What is the management approach for scrotal swelling following trauma?

Management of Scrotal Swelling Following Trauma

Surgical exploration and debridement with tunical closure should be performed in patients with suspected testicular rupture following scrotal trauma, as early intervention prevents complications such as ischemic atrophy and infection. 1

Initial Assessment and Imaging

• Ultrasound evaluation is essential for patients with scrotal trauma when testicular rupture is not clinically obvious 1, 2

  • Most specific findings indicating testicular rupture: loss of testicular contour and heterogeneous echotexture of parenchyma 1
  • Additional concerning findings: presence of hematocele, disruption of the tunica albuginea, and/or extrusion of seminiferous tubules 3

• Clinical indicators suggesting testicular rupture:

  • Scrotal ecchymosis and swelling
  • Difficulty identifying testicular contours on physical exam
  • Note: Testicular rupture can occur even without tenderness 3

Management Algorithm

1. For Suspected Testicular Rupture:

• Immediate surgical exploration is indicated for:

  • Clinical or ultrasonographic evidence of testicular rupture 1
  • Patients with large hematoceles 3
  • All penetrating scrotal injuries (due to high incidence of testicular rupture) 2

• Surgical approach:

  • Debride non-viable tissue
  • Close the tunica albuginea when possible
  • Consider tunica vaginalis grafts when primary closure isn't possible 1
  • Perform orchiectomy only when testis is non-salvageable 1

2. For Extensive Genital Skin Loss or Injury:

• Perform exploration and limited debridement of clearly non-viable tissue 1
• Wound management options:
  • Gauze dressings with frequent changes
  • Silver sulfadiazine or topical antibiotic with occlusive dressing
  • Negative pressure dressings 1
• Definitive reconstruction may require multiple procedures:
  • Primary closure and advancement flaps
  • Skin grafts
  • Free tissue flaps
  • Pedicle-based skin flaps 1

3. For Intratesticular Hematoma Without Rupture:

• Conservative management can be successful 3
• Follow-up with interval ultrasound to assess resolution 3

Special Considerations

• Evaluate for concomitant urethral injury if scrotal trauma is present, especially with:

  • Blood at the urethral meatus
  • Gross hematuria
  • Inability to void 1

• Consider intra-abdominal pathology in cases of acute scrotal swelling, especially in patients with:

  • Risk factors for bleeding (anticoagulation therapy)
  • Hematocele without direct scrotal trauma
  • In these cases, both scrotal and abdominal imaging should be performed 4

• Timing is critical: Early exploration and repair prevent complications such as:

  • Ischemic atrophy of the testis
  • Infection
  • Delayed need for orchiectomy 1, 2

Pitfalls to Avoid

• Do not delay surgical exploration in cases of suspected testicular rupture, as timely intervention within 6-8 hours maximizes testicular salvage rates 2

• Do not rely solely on clinical examination for diagnosis, as:

  • Soft tissue swelling may obscure findings
  • Testicular pain may limit thorough examination
  • Testicular rupture doesn't always present with pain or tenderness 2, 3

• Do not overlook rare causes of scrotal swelling following trauma:

  • Incarcerated scrotal hernia 5
  • Communicating hematocele from intra-abdominal bleeding 4

By following this evidence-based approach to scrotal trauma management, clinicians can optimize outcomes and minimize complications related to testicular injury.