You are in: eMedicine Specialties > Urology > Trauma Scrotal TraumaArticle Last Updated: Jan 29, 2007AUTHOR AND EDITOR INFORMATIONSection 1 of 12
  Author: Robert A Mevorach, MD, Associate Professor, Departments of Urology and Pediatrics, University of Rochester School of Medicine Robert A Mevorach is a member of the following medical societies: American Academy of Pediatrics and American Urological Association Editors: Edmund S Sabanegh, MD, Assistant Professor of Urology, Uniformed Services of the Health Sciences; Chief, Section of Male Infertility, Glickman Urological Institute, Cleveland Clinic Foundation; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Martin I Resnick, MD †, Former Lester Persky Professor and Chair, Department of Urology, Former Professor, Department of Oncology, Case Western Reserve University School of Medicine; J Stuart Wolf, Jr, MD, FACS, David A Bloom Professor of Urology, Director, Division of Minimally Invasive Urology, Department of Urology, University of Michigan Medical Center; Stephen W Leslie, MD, FACS, Founder and Medical Director of the Lorain Kidney Stone Research Center, Clinical Assistant Professor, Department of Urology, Medical College of Ohio Author and Editor Disclosure Synonyms and related keywords: scrotal trauma, testis trauma, scrotal avulsion, blunt scrotal trauma, penetrating scrotal trauma, scrotal swelling, scrotal hematoma, scrotal wall ecchymosis, scrotal injury avulsion, scrotal injury, scrotum injury, scrotum trauma INTRODUCTIONSection 2 of 12
  A wide variety of traumatic 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. History of the ProcedureSurgical care of scrotal trauma has evolved minimally since the early descriptions of 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 association with complete avulsion injuries. The latter trend has gained universal acceptance only within the last 10 years. ProblemThe topic of scrotal trauma includes the following 3 areas of discussion: scrotal injury avulsions, blunt and penetrating trauma, and injury to scrotal contents (ie, testes, epididymis, spermatic cord contents, urethra). 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). 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). FrequencyScrotal 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). Etiology
PathophysiologyBlunt and/or penetrating trauma to the scrotal area resulting in injury ClinicalAcute 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:
INDICATIONSSection 3 of 12
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. RELEVANT ANATOMYSection 4 of 12
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. CONTRAINDICATIONSSection 5 of 12
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 assure compliance. WORKUPSection 6 of 12
Lab Studies
Imaging Studies
TREATMENTSection 7 of 12
Medical therapy
Surgical therapyScrotal avulsion 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 detrusor 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. Preoperative detailsStabilization 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. Intraoperative detailsSee Surgical therapy. Postoperative detailsImmobilize 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. Follow-upAs in all cosmetic interventions, the initial care is followed by prolonged observation to manage wound infections, seromas, and scar formation. COMPLICATIONSSection 8 of 12
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. OUTCOME AND PROGNOSISSection 9 of 12
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 is largely dependent on the extent of tissue devascularization. Statistical analysis is not pertinent and must be individualized. FUTURE AND CONTROVERSIESSection 10 of 12
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 obviate the need for mere skin coverage of the scrotum, which is never a true cosmetic success. 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. MULTIMEDIASection 11 of 12
REFERENCESSection 12 of 12
Article Last Updated: Jan 29, 2007 | ||||||||||||||||||||||||||
