A wide variety of mechanisms have been reported to result in scrotal trauma, with a common endpoint of blunt and/or penetrating trauma to the scrotal area. In all cases but avulsion, this trauma manifests as scrotal swelling with intratesticular and scrotal hematoma and various degrees of scrotal wall ecchymosis. Immediate presentation is the standard for penetrating wounds, but blunt force trauma frequently has a delayed presentation if it is not associated with testicular dislocation or multisystem injury.
The topic of scrotal trauma includes the following three areas of discussion:
Minor injuries that result in extensive scrotal pain, swelling, or ecchymosis must be considered for secondary testis torsion and managed per that algorithm (see Testicular Torsion).[1, 2] Painless hematoceles, especially in the pediatric population, can occur with abdominal injury (splenic laceration) and a persistent patent processus vaginalis (ie, indirect inguinal hernia) (see Abdominal Hernia).
Surgical care of scrotal trauma has evolved minimally since the early descriptions by Galen. The only significant shift in surgical care has been the use of early skin grafting (reducing the duration of thigh pouches for testicles) in patients with complete avulsion injuries. The latter trend has gained universal acceptance only within the last decade.
Areas of research that eventually may impact scrotal trauma include tissue engineering and the biochemical modifiers for ischemic tissue damage.
Tissue engineering has already produced acceptable skin for grafting, but even more interesting would be a reconstruction of the scrotal wall, detrusor included, that could be grafted to a clean wound bed. This would eliminate the need for mere skin coverage of the scrotum, which is never a true cosmetic success.
The scrotal skin is supplied by branches of the external pudendal artery and inconsistent branches of the circumflex iliac artery. The dartos layer of muscle, which subtends the epithelial layer, is contiguous with Colles fascia and demonstrates a rich plexus of fascial perforating vessels. The dartos layer forms a septum beneath the median raphe of the scrotum that divides the sac into right and left compartments.
The testis, epididymis, and spermatic cord contents (ie, vas deferens, internal spermatic artery, veins) occupy each hemiscrotum and are contained within the tunica vaginalis. The bulbous urethra and proximal corpora cavernosa occupy a midline position deep to the septum and beneath the Buck fascia.
Scrotal trauma accounts for less than 1% of all traumas in the United States annually. The peak age range for this injury is 10-30 years. The right testis is injured more often than the left because of the greater possibility of trapping it against the pubis (70% higher riding).
Historically, wounds to the genitourinary (GU) structures have been less common than extremity and penetrating abdominal trauma in combat operations. The use of improvised explosive devices (IEDs) has resulted in a significant increase in GU wounds since 2001. Studies report that 39-55% of GU injuries involved the scrotum.[3, 4]
Pubic hair grooming–related injuries, including lacerations and burns, have been reported, with the scrotum as the most common site for injury (67.2%). In a cross-sectional study of US adults, 66.5% of men reported a history of pubic hair grooming, with 23.7% having sustained an injury. Although most injuries reported were minor, 1.4% required medical attention. Men who removed all their pubic hair had an increased risk for grooming injury.[5]
Long-term success with skin grafting for scrotal injury is excellent. Only 20% of patients require significant revisions or reconstructions, and these are routinely outpatient procedures.
Testis viability is highly variable and depends largely on the extent of tissue devascularization. Statistical analysis is not pertinent and must be individualized.
Acute scrotal pain, swelling, bruising, and any associated skin loss from injury are the primary clinical findings. Even in isolated injuries, abdominal pain, nausea, emesis, and difficulty with voiding may occur. Embarrassment associated with the site, mechanism, or circumstance of injury often results in delayed presentation and may complicate diagnostic evaluation.
Physical examination includes a general survey, with particular attention to abdominal and pelvic injuries and areas of bruising inferior to the area caudal to the anterior superior iliac spine.
Penile examination should assess corporal integrity and should include inspection of the urethral meatus for blood that may indicate urethral injury.
Scrotal examination must document all of the following elements:
Location of swelling
Skin ecchymosis - Extent and location
Skin loss - Percent and integrity of remaining tunics
Exit and entry wounds
Testes/epididymides - Location, integrity, pain to palpation, and response to cremasteric reflex (stroking inner thigh)
Transillumination in instances without hematocele in which the testis is impalpable
Perform wound cultures for aerobic, anaerobic, and fungal organisms from all avulsing or penetrating injuries. Cultures allow broad-spectrum coverage (which is based partially upon mechanism or geographic site of injury) to begin, while isolates allow directed treatment for completion of care.
A Gram stain of chronic wounds may allow directed therapy when an accurate history cannot be obtained to aid in appropriate coverage.
Urinalysis to assess for hematuria may be the only indication of urinary tract and possible urethral injury when symptoms are absent or history is not attainable.
Urine culture may aid in therapy, particularly with penetrating and contaminated wounds, even if drainage is not present.
Color Doppler ultrasound imaging, with or without contrast[6, 7]
Isolated blunt injuries are managed best with a thorough knowledge of the internal anatomy and testicular perfusion. Hematomas, intratesticular and extratesticular, are expected.
In one series, scrotal ultrasound sensitivity and specificity in penetrating scrotal trauma was 100% and 84.6%, respectively.[8]
A completely intact tunica albuginea is the only finding that can preclude scrotal exploration in the face of abnormal physical examination findings and evidence of hematocele on ultrasonography. The incidence of testis rupture or epididymal disruption in this scenario is at least 80%. Nonperfusion of the testis may indicate testicular torsion, vascular avulsion, or cord thrombosis and should be immediately explored.
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Transverse scrotal ultrasound image shows left intratesticular hematoma and hematocele consistent with testis rupture. Increased testis size on left i....
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Longitudinal image of left testis showing discontinuity of tunica albuginea. This finding mandates scrotal exploration.
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This longitudinal Doppler image shows perfused testicular tissue exuding through disrupted tunica albuginea, eliminating any doubt regarding the diagn....
Retrograde urethrography
This study is warranted in suspected urethral injury, based upon mechanism of injury, findings of hematuria, or rectal examination that demonstrates hematoma or an abnormal prostate (eg, high-riding prostate, impalpable prostate).
CT scan
In multisystem trauma, the abdominopelvic CT scan may be extended to the upper thigh, which provides information regarding testis dislocation, anatomy of intratesticular structures, and some indication of perfusion. For cases in which short time to the operating room becomes important, this precludes ultrasound examination.
Patients with trauma to the abdomen, pelvis, or lower extremity often have associated trauma to the scrotum and are managed per advanced trauma life support (ATLS) prioritization. In addition, isolated scrotal injuries, at times self-inflicted, are an indication for surgical intervention.
Aside from injuries to the scrotal contents that may pose a significant source of hemorrhage, spasm within the dartos muscle layer often provides effective hemostasis for even near-total scrotal avulsion. Associated injuries set the priority for surgical intervention, and scrotal injuries may be managed in a delayed fashion (with saline dressings and general wound care) if they occur in the setting of life-threatening trauma.
Extensive skin loss (eg, burn victims) may delay grafting until more vital coverage has been addressed and remains one of the best indications for placing testes within a thigh pouch in total scrotal avulsion.
In self-inflicted injuries, cosmetic interventions should be pursued only when the patient has been stabilized both medically and from a psychiatric standpoint to ensure compliance.
Stabilization of the trauma patient often delays care of scrotal trauma. Wet-to-dry saline dressings, appropriate wound cultures, and tetanus prophylaxis are indicated prior to definitive therapy.
Modifiers of free-radical injury (eg, allopurinol) may be useful adjuncts to surgical intervention in patients who may have a borderline viability of the testis or who are considered for revascularization.
Two specific scenarios warrant initiation of antibiotics prior to return of culture findings:
First, field-related avulsions or penetrations (eg, farming, hunting, military) must be treated with clindamycin (900 mg IV/IM q8 h) and high-dose penicillin (nafcillin, 1-2 gm IV q4 h) to cover Clostridium perfringens and tetanus.
Second, treatment of animal bites should cover Streptococcus species and Pasteurella multocida. The antibiotic of choice is amoxicillin-clavulanate (500-875 mg PO bid).
Partial loss of the scrotum is managed by debridement, excision of any islands of remnant full-thickness scrotal wall, and primary closure with absorbable sutures. The vascularity of the dartos layer and its significant compliance and elasticity allow scrotal flaps to be used to cover substantial areas of loss.
Complete scrotal loss requires skin grafting. Split-thickness grafting (0.008-0.014 in) that is meshed to allow fluid to drain is ideal for scrotal coverage because it does not result in hair growth. Testicles should be pexed together and dependently to minimize motion and maximize graft take. Although thigh pouches may be necessary with infected wounds until they are managed adequately to allow grafting, acute trauma without infection can be managed simply with wet-to-dry dressings until the patient is available for definitive graft placement.
Blunt trauma
This injury rarely results in scrotal necrosis, and surgical management is based upon testicular integrity. When explored emergently, salvage of a ruptured testis through debridement and primary closure of the tunica albuginea occurs in 80% of cases. Epididymal avulsion or rupture often requires epididymectomy with surgical attention to preserving the internal spermatic artery because the vasal artery is obligated to ligation. Testis torsion as a result of minor trauma should be managed by orchidopexy.
Dislocation of the testis can occur in blunt trauma and should be approached inguinally to minimize blind manipulation of cord structures as occurs during an orchidopexy.
Massive hemorrhage after minor injuries should dictate a close evaluation of the preoperative ultrasound because testis tumors can present in this fashion. When uncertain, inguinal exploration with early securing of the cord structures is a reasonable technique.
Penetrating trauma
Low-velocity missiles and stab wounds require exploration above and below any sign of injury and often necessitate a combined inguinal and scrotal approach. Bleeding is controlled with testis salvage in mind. In the case of complete vascular transection with immediate exploration, a microvascular reanastomosis can be performed with cold ischemia of over 24 hours. If the native cord vessels have been thrombosed, microreimplantation using the inferior epigastric vessels is possible, but warm ischemia beyond 30 minutes should discourage such efforts, particularly if the contralateral gonad is unharmed.
High-velocity missile injury carries a higher incidence of subsequent vascular thrombosis and increased tissue loss. Skin should be debrided to bleeding edges to limit the need for reoperation. The use of drains is mandatory as the demarcation of injury may be underestimated, and guarded optimism is warranted when discussing outcome with patients and family members.
Postoperative Care
Immobilize the site for graft take; in cases of testis replantation for organ survival, maintain immobilization for 5 days. All manner of creative dressings have been used; however, during bedrest periods, exercise prophylaxis for deep vein thrombosis. Pneumatic compression stockings are essential during surgery and initially postoperatively. Administration of low-dose heparin and other anticoagulant agents still is under some debate.
In cases of Fournier gangrene or primary wound-closure separation, vacuum-assisted dressings have substantially enhanced healing.[9]
The successful use of Integra bilayer matrix wound dressing and a subsequent split-thickness skin graft for reconstruction of the anterior scrotum and coverage of the exposed testes caused by Fournier gangrene has been reported. Stable testicular coverage was achieved with closely matched skin and minimal donor-site morbidity.[10]
Infection and necrotic tissue necessitates repeat debridement if progressive on antibiotics. Crepitus signals Fournier gangrene. This synergistic infection of gram-negative and gram-positive anaerobes and aerobes requires aggressive debridement to prevent death, which occurs in 30% of patients.
Testicular atrophy may follow testicular rupture or torsion but requires no additional treatment.
Outcome is highly dependent upon the specifics of the injury and, as in all traumas affecting nonvital organ systems, often relates to the emotionally charged nature of the anatomy.
The American Urology Association (AUA) guidelines for diagnosis and management of genitourinary injuries were amended in 2017 to reflect literature that was released since the original publication in 2014. Key recommendations for the genital trauma include[11] :
Clinicians must perform evaluation for concomitant urethral injury in patients with penile fracture or penetrating trauma who present with blood at the urethral meatus, gross hematuria, or inability to void.
Surgeons should perform scrotal exploration and debridement with tunical closure (when possible) or orchiectomy (when non-salvagable) in patients with suspected testicular rupture.
Surgeons should perform exploration and limited debridement of non-viable tissue in patients with extensive genital skin loss or injury from infection, shearing injuries, or burns (thermal, chemical, electrical).
Clinicians should initiate ancillary psychological, interpersonal, and/or reproductive counseling and therapy for patients with genital trauma when loss of sexual, urinary, and/or reproductive function is anticipated.
Robert A Mevorach, MD, Associate Professor, Departments of Urology and Pediatrics, University of Rochester School of Medicine
Disclosure: Nothing to disclose.
Specialty Editors
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.
Chief Editor
Bradley Fields Schwartz, DO, FACS, Professor of Urology, Director, Center for Laparoscopy and Endourology, Department of Surgery, Southern Illinois University School of Medicine
Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: AUA Journal of Urology<br/>Serve(d) as a speaker or a member of a speakers bureau for: Cook Medical; Olympus, .
Additional Contributors
Edmund S Sabanegh, Jr, MD, Chairman, Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation
Transverse scrotal ultrasound image shows left intratesticular hematoma and hematocele consistent with testis rupture. Increased testis size on left is a soft sign, as hematoma alone could result in this finding.
Longitudinal image of left testis showing discontinuity of tunica albuginea. This finding mandates scrotal exploration.
This longitudinal Doppler image shows perfused testicular tissue exuding through disrupted tunica albuginea, eliminating any doubt regarding the diagnosis of testicular rupture.
Transverse scrotal ultrasound image shows left intratesticular hematoma and hematocele consistent with testis rupture. Increased testis size on left is a soft sign, as hematoma alone could result in this finding.
Longitudinal image of left testis showing discontinuity of tunica albuginea. This finding mandates scrotal exploration.
This longitudinal Doppler image shows perfused testicular tissue exuding through disrupted tunica albuginea, eliminating any doubt regarding the diagnosis of testicular rupture.
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