What is the management approach for a patient with a scrotal injury presenting with hematoma and bruising to the suprapubic area?

Management of Scrotal Injury with Hematoma and Suprapubic Bruising

Surgeons should perform scrotal exploration and debridement with tunical closure (when possible) or orchiectomy (when non-salvageable) in patients with suspected testicular rupture. 1

Initial Assessment

• Evaluate for signs of testicular rupture:

  • Scrotal ecchymosis and swelling
  • Difficulty identifying testicular contours on physical exam
  • Suprapubic bruising (may indicate more extensive trauma)
  • Pain and tenderness

• Obtain scrotal ultrasound immediately:

  • Most specific findings for testicular rupture: loss of testicular contour and heterogeneous echotexture of parenchyma 1
  • Look for hematocele, intratesticular hematoma, or disruption of tunica albuginea

Management Algorithm

If Testicular Rupture is Suspected or Confirmed:

1. Immediate surgical exploration is indicated 1, 2

   • Early exploration and repair (within 72 hours) significantly increases testicular salvage rates 2, 3
   • Delay in surgical intervention can lead to ischemic atrophy and infection 1

2. Surgical approach:

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

If Hematocele Without Clear Signs of Rupture:

• Early surgical intervention is still recommended as literature suggests better outcomes with exploration within 72 hours 2, 3
• Hematoceles without intervention have higher rates of complications and may require delayed orchiectomy 4

If Isolated Scrotal Wall Hematoma Without Testicular Involvement:

• Conservative management may be appropriate 3
• Monitor with serial ultrasound examinations
• Provide scrotal support, ice packs, and analgesics

Special Considerations

• Evaluate for concomitant urethral injury if there is:

  • Blood at urethral meatus
  • Gross hematuria
  • Inability to void 1
  • Perform retrograde urethrography before catheterization if urethral injury is suspected 1

• Suprapubic bruising:

  • May indicate associated pelvic trauma or urethral injury
  • Consider CT imaging with IV contrast if mechanism suggests more extensive trauma 1
  • Evaluate for bladder injury if gross hematuria is present 1

Post-Operative Care

• Apply pressure dressing to prevent post-operative hematoma and edema 5
• Monitor for signs of infection
• Provide adequate analgesia
• Follow-up ultrasound to assess healing

Pitfalls and Caveats

1. Delayed diagnosis risk: Even with normal-appearing ultrasound, testicular rupture may still be present. When in doubt, surgical exploration is safer than observation 2, 4

2. Conservative management risks: Purely conservative management of suspected testicular rupture or significant hematocele can lead to:

   • Testicular loss
   • Infection
   • Chronic pain
   • Need for delayed orchiectomy 4

3. Incomplete evaluation: Always assess for associated urinary tract injuries, especially with suprapubic bruising or high-energy trauma mechanisms 1

Remember that early surgical intervention for testicular rupture offers the best chance for testicular preservation and reduces complications such as infection, atrophy, and chronic pain.