Adam J. Singer, MD; Virenda H. Sanghvi, MD

Infect Urol 16(4):106-108, 2003. © 2003 Cliggott Publishing, Division of SCP Communications

Posted 12/15/2003

A healthy 22-year-old man presented to the emergency department 30 minutes following acute scrotal trauma. He had sustained a straddle injury to the scrotum from falling through the rungs of a ladder. His physical examination demonstrated a tense hematoma in the right hemiscrotum that prevented palpation of the intrascrotal contents on that side. The remainder of his examination was unremarkable. His complete blood cell count, serum electrolyte levels, and urinalysis results were within normal limits. Scrotal ultrasonography revealed an intra scrotal hematoma surrounding a fractured right testicle with extrusion of testicular parenchyma (Figure). Cefazolin, 1 g, was administered intravenously before surgery.

Figure 1. Scrotal ultrasonography shows a fractured right testicle demonstrating discontinuity of the tunica albuginea and extrusion of testicular parenchyma (curved arrow). Mixed echogenicity from an intratesticular hemorrhage (straight arrow) and a scrotal hematoma (arrowheads) are also visible.

Right transscrotal exploration confirmed 2 testicular lacerations: a 4-cm horizontal mid anterior laceration and a noncontiguous 1.5-cm vertical laceration 1 cm below it. The hematoma was evacuated, and both lacerations were repaired with 0000 chromic sutures. A Penrose drain was placed at the conclusion of surgery and removed 2 days later. Cephalexin, 250 mg PO, was prescribed for 7 days following surgery.

Which of the following statements is correct?

Straddle injuries are the leading causes of testicular fractures. Ultrasonography accurately diagnoses all cases of testicular fracture. Testicular fractures are best treated by nonsurgical conservative therapies. Early surgical exploration of a fractured testicle is associated with higher rates of testicular salvage.

Straddle injuries are the leading causes of testicular fractures is not correct. In a review of the literature, Schuster^[1] found that falls, straddle injuries, and a variety of other miscellaneous causes were the least common sources of testicular fractures. More than half were caused by sporting injuries and kicks to the groin. Motor vehicle and motorcycle accidents were implicated in 9% to 17% of cases. Patients ranged in age from 8 to 71 years (average, 25.1 years), with the majority of trauma incidents occurring in those between 16 and 20 years. Fractures were transverse (58%), longitudinal (21%), multiple (8%), and stellate (8%), when reported. An internal hematoma and avulsion of a pole each occurred 6.5% of the time.

In another review, Brown and Dinchman^[2] found no specific symptoms or signs that separated testicular rupture from other acute scrotal emergencies and stressed the importance of clinical correlation. Although most patients had acute severe pain often associated with nausea and vomiting, physical findings were nonspecific, including exquisite tenderness with a variable amount of scrotal swelling, hematoma, and ecchymosis.

Fournier and coworkers^[3] also found that the amount of scrotal swelling and ecchymosis was highly variable, depending on the location of testicular fracture, associated rupture of intrascrotal vessels or subalbugineal arterioles, and the ability of contiguous structures such as the tunica vaginalis and epididymis to tamponade bleeding and pa renchymal extrusion. In their experience, the differential diagnosis for testicular fracture included simple hematocele without testicular rupture, torsion of the testis, torsed appendix testis, testis tumor, epididymitis, reactive hydrocele, hematoma of the epididymis, and hematoma of the spermatic cord.

Ultrasonography accurately diagnoses all cases of testicular fracture is not correct. In reviewing the literature, Corrales and associates^[4] found that ultrasonography had a sensitivity, specificity, positive predictive value, and negative predictive value of 64%, 75%, 77.8%, and 60%, respectively, for the diagnosis of testicular rupture. These investigators censored a study by Anderson and coworkers,^[5] who reported no false diagnoses in 10 patients because 7 were not surgically explored and could have represented false-negative diagnoses. Although disruption of the tunica albuginea of the testicle and extrusion of testicular parenchyma with or without hematocele formation would be expected to be found on ultrasonography, Horstman^[6] reported that direct evidence of testicular rupture was often not seen sonographically and that a discrete fracture plane was only observed 17% of the time.

In light of these and other reports, most investigators recommended surgical exploration whenever disruption was suspected based on history and physical examination, because false-negative sonographic readings occurred in 31% to 50% of the cases in some series.^[4]

Testicular fractures are best treated by nonsurgical conservative therapies is not correct. Literature reviews have consistently demonstrated that nonsurgical conservative therapies, such as heat, ice packs, elevation, anti-inflammatory agents, and antibiotic medications, were not beneficial and led to a higher rate of complications.^[1,7] Regardless of the cause, reports showed that testicular fracture was best managed by immediate surgery.^[7]

Early surgical exploration of a fractured testicle is associated with higher rates of testicular salvage is correct. The likelihood of testicular salvage is approximately 90% if surgery is done within 72 hours but drops to 45% if surgery is performed after this time.^[3,6] In addition, surgery has been shown to control bleeding more effectively, reduce infection rates, decrease the potential for testicular atrophy or necrosis, and shorten convalescence, compared with nonsurgical conservative therapies.^[1,3,4,7] Al though immediate surgical exploration is ideal, Jordan^[8] reported a patient who had surgery 3 weeks after fracturing his testicle and had prompt resolution of swelling and symptoms.

Exploration should be done through an inguinal incision if a testicular tumor is suspected, and radical orchiectomy should be performed if a malignant testicular tumor is found.^[2,7] Otherwise, a transscrotal approach is recommended for exploration and repair.^[2,7] In the absence of malignancy, the mainstays of surgical management include hematoma evacuation, debridement of nonviable testicular tissue, closure of the tunica albuginea to salvage the testicle, and temporary external drainage of the scrotal cavity for 2 to 4 days.^[2,4,7,8] In cases of penetrating trauma with contamination, open dressing of the scrotal laceration and delayed skin closure should be considered.^[8] Although some have recommended absorbable sutures to repair the tunica albuginea,^[2,4,7] others have recommended small monofilament permanent sutures.^[8]

The use of prophylactic antibiotics is also controversial. Most agree that prophylactic antibiotics should be administered for fractured testicles from penetrating trauma and/or in the presence of infection; however, opinion is divided on whether to use prophylactic antibiotics for testicular fractures that result from blunt nonpenetrating trauma in the absence of infection.^[3,7]

As demonstrated in the present case report, it is our preference to repair fractured testicles with absorbable suture and use prophylactic antibiotics liberally, because testicular repair and scrotal drainage expose the intrascrotal contents to potential infection from skin cross-contamination during the recovery period.

Outcome

One year later, the patient is asymptomatic, and his right testicle has not atrophied.

1. Schuster G. Traumatic rupture of the testicle and a review of the literature. J Urol. 1982;127:1194-1196.
2. Brown SL, Dinchman KH. Testicular trauma. Atlas Urol Clin North Am. 1998;6:119-125.
3. Fournier GR Jr, Laing FC, McAninch JW. Scrotal ultrasonography and the management of testicular trauma. Urol Clin North Am. 1989;16:377-385.
4. Corrales JG, Corbel L, Cipolla B, et al. Accuracy of ultrasound diagnosis after blunt testicular trauma. J Urol. 1993;150:1834-1836.
5. Anderson KA, McAninch JW, Jeffrey RB, Laing FC. Ultra so nography for the diagnosis and staging of blunt scrotal trauma. J Urol. 1983;130:933-935.
6. Horstman WG. Scrotal imaging. Urol Clin North Am. 1997;24: 653-671.
7. Haas CA, Brown SL, Spirnak JP. Penile fracture and testicular rupture. World J Urol. 1999;17:101-106.
8. Jordan GH. Lower genitourinary tract trauma and male external genital trauma (nonpenetrating injuries, penetrating injuries, and avulsion injuries). Part 2. AUA Update Series. 2000;19:82-87.