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Testicular trauma

Huda A.K. Hamouda 4th year MBBS 09090116

Introduction
Testicular trauma is the third most common cause of acute scrotal pain Despite the vulnerable position of the testicles, testicular trauma is relatively uncommon. Mobility of the scrotum may be one reason severe injury is rare. Given the importance of preserving fertility, traumatic injuries of the testicle deserve careful attention.

Mechanism of injuries

Blunt trauma Ex. ( a kick to the groin or a baseball injury, sport injuries, vehicle accidents ..)
refers to injuries sustained from objects applied with any significant force to the scrotum and testicles

Penetrating trauma Ex.( gunshot and stab wounds , selfmutilation, animal bites (usually dog), and emasculation)
refers to injuries sustained from sharp objects

degloving trauma or avulsion injuries , less common , the scrotal skin is sheared off. Ex(when a testicle becomes trapped in heavy machinery (industrial or farming accidents)) Iatrogenic injuries Ex ( as a complication of inguinal herniorrhaphy or orchiectomy , spermatic cord transection )

typically seen in males aged 15-40 years. Blunt trauma 85% of cases The right testis is more likely to be injured in this way than the left testis anatomically slightly higher than the left one . Bilateral testicular injuries and ruptures are rarer; they are seen in approximately 1.5% of cases of blunt scrotal trauma. 5%8% of cases of torsion of the spermatic cord are thought to be precipitated by trauma , bell clapper deformity as predisposing factor . penetrating trauma 15% of cases Penetrating injuries are more likely to be bilateral, with an incidence rate of about 30%

Relevant anatomy
Layers : Scrotal Skin the dartos muscle/fascia external, middle, and internal spermatic fasciaetunica vaginalis outer (parietal) layer and an inner (visceral) layer ) tunica albuginea (You need a force of as much as 50 kg to rupture TA) tunica vasculosa , testis , epididymis , vas deferens in spermatic cord. A tear in the tunica albuginea intratesticular hemorrhage escapes into the tunica vaginalis hematocele. Disruption of the tunica vaginalis /extension to the epididymis bleeding into the scrotal wall scrotal hematoma.

Clinical features

History : Hx. of injury Intense pain of testis Occasionally with nausea, vomiting, Fever or even fainting.

Bruising or discoloration of the scrotum , Swelling of the scrotum. Blood in the urine , Difficulty urinating.

Clinical features

PE :
swollen, severely tender testicle with a visible hematoma. Scrotal or perineal ecchymosis Bilateral testicular examination and perineal examination should always be performed to rule out associated pathologies. absence of scrotal swelling and hematoma benign injury. absence of pain with scrotal swelling and hematoma testicular infarction or spermatic cord torsion.

Non-palpable / dislocated testis : Subcutaneous dislocation epifascial displacement of the testicle Internal dislocation in the superficial inguinal ring , inguinal canal or abdominal cavity - evaluate the femoral vessels. - Physical examination is often difficult radiologic evaluation or surgical exploration may be required.
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Investigations
Laboratory Studies Obtain a urinalysis to rule out urinary tract infection or epididymo-orchitis. Imaging Studies - Scrotal ultrasonography with Doppler studies is valuable for diagnosing and staging testicular injuries and helpful in determining the nature and extent of injury. - The sensitivity and specificity 93.5% & 100%, respectively.

US with Doppler studies findings

A normal parenchymal echo pattern, with normal blood flow in cases of blunt trauma exclude significant injury.

US with Doppler studies findings

Acute bleeding or contusion of the testicular parenchyma typically hyperechoic lesion , old blood hypoechoic lesion.

US with Doppler studies findings

testicular rupture disruption of the tunica albuginea with testicular contour abnormality

US with Doppler studies findings

Testicular frucutre hypoechoic avascular band that crosses the testicular parenchyma. A fracture line is rare and is seen in only about 17% of cases

US with Doppler studies findings

- Absence of flow implies by Doppler torsion or devascularizing injury to the spermatic cord.

US with Doppler studies findings

Acute and chronic hematoceles mixed hypoechoic and hyperechoic areas confined by the tunica vaginalis.

US with Doppler studies findings

US with Doppler studies findings

Traumatic epididymitis heterogeneous and enlarged epididymis with increased vascularity

US with Doppler studies findings

Investigations
Imaging Studies ( Cont.) injury severity scales, such as (AAST), to dictate if nonoperative management is appropriate in certain cases of testicular trauma.

AAST

G1
G2 G3 G4 G5

Contusion , Hematoma
Subclinical laceration of tunica albuginea Laceration of TA + <50% parenchymal loss Major laceration of TA + 50% parenchymal loss Total testicular destruction or avulsion

Advance one grade for bilateral injuries up to grade 5

Other Imaging Studies : MRI , CT to obtain additional information in equivocal cases. provide information regarding prognosis

Management
Medical Therapy If minor trauma : Institute conservative - bed rest for 24-48 hours & scrotal support to decrease scrotal mobility - ice packs applied to the groin at least every 3-4 hrs to decrease swelling in acute phase - NSAIDS to decrease scrotal edema and provide nonsedating analgesia - If associated epididymitis or UTI antibiotic therapy. - Failure of medical management warrants imaging of the scrotum with ultrasonography and Doppler studies. - In the case of testicular dislocation, manual reduction has been used successfully in 15% of cases. - Future elective orchiopexy should still be performed to minimize the risk of torsion.

Management

Surgical Therapy

Indications for scrotal exploration include the following: Uncertainty in diagnosis after appropriate clinical and radiographic evaluations Clinical findings consistent with testicular injury Clinical hematoceles that are expanding or of considerable size (eg, 5 cm) If the testis is fractured, testicular debridement and surgical closure of the tunica albuginea are necessary. Penetrating testicular trauma Degloving injuries require debridement , Skin closure may or may not be possible in the acute setting. The absence of blood flow on ultrasonography may represent spermatic cord torsion, avulsion, or infarction.

Management

Surgical Technique :
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transverse scrotal incision on the affected side Drainage of the hematocele reparation of the tunica albuginea and testicular parenchyma with debridement of nonviable tissue. Relocation of tests n cases of dislocation. Orchiectomy in cases of massive out burst Penrose drainage. Closing of the scrotal wall.

Management
Surgical Therapy In case of penetrating trauma: - prophylaxis with Amoxicillin/clavulanate - tetanus vaccine if >5 years has elapsed since administration of last dose (passive with Toxoid and active with mmunoglobulin 250 IU). - In highly contaminated wounds, (bites, goring, etc.), Vancomycin and Metronidazole are added. In animal bites, the need for rabies vaccine should be assessed.

Complications

Complications associated with untreated testicular injuries include :


Testicular infarction and torsion Testicular or epididymal abscess Testicular necrosis and atrophy Infertility

Complications associated with scrotal exploration & testicular salvage include :

Bleeding Infection Loss of testis

Prognosis
More than 80% of ruptured testes can be salvaged, with a high success rate, if surgical repair is performed within 72 hours of testicular injury Following repair of penetrating testicular trauma caused by conventional bullet wounds, fertility results are approximately 62%. If the wound sustained was the product of high-velocity ammunition, fertility rates are much lower.

Thank you