What are the recommended management and treatment options for a patient with a constant dull ache in the testes that worsens with movement two weeks after blunt trauma?

Management of Persistent Testicular Pain Two Weeks After Blunt Trauma

This patient requires urgent scrotal ultrasound to evaluate for testicular rupture or delayed complications, followed by surgical exploration if imaging shows loss of testicular contour, heterogeneous parenchyma, or if clinical suspicion remains high despite equivocal imaging. 1

Immediate Diagnostic Evaluation

Clinical Assessment

• Examine for scrotal ecchymosis, swelling, and ability to identify testicular contours on physical exam - difficulty palpating normal testicular anatomy suggests possible rupture 1
• Pain worsening with movement at two weeks post-injury is concerning for ongoing pathology rather than simple contusion 2
• Check for dysuria (present in 10% of cases) and perform urinalysis for microhematuria (found in 11.8% of blunt scrotal trauma) 2

Ultrasound Imaging

• Scrotal ultrasound is the primary diagnostic modality and should be performed urgently 1, 3
• The most specific ultrasonographic findings indicating testicular rupture are: loss of testicular contour and heterogeneous echotexture of parenchyma 1
• Intratesticular lucencies representing hematoma or extruded parenchyma suggest disruption 3

Critical caveat: Ultrasound has significant limitations in diagnosing testicular rupture. Studies show it fails to identify rupture in the majority of cases, with nonspecific findings common even when rupture is present 4. In one series, 6 of 8 patients with testicular rupture had ultrasonography that showed only nonspecific abnormalities 4. However, testicular rupture is universally associated with an abnormal ultrasound scan 4.

Surgical Decision-Making

Indications for Immediate Exploration

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

Explore surgically if:

• Ultrasound shows loss of testicular contour or heterogeneous parenchyma 1
• Physical exam reveals difficulty identifying normal testicular anatomy despite imaging 1
• High-energy mechanism of injury with abnormal ultrasound (even if nonspecific findings) 4
• Persistent or worsening pain at two weeks suggests ongoing pathology 2

Surgical Technique

• Debride non-viable tissue and close the tunica albuginea when possible 1
• Tunica vaginalis grafts may be used when primary closure of tunica albuginea is not feasible 1
• Evacuate hematoma during exploration 5

Outcomes Based on Management Timing

The evidence strongly favors early surgical exploration over conservative management:

• Conservative management of blunt trauma led to complete testicular loss in 21% of cases versus only 6% with prompt exploration 5
• Early exploration and repair prevents complications including ischemic atrophy and infection 1
• Testicular salvage rate approaches 100% with urgent exploration in true rupture cases 4
• Delayed presentation (mean 3.5 days) is common but does not preclude excellent salvage rates with exploration 4

Conservative Management Considerations

If ultrasound is completely normal and physical exam is reassuring, conservative management may be appropriate 4:

• Injuries with normal testicular ultrasonography may be managed conservatively 4
• However, 25.1% of patients develop prolonged scrotal pain lasting more than 2 weeks after blunt trauma 2
• This patient's persistent pain at two weeks warrants aggressive evaluation given the risk of missed rupture

Clinical Algorithm

1. Perform urgent scrotal ultrasound 1, 3
2. If ultrasound shows loss of contour or heterogeneous parenchyma → immediate surgical exploration 1
3. If ultrasound shows nonspecific abnormalities with high clinical suspicion (persistent pain, difficulty palpating normal anatomy, high-energy mechanism) → surgical exploration 4
4. If ultrasound is completely normal with reassuring exam → conservative management with close follow-up 4

Given this patient's persistent pain worsening with movement at two weeks post-injury, the threshold for surgical exploration should be low, as delayed rupture or evolving complications may be present despite initial conservative management.