Practice Essentials
A wide variety of mechanisms can 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:
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Scrotal injury avulsions
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Blunt and penetrating trauma
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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). [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.
Relevant Anatomy
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.
Etiology
Avulsions may result from the following:
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Animal attacks
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Motor vehicle accidents
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Assaults (sharp or high-velocity missiles)
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Self-mutilation
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Machinery-related (ie, industrial, agricultural) accidents
Blunt injury may result from the following:
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Sports
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Motor vehicle accidents
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Assault
Penetrating injury (low velocity) may result from the following:
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Assaults
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Animal attacks
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Motor vehicle accidents
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Self-mutilation
High-velocity penetrating injury is most often the etiology in military casualties.
Epidemiology
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]
Prognosis
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.
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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.
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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 diagnosis of testicular rupture.
