CHAPTER

Blunt Scrotal
Trauma 77
Presentation
Blunt injuries to the scrotum usually occur in patients who are younger than 50 years of age as
a result of an athletic injury, a straddle injury, an automobile or industrial accident, or an
assault. Patients present with various degrees of pain, ecchymoses, and swelling as well as
faintness, nausea, or vomiting (Figure 77-1). The symptoms from minor injuries will gradually
resolve on their own after 1 to 2 hours. With testicular rupture, pain is usually severe, and the
scrotal sac appears full, ecchymotic, and very tender.

What To Do:
✓ Get a clear history of the exact mechanism, the force of the trauma, and the point of
maximum impact. Determine if there was any bloody penile discharge or hematuria and

Figure 77-2 Scrotal support.

Figure 77-1 Blunt injury to the scrotum.

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MINOR EMERGENCIES: SPLINTERS TO FRACTURES

whether or not the patient has any preexisting genital disease, such as previous genitourinary
surgery, infection, or mass.

✓ Gently examine the external genitalia with the understanding that intense pain may
result in a suboptimal examination. If scrotal swelling is not too severe, try to palpate and
assess the intrascrotal anatomy. When there is minimal pain and tenderness, with normal
anatomy, no further evaluation is necessary.

✓ There is a high risk for urethral injury in straddle injuries. Obtain a urinalysis. If
blood is present in the urine (or at the urethral meatus), do a retrograde urethrogram
and obtain urologic consultation.

✓ After any significant blunt trauma, when pain or swelling prevents demonstration
of normal intrascrotal anatomy, obtain a testicular color Doppler ultrasound to help
determine the need for operative intervention.

✓ Hematomas can involve the testis, epididymis, or scrotal wall. Patients with intratesticular
hematomas fare poorly without exploration. Forty percent of these hematomas result in
testicular infection or necrosis, which often requires orchiectomy. Scrotal exploration is
warranted if there is compelling evidence of testicular fracture or rupture on scrotal
sonography or physical examination. It is most appropriate to explore a grossly abnormal
scrotum without ultrasonography when the index of suspicion is high. This should occur
when there is persistent moderate-to-severe pain, tender ecchymotic fullness of the scrotal
sac, and a testicle that feels enlarged and/or irregular or is difficult to palpate. The presence of
a large hematocele on ultrasound is another indication for exploration.

✓ Small hematoceles, epididymal hematomas, or contusions of the testis generally

pose little risk to the patient and do not require surgical exploration. All post-traumatic
lesions should be followed to demonstrate sonographic resolution, because 10% to 15% of
testicular tumors first present after an episode of scrotal trauma.

✓ Simple scrotal lacerations can be closed using Vicryl absorbable suture or tissue
adhesive (Dermabond).

✓ When urologic intervention is not required, provide analgesia (consider NSAIDs),

bed rest, scrotal support, a cold pack, and urologic follow-up (Figure 77-2).

✓ Patients should always be instructed to return immediately if pain increases, becomes

severe, or is accompanied by vomiting or lightheadedness.

What Not To Do:

✗ Do not miss testicular torsion, which is associated with minor-to-moderate blunt
trauma approximately 20% of the time. (See symptoms and signs of testicular torsion in
Chapter 79.)

✗ Do not miss the rare traumatic testicular dislocation that results in an “empty scrotum.”
The testis is found superficially beneath the abdominal wall in approximately 80% of such
cases. Immediate urology consultation is required.

✗ Do not discharge a patient until he can demonstrate the ability to urinate.

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Discussion
Blunt testicular trauma occurs from a direct blow
to the testes with impingement against the
symphysis pubis or ischial ramus. Trauma can
result in contusion, hematoma, fracture, rupture,
or, rarely, dislocation of the testis. Testicular
rupture is a surgical emergency. More than 80%
of ruptured testes can be saved if surgery is
performed within 72 hours of injury.
Complications of testicular trauma include
testicular atrophy, infection, infarction, and
infertility, which are much more likely with
nonoperative management of serious injuries.
If Doppler studies demonstrate a serious injury,
early exploration, evacuation of hematoma, and
repair of testicular rupture tend to result in an
earlier return to normal activity, with less risk for
testicular atrophy, infection, infarction, and
infertility.
Sonographic findings in testicular rupture
include interruption of the tunica albuginea;
contour abnormality; a heterogeneous testis
with irregular, poorly defined borders; scrotal
wall thickening; and a large hematocele. The
sonographic appearance of hematomas varies
with time. Acute hematomas appear hyperechoic
and subsequently become complex, with cystic
components. Color Doppler sonography in
post-trauma patients may reveal focal or diffuse
hyperemia of the epididymis, which represents
traumatic epididymitis.

Suggested Readings
Dogra V, Bhatt S: Acute painful scrotum. Radiol Clin North Am 42: 349-363, 2004.

Ko S, Ng S, Wan Y, et al: Testicular dislocation: an uncommon and easily overlooked

complication of blunt abdominal trauma. Ann Emerg Med 43:371-375, 2004.

Rosenstein D, McAninch JW: Urologic emergencies. Med Clin North Am 88: 495-518, 2004.

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