BJU International (2000), 86, 344±348
Testicular, epididymal and vasal injuries
W . F . HE N D R Y
St Bartholomew's and Royal Marsden Hospitals, London
Introduction
Testicles are very precious to a man; they are the source
of the hormone that produces his masculinity and they
provide the spermatozoa that allow him to become a
father. They are also very precious to his female partner,
as most women anticipate maternity and raising a family.
Damage to the testicles can thus have an adverse effect
on not one but two peoples' lives. If the circumstances
that lead to such damage, or the way it was managed,
imply negligence then the injured man, or his partner,
may reasonably seek compensation. The medical expert
who is called upon to provide an opinion must be familiar
with the anatomy and physiology of the testicle, the
variation in normal function in the population as a
whole, and the anomalies that may occur in this organ
system. The consequences of damage to one or both
testes, or their drainage systems, the epididymes, vasa
deferentia and ejaculatory ducts, need to be accurately
assessed.
Testicles are very vulnerable. Placed outside the body
to provide the cool environment essential for spermato-
genesis, they may be struck accidentally, deliberately
injured in an assault, subjected to abuse during torture,
poisoned by environmental chemicals or damaged
inadvertently during surgical procedures carried out in
the scrotum or groin. Of course, care should be taken to
protect them. Public education can do much to help
people recognize the vital importance of these oft-
denigrated organs. For example, wearing a `box' or
protector when playing certain sports, e.g. cricket, careful
seating on a motor cycle, and avoidance of foolish play
may help to avoid the sort of tragedy that can result from
simple events.
The surgeon has great responsibility when operating
on testicles. During inguinal hernia repair in children,
the structures of the spermatic cord are very vulnerable
and testicular blood supply is at risk. Early orchidopexy is
now the rule, to preserve testicular function as far as
possible. Great care must be taken when operating at this
age, when the loss of a testicle provides highly suggestive
evidence that standards of care fell below those that
should reasonably be expected. Not so obvious is damage
to the vas deferens, usually not recognized at the time but
discovered many years later when infertility is investi-
gated. There is an old adage that a man can `®re perfectly
344
well on one cylinder', implying that so long as one testicle
is preserved, it matters little what happens to the other.
Modern immunological techniques have revealed that
this is not so. Unilateral damage to the vas or epididymis
can lead to the production of antisperm antibodies
in some individuals, and that can produce sterility.
Sympathetic ophthalmia is well recognized with eye
injuries; sympathetic orchiopathia, dif®cult to de®ne
exactly, may have a similarly damaging effect on the
contralateral organ in the long-term [1]. There can be no
excuse for adopting a cavalier attitude to the testicle or its
appendages even in the presence of a normal contra-
lateral organ. The solitary testicle is particularly precious;
whether congenital or acquired, the man knows that he
is vulnerable and reasonably takes great care with, and
expresses great anxiety about, the organ.
The surgeon must avoid damage to the testicle or its
appendages whilst operating in the groin area; this
requires detailed knowledge of its structure, its efferent
passages, its blood supply and venous drainage. From this
knowledge recommendations can be made to minimize
the risk of damage. Once damage has occurred, an
assessment of its likely effect on masculinity and
subsequent fertility may require a detailed evaluation.
Apportionment of blame is never easy, and testicular
function is particularly dif®cult to assess; these topics are
discussed in this review.
Clinical anatomy
The parenchyma of the testis is composed of many
convoluted seminiferous tubules, each of which is a
continuous loop with its convexity anteriorly, uniting
with adjacent tubules posteriorly to open into the rete
testis. The spermatozoa leave the rete through 15±20
small tubules (the ductuli efferentes) that pierce the
tunica albuginea and enter the caput epididymis, where
they become convoluted to form small conical masses
(the lobules of the epididymis). The ductuli efferentes
have a thin layer of smooth muscle in their wall and are
lined by ciliated columnar epithelium. At the junction of
the caput and corpus epididymis, the ductuli efferentes
unite into the single duct of the epididymis, an
extraordinarily tortuous tube <60 cm long (in man)
that forms the corpus and cauda epididymis. This duct
has a different lining, of pseudo-strati®ed columnar
# 2000 BJU International
 T E S T I C U L A R , EP I D I D Y M AL AN D V A S A L I N J U R IE S
epithelium with microvilli, surrounded by circular
unstriated muscle. At the tail of the epididymis, the
ductus deferens is formed, which has a thick muscular
coat composed mostly of circular ®bres, together with
inner and outer longitudinally directed ®bres. The
muscular wall becomes thicker as the ductus leaves the
epididymis to continue in the spermatic cord, where it is
commonly referred to as the vas deferens. At < 45 cm
long, it is convoluted at its upper and lower ends so that
the actual distance traversed is f 30 cm. After passing
through the inguinal canal, the vas separates from the
testicular vessels to curve medially across the side wall of
the pelvis. After hooking round the ureter, the vas passes
downwards and medially behind the base of the bladder
where it becomes sacculated and dilated to form the
ampulla. Immediately above the base of the prostate the
ductus deferens becomes once more a slender tube and is
joined by the duct of the seminal vesicle to form the
ejaculatory duct. This delicate tube is <2.5 cm long, and
lies close to its partner on the other side as it passes
downwards and forwards through the prostate behind its
median lobe. The ducts open by slit-like apertures into the
prostatic part of the urethra, one on each side of the
mouth of the prostatic utricle on the verumontanum.
The testicular artery, a branch of the aorta, provides
the blood supply to the testicle. This artery becomes
coiled as it approaches the testis, where it lies close to the
pampiniform plexus, formed by the veins leaving the
testis. It is likely that this arrangement produces a
counter-current heat-exchange system, whereby rela-
tively cool blood leaving the testis normally cools the
warm arterial blood ¯owing into it. The testicular artery
supplies the body of the testis and sends a branch to
supply the upper part of the epididymis. The artery to the
vas, a branch of the inferior vesicle artery, and the
cremasteric artery, which is a branch of the inferior
epigastric artery, anastomose freely with the testicular
artery and can sustain the viability of the testis if the
testicular artery is divided [2].
Varicocele occurs in < 10% of the normal male
population, and in < 20% of men attending a subfertility
clinic. Retrograde caval venography has shown that the
basic abnormality is a reversed blood ¯ow caused by
incompetent valves in the testicular vein [3]. This results
in pooling of blood around the testicles and an increase in
the temperature of the scrotum; this is probably the cause
of the depression of spermatogenesis that may accom-
pany this condition. Most varicoceles only involve the left
side, although bilateral varicoceles have been described
in up to 15% of cases; the right side is affected alone
very rarely, when a search should be made for situs
inversus.
The lymph vessels of the testis pass upwards in the
spermatic cord and end in the paracaval and para-aortic
# 2000 BJU International, 86, 344±348
345
lymph nodes. Sympathetic and parasympathetic nerve
®bres run with the ductus deferens.
Direct testicular injury
Most blunt testicular injuries are accidental, often
sustained during sporting activity [4]. Some are deliber-
ate, e.g. a knee injury or a kick in an assault, or a blow
from a ri¯e butt, commonly sustained by those being
tortured [5]. The testicle may be ruptured in up to half of
all such injuries [6]. Falling astride an object with a sharp
edge, motorcycle-rider injuries [7], assault with a knife,
or gunshot wound may cause penetrating injuries [8].
The latter injury is not uncommonly a form of revenge,
resulting from jealousy or perceived in®delity. Blunt
injuries are twice as common as penetrating injuries [9].
Usually, only one testicle is damaged with the former type
of injury, whereas both testes are damaged in up to a
third of penetrating injuries [10].
On presentation, the scrotum is usually distended,
bruised and ®lled with blood. It may be dif®cult or
impossible to feel the testicles. Other injuries may be
present, which take precedence, e.g. to great vessels of
the thigh, and the penis may be injured [11]. Some
patients may present a few days after the injury, when
the assessment is even more dif®cult. Ultrasonography
may detect testicular rupture [12], but may not
distinguish intratesticular haematoma from rupture
[13].
Experience from several reported series indicates that
testicular loss is signi®cantly higher, at < 20%, if the
injury is managed conservatively rather than with early
exploration and repair, when the loss falls to < 6% [14].
Bilateral injuries particularly should be managed by
partial orchidectomy and repair [10]; even a shattered
solitary testicle can be salvaged [15]. Follow-up indicates
that testicular salvage preserves fertility better than
orchidectomy [16]. Although some patients may develop
testicular atrophy, there is little evidence that the damage
is immunologically mediated [17], even though there is
some evidence that such a phenomenon can be provoked
in experimental animals [18,19].
In summary, it is well established that early explora-
tion of the scrotum in patients with testicular trauma can
reduce the orchidectomy rate, shorten hospital stay,
reduce the period of disability and lead to a faster return
to normal activity [6]. It has been known for 30 years
that there is a direct relationship between salvageability
of the testis and early operative procedure [20].
Vascular injury
The testicular artery is long and tortuous; it originates as
a branch of the aorta and descends over the posterior
346 W.F. HENDRY
abdominal wall to enter the inguinal canal, where it is
joined by two other arteries, the cremasteric and the
artery to the vas. These three arteries are not end arteries,
as they anastomose freely so that ligation of one does not
lead to testicular atrophy. High ligation of the testicular
veins in the treatment of varicocele is often accompanied
by ligation of the testicular artery. A prospective trial has
shown that this does not lead to reduced testicular size,
and the results in terms of improvement in sperm quality
were no different whether the artery was ligated or not
[21]. Ligation of the testicular artery during high ligation
should not be regarded as incorrect practice. However,
multiple ligation of the pampiniform plexus at a lower
(scrotal) level can interfere with more than one artery
and can lead to atrophy [22]. High ligation is therefore to
be preferred, although embolization is now generally
considered to be the treatment of choice [23]. Torsion is
the most catastrophic vascular event for the testicle, and
is the subject of another section in this issue (Cuckow and
Frank, page 349).
Testicular atrophy can follow groin surgery such as
inguinal hernia repair. This is an uncommon but well
recognized complication that frequently results in litiga-
tion. In a recent review of 10 cases of testicular atrophy
after inguinal hernia repair, identi®able risk factors were
present in eight. Previous groin or scrotal surgery
increases the risk, and the patient should be warned of
an increased risk under these circumstances. Overzealous
dissection of the distal hernia sac, dislocation of the testis
from the scrotum and concomitant scrotal surgery
should all be avoided [24]. The author has seen testicular
atrophy after synchronous inguinal ligation of varicocele
and testicular exploration with reconstruction, which
was a source of grief to the patient and his partner.
Experience with this patient lead to a general policy of
`one thing at a time' with surgery of the testicle. Advice
from the USA con®rms the following points: leave the
distal part of indirect inguinal hernia sacs; never dissect
beyond the pubic tubercle; and use the preperitoneal
space, e.g. in recurrent hernias, to avoid dissection of the
cord altogether [25]. Following these guidelines reduced
the incidence of testicular atrophy from 0.65% (11 of
1682) to 0.03% (one of 3634); in recurrent hernias, the
incidence was reduced from 2.25% (seven of 311) to
0.97% (eight of 827) [26].
Amongst a population of 131 infertile men who had
undergone inguinal herniotomy, 19 (14.4%) were found
to have a smaller testis on the side of the operation. All
had decreased sperm quality, with elevated serum FSH
and decreased serum testosterone levels [27]. Such
damage, even on only one side, may have severe
consequences in later life [28]. Particular care should
be taken after previous surgery in childhood; recently,
the present author narrowly avoided removing the
wrong testicle for seminoma, after previous orchidopexy
with scrotal transposition (Ombredonne procedure) [29].
Vasal and epididymal injury
Several studies have shown a high incidence of unilateral
vasal obstruction in patients who underwent inguinal
hernia repair in childhood. For example, Matsuda et al.
[30] found an incidence of 26.7% in subfertile men with
such a history. Sheynkin et al. [31] found iatrogenic
injury to the vas deferens in 34 (7.2%) of 472 patients
surgically explored for obstructive azoospermia. The
mean obstructive interval was < 20 years, and followed
bilateral inguinal hernia repair [19], unilateral hernia
repair [11], renal transplantation [2], appendicectomy
[1] and excision of spermatocele. Thus, paediatric
inguinal hernia repair was by far the most common
aetiology of vasal injury.
In the author's experience of unilateral testicular
obstruction, surgical damage to the testicular out¯ow
tracts was not uncommon in subfertile men. In a review
of 50 such cases, the causes of the blocks included
hernia repair (29 patients, mean age at surgery
6 years), hydrocele operations (six), epididymal cyst
removal, epididymal biopsy, and other groin or genital
operations or injuries [32]. Although unilateral testi-
cular obstruction does not necessarily cause infertility, it
may do so under certain circumstances; e.g. if the
function of the contralateral testis is impaired, then the
total sperm output may be reduced to such an extent
that the man becomes infertile [33]. Additionally,
obstruction to the out¯ow of spermatozoa results in
the formation of antisperm antibodies, because of the
absorption of spermatozoa via the lymphatics and their
ultimate destruction in the abdominal lymph nodes
[34]. Subfertile men who had unilateral genital tract
injury in childhood had signi®cantly higher antisperm
antibody titres than those with bilateral injuries,
indicating that unilateral injury with no antibody
production is probably compatible with the mainte-
nance of normal fertility [35].
The prepubertal vas is very vulnerable [36].
Examination of the vasa from 34 young males showed
no change in vasal size from birth up to 11 years; from
15 years onwards the vas was of normal adult size. Before
puberty, the vas is only 1 mm in external diameter,
doubling to average 2 mm after mid-puberty [37]. This
means that great care must be taken in handling the
prepubertal vas, as repair is likely to be dif®cult [38].
Furthermore, abdominopelvic segmental vasal atrophy
may occur after prepubertal injury to the vas in the groin
[39], and sympathetic changes may occur in the
contralateral testicle [40].
# 2000 BJU International, 86, 344±348
 T E S T I C U L A R , EP I D I D Y M AL AN D V A S A L I N J U R IE S
Conclusions
The testicles may be injured directly by blunt or
penetrating trauma, their blood supply may be cut off
by groin surgery, and the seminal out¯ow tracts may be
blocked on one or both sides, especially by surgery in
infancy or childhood. Lesions that affect one testicle may
have an indirect effect upon the other. Although the
mechanisms by which this occurs remain unclear, there
is no doubt that interruption of the seminal out¯ow from
one testicle may provoke antisperm antibody production,
which can render the man infertile.
It is therefore imperative that the surgeon who
manages testicular trauma should be fully aware of the
currently available methods for repairing rupture and
preserving the testicle. The surgeon who operates in the
inguinal region or the scrotum, especially in childhood,
must be conscious of the importance of avoiding
iatrogenic damage to the testicular blood supply, the
vas deferens and the epididymis. Failure to do so may lead
to successful litigation if negligence can be proved, if the
result is atrophy or obstruction to the testicle leading to
infertility.
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Author
W.F. Hendry, MD, ChM, FRCS, Consultant Urologist, 149
Harley St, London W1N 2DE, UK.
# 2000 BJU International, 86, 344±348