrocele. The correct history of the injury, pain during palpation, and a negative transillumination symptom are decisive in the diagnosis.

However, it is not always possible to clearly differentiate between extravaginal and intravaginal hemorrhages. Severe injuries lead to accumulation of blood in various layers of the scrotum and a combination of various hemorrhages.

Closed or subcutaneous injuries of the scrotum organs, especially the testicle and epididymis, causing severe pain, are often accompanied by vomiting, convulsions, fainting, shock. Often there is an increase in the volume of the scrotum, tension, and a non-palpable testicle. Expressed hematocele can develop even without damage to the testicle.

Testicular dislocation is often detected in patients with multiple injuries (based on abdominal CT). In case of dislocation (dislocation), the testicle is most often not damaged, but sometimes twists in the area of the spermatic cord, which is facilitated by a wide inguinal canal and false cryptorchidism. This leads to a disruption of the organ's blood supply. Twisting of the dislocated testicle is accompanied by a rupture of its protein coat. Diagnosis of testicular dislocations immediately after injury is not difficult, although in serious accidents, victims may have multiple organ damage, and the "missing" testicle may remain unnoticed. If the patient is conscious, he may complain of severe pain in the groin. During examination, an empty half of the scrotum is determined, the testicle can often be palpated in the groin area. Palpation of the displaced testicle is extremely painful.

Closed injuries of the spermatic cord are relatively rare, since the spermatic cord is quite well protected. As a rule, only a contusion of the spermatic cord is determined in case of injuries, which does not require surgical intervention. The latter is possible in case of large hematomas.

Complications of scrotal and testicular trauma

The consequence of testicular damage and subsequent traumatic orchitis and periorchitis are sclerotic and atrophic changes in the testicular parenchyma. Formation and suppuration of hematomas occur with unjustified refusal of surgery and wound drainage. Prevention of these complications consists of timely and thorough surgery and the use of antibacterial therapy.

[ 4 ], [ 5 ], [ 6 ]

Diagnosis of scrotal and testicular trauma

Despite the pronounced clinical picture, the diagnosis of closed injuries of the scrotal organs is often difficult due to concomitant injuries to the scrotum.

[ 7 ], [ 8 ], [ 9 ], [ 10 ], [ 11 ]

Instrumental diagnostics of scrotum and testicle trauma

In blunt testicular injuries, the use of ultrasound is the subject of controversial discussions, since the sensitivity and specificity data of this method are different. However, as a means of primary examination, ultrasound has its significant place, since it makes it possible to diagnose intra- and/or extratesticular hematoma, testicular rupture, sometimes even testicular concussion or a foreign body.

Some authors believe that the use of ultrasound is indicated only in cases where there is no hematocele (hydrocele is considered an indication for surgery) and the physical examination data are not informative.

To summarize, we can conclude that ultrasound is indicated if conservative treatment is to be performed, and normal ultrasound data can serve as justification for this. It should also be noted that epididymal injuries are poorly amenable to ultrasound imaging.

Information obtained using ultrasound can be supplemented by Doppler duplex tomography, which provides information on the state of testicular perfusion, as well as the ability to identify vascular damage and false aneurysms.

Ultrasound and MRI are informative for detecting subcutaneous ruptures of the testicles. CT or MRI can provide additional information in case of scrotal injuries. But sometimes even with the help of these studies it is impossible to absolutely accurately determine the nature of the damage to the scrotum and its organs and exclude damage to the testicle. In such situations, surgery is indicated - revision of the scrotum.

Differential diagnosis of scrotal and testicular trauma

Recognizing testicular dislocation immediately after injury is not difficult. Dislocation is manifested by pain at the site of the displaced testicle, its absence in the scrotum, where it was before the injury. Palpation of the displaced testicle is sharply painful. A carefully collected anamnesis helps to distinguish an old testicular dislocation from its retention or ectopia.

If the scrotum is damaged, torsion of the spermatic cord and testicle may occur, which is facilitated by a wide inguinal canal, false cryptorchidism.

[ 12 ], [ 13 ], [ 14 ], [ 15 ]

Treatment of scrotum and testicle injury

Treatment of closed scrotal injuries depends on the nature and severity of the injury.

Non-drug treatment of scrotal and testicular trauma

Bruises with the formation of superficial hemorrhages and minor hemorrhagic infiltration of the scrotum wall are treated conservatively. In the first hours after the injury, the scrotum is immobilized, which is given an elevated position by applying a suspensory or a pressure bandage. For local cooling of the damaged scrotum, an ice pack wrapped in a towel is used. Starting from the 2nd-3rd day after the injury, thermal procedures of increasing intensity are used: warming compresses, heating pads, sollux, sitz baths, paraffin applications. Abundant blood supply to the scrotum promotes rapid resorption of hemorrhages.

If there is only a hematocele without a testicular rupture, then conservative treatment is possible if the hematocele does not exceed the volume of the contralateral testicle by 3 times. However, such an approach cannot be considered as a standard, since with a large hematocele, the need for delayed (more than 3 days) surgical intervention and orchiectomy is quite high, even in the absence of a testicular rupture. Late intervention in 45-55% of cases leads to the need for orchiectomy, and the factors contributing to this are pain and infection. The opposite opinion to the above: early surgical intervention makes it possible to save the testicle in more than 90% of cases and reduce the duration of hospitalization.

Surgical treatment of scrotum and testicle trauma

In case of closed trauma of the scrotum and its organs, conservative methods of treatment have recently prevailed. At the same time, active surgical tactics are currently recognized as more preferable than the tactics of waiting. As clinical experience shows, earlier (in the first hours and days after the injury) surgical intervention is the most effective way to preserve the viability and function of testicular tissues, and contributes to the patient's speedy recovery compared to the tactics of waiting.

Indications for early, i.e. in the first hours and days after the injury, surgical treatment are: rupture of the testicle, extensive superficial hemorrhages of the body of the hemorrhagic infiltration of the scrotum; deep hemorrhages, especially with their rapid increase and combination with severe pain, nausea, vomiting, shock; closed dislocations of the testicle after an unsuccessful attempt at bloodless reduction, torsion of the spermatic cord. In favor of surgical treatment is the presence of doubts that the damage to the scrotum and its organs is more serious than a simple bruise.

Indications for surgery at later stages are long-term non-resolving hematomas of the scrotum. There are practically no contraindications to surgery for isolated closed injuries of the scrotum and its organs.

In case of severe combined trauma, scrotal surgery can be performed as a second-line procedure. Preoperative preparation is standard. Trimecaine, procaine (novocaine) blockade of the spermatic cord is indicated for severe pain and shock caused by damage to the testicle and its appendage. Standard anti-shock measures are taken at the same time. In case of extensive hemorrhages of the scrotum, the blockade is performed by infiltration of the spermatic cord within the inguinal canal with a solution of trimecaine, procaine (novocaine). In case of isolated closed injuries to the scrotum and its organs, surgical interventions can be performed under local infiltration anesthesia in combination with conduction anesthesia.

Depending on the existing damage, the following is carried out:

• removal of superficial and deep hematomas and final stopping of bleeding;
• revision of the scrotum organs, removal of clearly non-viable tissues of the testicle, its appendage, and membranes;
• application of catgut sutures to the tunica albuginea of the testicle, resection of the testicle, its removal, ependymectomy;
• lowering the testicle into the scrotum and fixing it in case of dislocation, untwisting the spermatic cord and fixing the testicle in a normal position in case of torsion of the spermatic cord:
• suturing or ligation of the vas deferens.

In case of rupture of the tunica albuginea of the testicle, the bulging parenchyma tissue is cut away from the healthy tissue and the tunica albuginea is sutured with absorbable sutures. The vaginal membrane is sutured over the testicle and a small drainage tube (0.5-0.6 cm in diameter) is installed within it, which is brought out through the lower part of the scrotum. In case of scalped wounds of the scrotum, the testicles are temporarily placed under the skin of the thigh or suprapubic area. In case of open injuries, broad-spectrum antibiotics must be prescribed.

In most cases, it is impossible to perform reconstructive surgery when the spermatic cord is damaged or the testicle is torn off. Therefore, a wait-and-see approach can be used, especially when both testicles are damaged, since the peculiarities of the blood supply to the scrotum and its organs, the development of collateral vessels in some cases can ensure the viability of the damaged testicle and its appendage when the spermatic cord is torn off. As a rule, the scrotum and its organs are torn off due to careless work with rotating mechanisms at work. In most cases, the damage to the testicles in such an injury is total and does not allow reconstructive surgery. Cases that may require microsurgery include intentional amputations of the scrotum and testicles by mentally ill people. If the testicles are intact, an attempt at their microsurgical revascularization can be made within the next few hours after the injury.

In case of testicular dislocation, if there are no other serious injuries and the testicle is not changed during palpation, the patient is given intravenous anesthesia to improve the condition and relieve pain. Using gentle massaging movements, it is necessary to try to push the testicle back into the scrotum. If this is not successful or if there is doubt about the structural integrity of the testicle, the patient must be taken to the operating room for a routine revision, during which the integrity of the testicle is restored and it is moved into the scrotum.

Thus, in case of testicular dislocation, closed reposition of the dislocated testicle is indicated first, and if it is ineffective, open revision is performed, during which orchiopexy or (if the organ is non-viable) orchiectomy is performed. It has been proven that even in case of bilateral dislocation, orchiopexy does not lead to deterioration of sperm parameters.

All operations for testicular trauma end with wound drainage and bandaging, giving the scrotum an elevated position. The most serious complication of closed injuries is gangrene of the scrotum.