What is the management for a scrotal injury with severe swelling?

Management of Scrotal Injury with Severe Swelling

Patients with suspected testicular rupture after scrotal injury with severe swelling should undergo prompt surgical exploration, debridement, and tunical closure when possible, or orchiectomy when non-salvageable, to prevent complications such as ischemic atrophy and infection. 1

Initial Evaluation

• Ultrasound with Doppler is the first-line imaging modality for evaluating scrotal trauma with severe swelling, with high sensitivity for distinguishing between various etiologies 2
• The most specific findings on ultrasound suggesting testicular rupture include:
  • Loss of testicular contour 1
  • Heterogeneous echotexture of testicular parenchyma 1
  • Discontinuity of the echogenic tunica albuginea 3
• Clinical signs of testicular rupture include scrotal ecchymosis, swelling, and difficulty identifying testicular contours on physical examination 1
• If ultrasound is equivocal or diagnosis remains in doubt, surgical exploration should be performed 1

Management Algorithm

For Blunt Scrotal Trauma:

• If clinical examination or ultrasound suggests testicular rupture:

  • Immediate surgical exploration is indicated 1
  • Debridement of non-viable tissue and closure of the tunica albuginea should be performed when possible 1
  • Tunica vaginalis flap or graft may be used when primary closure of tunica albuginea is not possible 1
  • Orchiectomy should be performed only when the testis is non-salvageable 1

• If no evidence of testicular rupture (intact tunica albuginea on ultrasound):

  • Conservative management with:
    • Bed rest 4
    • Scrotal elevation 2
    • Analgesics 4
    • Follow-up ultrasound to assess resolution of intratesticular hematoma 5

For Penetrating Scrotal Trauma:

• Prompt surgical exploration is required regardless of ultrasound findings due to:
  • High rate (>50%) of testicular injury 1
  • Limited sensitivity of ultrasound in this setting 1
  • Need for debridement and primary repair 1
  • Risk of concomitant injuries to spermatic cord, contralateral testicle, penile structures, or urethra 1

Rationale for Surgical Intervention

• Early exploration and repair prevent complications including:

  • Ischemic atrophy of the testis 1
  • Infection 1
  • Testicular necrosis and abscess formation 6
  • Long-term testicular atrophy and subfertility 6

• Surgical intervention for testicular rupture significantly improves clinical outcomes and reduces the need for delayed orchiectomy 6

Special Considerations

• Evaluate for concomitant urethral injury if there is:

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

• For extensive genital skin loss or injury:

  • Perform exploration and limited debridement of clearly non-viable tissue 1
  • Genital skin is well-vascularized and tissues with marginal viability may survive due to collateral blood flow 1
  • Multiple procedures may be required before definitive reconstruction 1

• Wound management options include:

  • Gauze dressings with frequent changes 1
  • Silver sulfadiazine or topical antibiotic with occlusive dressing 1
  • Negative pressure dressings 1

• Patients with clinical hematocele should proceed directly to surgical exploration without waiting for ultrasound results 5