Johnny English, a 42-year-old previously healthy male, presents to the ER with a 3-hour history of pain and swelling localized to the scrotum. He is systemically well and denies lower urinary tract or gastrointestinal symptoms.
Upon further questioning, Johnny tells a bizarre story about saving the world by chasing a traitorous MI7 agent through the Swiss Alps and then fighting him to the death. English explains that during their fight he received multiple blows to the scrotum. English reports that he was not in any immediate pain as he has learned that “the mind is the master of the body” while studying with Tibetan monks. However, upon return home, he became aware of severe pain in his scrotum and noticed significant swelling. English has not urinated since the accident and deflects further questions by chuckling and muttering “if I told you that I’d have to kill you.”
Although English’s story seems like a bizarre delusion, a physical examination is warranted. English’s physical examination was not captured on film to preserve patient privacy, but we presume that he would have had the follow findings:
- Stable vitals
- No flank ecchymosis and a soft, non-tender abdomen
- Ecchymotic, swollen scrotum, with the left hemi-scrotum swollen to approximately twice the size of the right hemiscrotum. Right testis normal to palpation. Left testicular examination limited by swelling and pain. No trans-illumination of the scrotum.
- Normal penis, but blood present at the meatus
- Normal digital rectal examination
- No other obvious injuries.
ACUTE SCROTUM – GENERAL THOUGHTS
There are several diagnoses that must be ruled out immediately in any patient presenting with an acute scrotum. These include referred pain from intra-abdominal processes such as AAA or appendicitis, Fournier’s gangrene, epididymitis, and testicular rupture or torsion, which threaten the viability of the testicles. English’s history of blunt scrotal trauma puts testicular contusion, rupture, hematocele, and/or hematoma high on the differential, but does not rule out torsion. 4-8% of testicular torsion is actually precipitated by trauma.1 The identification and management of torsion has been nicely described by Subhrata: https://canadiem.org/testicular-torsion/. Testicular rupture is generally associated with immediate pain, nausea, vomiting, and even fainting, after a force of at least 490 newtons is delivered to the testicles.2 A trained MI7 agent would likely be able to generate the same amount of force as a taekwondo athlete, equating to about 1,000 to 2,000 newtons.3
Although physical exam findings, such as irregularities in the testicular contour or hematomas, can aid in determining a diagnosis, physical exams in scrotal trauma patients are often limited by pain and swelling. Furthermore, testicular injury may present without scrotal swelling or hematoma.4 Therefore, ultrasonography is a useful tool to identify the need for surgery.5 Disruption of the tunica albuginea or a heterogenous echotexture of the parenchyma are signs of testicular rupture, while Doppler can give an indication of tissue viability.2,5 In fact, ultrasonography has estimated to have a sensitivity of almost 100% and a specificity of 65-93.5% for testicular rupture.5,6
In English’s case, an ultrasound would be extremely helpful to identify underlying testicular damage, and to classify his swelling as a hematoma or hematocele.
WHO REQUIRES SURGERY?
The key question in any patient presenting with an acute scrotum is whether or not surgery is indicated. While management strategies for other encapsulated organs, such as renal trauma, are now primarily conservative, the American Urological Association (AUA) and European Association of Urology (EUA) still recommend early surgical exploration for suspected testicular injury.2,7 This recommendation is based largely off a series of three studies published by Cass et al. between 1983-1991, that showed a decreased rate of orchiectomy (21% to 6%) and a quicker recovery in patients treated with early surgical exploration rather than conservative management.8–10 However, several modern studies describe success with conservative management.11–14 These include a review of 667 blunt scrotal trauma and 1 testicular rupture patients where 99.6% were successfully managed conservatively.12 An orchiectomy was only required in one patient, who presented with torsion, and while 25% of conservatively managed patients had prolonged scrotal pain (>14 days), all surgically managed patients developed chronic scrotal pain.12 Although testicular rupture is widely considered a surgical emergency, multiple studies also demonstrate equivalent or superior testicular salvage rates in conservatively managed testicular rupture patients.13–15 While these studies call into question current practices, they are limited by small sample sizes and fail to capture time to recovery.13 Until stronger evidence for conservative management exists, the British Association of Urological Surgery (BAUS) consensus document gives a reasonable list of surgical indications, in which case patients require a urological consult:4
|Suspicion for testicular rupture||Threatens the viability of the testicle16|
|Large hematoceles (>3x contralateral testis)||80% of hematoceles are associated with testicular rupture4. Large hematoceles can be symptomatic and lead to an increased time to recovery7|
|Large / expanding intra-testicular hematoma||Could indicate significant testicular/ para-testicular damage, compromise testicular blood flow, and lead to secondary infection or pressure atrophy4,8,17 Symptom management7|
|No improvement with 72 hours of conservative treatment||Could be due to missed testicular / para-testicular damage4 |
|Severe pain||Symptom management7|
Johnny English presents with an acute scrotum and a clear history of trauma. Once an ultrasound has ruled out testicular rupture, torsion, and any threat to the testicular blood supply, it would be reasonable to manage English’s relatively small hematoma (2x size of contralateral testicle) conservatively. Little evidence exists surrounding conservative treatment, but dogma suggests scrotal support, ice, and 24 to 48 hours of bedrest as well as adequate analgesia and antibiotics to prevent infection of the hematoma.14,18–20 While a repeat ultrasound at 48 hours is often arranged to rule out expanding hematomas and ensure testicular viability, its necessity is unclear. However, patients should follow up with Urology to ensure swelling is improving and that there is no necessity for delayed intervention should be arranged. English should be advised that it may take 4 or more weeks for the swelling to dissipate.4During this time, he should try to limit physical alterations with villains, unless essential for his country, in which case the benefits might outweigh the harm to his testicle.
All patients with significant scrotal trauma should be evaluated for concomitant anterior urethral injuries, since compression of the bulbous urethra against the pubic symphysis can cause urethral rupture2. Posterior urethral injuries, defined as injuries to the urethra at or above the membranous urethra, are uncommon after blunt trauma to the perineum and are instead associated with pelvic fractures7.
The cardinal sign of urethral injuries is blood at the meatus, which is present in around 75% of anterior urethral injuries2. The inability to void, hematuria, dysuria, significant pelvic ecchymosis, and a high riding prostate on DRE should also raise the suspicion of a urethral injury2,7. A characteristic “butterfly” hematoma is seen if Buck’s fascia is disrupted by a urethral injuries distal to the urogenital diaphragm, since it allows blood to track to Colles’ fascia21. If a urethral injury is suspected, retrograde urethrography (RUG) should ensue, since about 10-30% are missed when diagnosing with signs and symptoms alone2,7,22. Sometimes this suspicion may be based solely on mechanism of injury.
The most important step in managing urethral trauma is securing bladder drainage. Failure to do so can result in extravasation of urine, and potentially leads to severe infections.23 Although there is a worry that blind catheterization of a partially disrupted urethra can lead to a complete disruption, there is little evidence to support this claim.24,25 Furthermore, there is evidence that re-alignment of posterior urethral disruptions facilitates later surgical repair and may decrease the incidence of strictures.25,26 Therefore, both the AUA and EAU endorse one gentle attempt at Foley placement by an experienced team member in posterior urethral injuries.2,7 Intuitively, this should be the same for anterior urethral injuries. However, two series looking at 78 and 53 patients with blunt straddle injuries found that primary realignment resulted in higher rates of stricture formation and requirement for urethroplasty.27,28 Therefore, initial suprapubic catheterization may be the best management for blunt anterior urethral injuries, and should be maintained for two weeks for partial ruptures and three weeks for complete ruptures.28 Anterior urethral injuries associated with penile fractures or penetrating trauma, on the other hand, are best managed with immediate surgery.2,7
All patients with urethral injuries should receive follow-up with Urology for catheter removal after patency of their urethra is confirmed. These patients should be advised that strictures are exceedingly common after urethral injury, and other complications such as erectile dysfunction and incontinence may also occur.2,7 Ultimately, many of these patients will require surgical management and even urethroplasty.
Since English presumably has the cardinal sign of urethral injury, namely blood at the meatus, immediate Foley catheterization should be avoided. A retrograde urethrogram should be performed, which would likely show a partial bulbar urethral rupture, due to the mechanism of injury. Placement of a suprapubic catheter and referral to Urology would then be indicated. English may also require some education regarding the importance of our pain response. English’s enemy, who was not taught to ignore pain by Tibetan monks, likely would have had less severe genitourinary injuries because he reacted to a scrotal blow by protecting himself (that is, if doing so had not led to his demise).
This post was copyedited by @alexsenger.
- 1.Seng Y, Moissinac K. Trauma induced testicular torsion: a reminder for the unwary. J Accid Emerg Med. 2000;17(5):381-382. doi:10.1136/emj.17.5.381
- 2.Kitrey ND, Djakovic N, Kuehhas FE, Lumen N, Serafetinidis E, Sharma DM. EAU Guidelines on Urological Trauma. European Association of Urology. Published 2018. https://uroweb.org/wp-content/uploads/EAU-Guidelines-on-Urological-Trauma-2018-large-text.pdf
- 3.Buśko K, Staniak Z, Szark-Eckardt M, et al. Measuring the force of punches and kicks among combat sport athletes using a modified punching bag with an embedded accelerometer. Acta Bioeng Biomech. 2016;18(1):47-54. https://www.ncbi.nlm.nih.gov/pubmed/27149957
- 4.Lucky M, Brown G, Dorkin T, et al. British Association of Urological Surgeons (BAUS) consensus document for the management of male genital emergencies – testicular trauma. BJU Int. 2018;121(6):840-844. doi:10.1111/bju.14163
- 5.Guichard G, El A, Del C, et al. Accuracy of ultrasonography in diagnosis of testicular rupture after blunt scrotal trauma. Urology. 2008;71(1):52-56. doi:10.1016/j.urology.2007.09.014
- 6.Buckley J, McAninch J. Use of ultrasonography for the diagnosis of testicular injuries in blunt scrotal trauma. J Urol. 2006;175(1):175-178. doi:10.1016/S0022-5347(05)00048-0
- 7.Morey A, Brandes S, Dugi D, et al. Urotrauma: AUA guideline. J Urol. 2014;192(2):327-335. doi:10.1016/j.juro.2014.05.004
- 8.Cass A, Luxenberg M. Testicular injuries. Urology. 1991;37(6):528-530. doi:10.1016/0090-4295(91)80317-z
- 9.Cass A. Testicular trauma. J Urol. 1983;129(2):299-300. doi:10.1016/s0022-5347(17)52062-5
- 10.Cass A, Luxenberg M. Value of early operation in blunt testicular contusion with hematocele. J Urol. 1988;139(4):746-747. doi:10.1016/s0022-5347(17)42620-6
- 11.Chandra R, Dowling R, Ulubasoglu M, Haxhimolla H, Costello A. Rational approach to diagnosis and management of blunt scrotal trauma. Urology. 2007;70(2):230-234. doi:10.1016/j.urology.2007.03.064
- 12.Rottenstreich M, Gofrit O. Blunt Scrotal Trauma in Soldiers-Epidemiology and Outcome. Mil Med. 2017;182(9):e1929-e1931. doi:10.7205/MILMED-D-16-00375
- 13.Redmond E, Mac N, Giri S, Flood H. Blunt testicular trauma – is surgical exploration necessary? Ir J Med Sci. 2018;187(4):1109-1113. doi:10.1007/s11845-017-1724-7
- 14.Cubillos J, Reda E, Gitlin J, Zelkovic P, Palmer L. A conservative approach to testicular rupture in adolescent boys. J Urol. 2010;184(4 Suppl):1733-1738. doi:10.1016/j.juro.2010.03.114
- 15.Lee S, Bak C, Choi M, Lee H, Lee M, Yoon S. Trauma to male genital organs: a 10-year review of 156 patients, including 118 treated by surgery. BJU Int. 2008;101(2):211-215. doi:10.1111/j.1464-410X.2007.07265.x
- 16.Bryk D, Zhao L. Guideline of guidelines: a review of urological trauma guidelines. BJU Int. 2016;117(2):226-234. doi:10.1111/bju.13040
- 17.Bowen D, Gonzalez C. Intratesticular hematoma after blunt scrotal trauma: a case series and algorithm-based approach to management. Cent European J Urol. 2014;67(4):427-429. doi:10.5173/ceju.2014.04.art24
- 18.Dalton D, Davis N, O’Neill D, Brady C, Kiely E, O’Brien M. Aetiology, epidemiology and management strategies for blunt scrotal trauma. Surgeon. 2016;14(1):18-21. doi:10.1016/j.surge.2014.06.006
- 19.Wang Z, Yang J, Huang Y, et al. Diagnosis and management of testicular rupture after blunt scrotal trauma: a literature review. Int Urol Nephrol. 2016;48(12):1967-1976. doi:10.1007/s11255-016-1402-0
- 20.Randhawa H, Blankstein U, Davies T. Scrotal trauma: A case report and review of the literature. Can Urol Assoc J. 2019;13(6 Suppl4):S67-S71. doi:10.5489/cuaj.5981
- 21.Rosenstein D, Alsikafi N. Diagnosis and classification of urethral injuries. Urol Clin North Am. 2006;33(1):73-85, vi-vii. doi:10.1016/j.ucl.2005.11.004
- 22.Zhang Y, Zhang K, Fu Q. Emergency treatment of male blunt urethral trauma in China: Outcome of different methods in comparison with other countries. Asian J Urol. 2018;5(2):78-87. doi:10.1016/j.ajur.2017.04.004
- 23.Mundy A, Andrich D. Urethral trauma. Part I: introduction, history, anatomy, pathology, assessment and emergency management. BJU Int. 2011;108(3):310-327. doi:10.1111/j.1464-410X.2011.10339.x
- 24.Shlamovitz G, McCullough L. Blind urethral catheterization in trauma patients suffering from lower urinary tract injuries. J Trauma. 2007;62(2):330-335; discussion 334-5. doi:10.1097/01.ta.0000221768.68614.36
- 25.Brandes S. Initial management of anterior and posterior urethral injuries. Urol Clin North Am. 2006;33(1):87-95, vii. doi:10.1016/j.ucl.2005.10.001
- 26.Hadjizacharia P, Inaba K, Teixeira P, Kokorowski P, Demetriades D, Best C. Evaluation of immediate endoscopic realignment as a treatment modality for traumatic urethral injuries. J Trauma. 2008;64(6):1443-1449; discussion 1449-50. doi:10.1097/TA.0b013e318174f126
- 27.Park S, McAninch J. Straddle injuries to the bulbar urethra: management and outcomes in 78 patients. J Urol. 2004;171(2 Pt 1):722-725. doi:10.1097/01.ju.0000108894.09050.c0
- 28.Elgammal M. Straddle injuries to the bulbar urethra: management and outcome in 53 patients. Int Braz J Urol. 2009;35(4):450-458. doi:10.1590/s1677-55382009000400009
Reviewing with Staff
Anna has done a terrific job outlining blunt scrotal trauma… a man’s worst nightmare! The scourge of scrotal trauma has increased dramatically since the war on terror began, and remains the bane of secret agents worldwide. Even young boys can suffer attacks from rogue bicycle components. Prevention remains the best policy, but sneaky attacks from international bad guys continues to be problematic, and so the management of this soft target is well described here in this vignette.
Scrotal exploration was classically taught as the gold standard in managing these patients, but the reality is that most males can be treated conservatively. Testicular tissue preservation is probably not improved with open surgical exploration, as orchiectomy often results. Surgery or not, pain will likely be an issue for days following the acute event. Expanding hematomas require urgent surgical care, but most cases do not need exploration unless there is evidence of abscess formation.
Associated urethral injuries should be considered, especially with blood at the meatus. If this diagnosis is contemplated, urological consultation should urgently occur before any instrumentation of the urethra is undertaken.
The humble scrotum attracts trouble like flies to garbage. Be alert, be brave, and don’t hesitate to call your local urologist for help. Together we can defend the family jewels.