Management of Scrotal Injury in Elderly Patients
For an elderly patient with scrotal trauma, immediate ultrasound evaluation is essential to rule out testicular rupture, which requires emergent surgical exploration within hours to salvage the testis, while simple contusions can be managed conservatively with rest, scrotal elevation, and analgesia. 1, 2
Initial Diagnostic Approach
Critical Time-Sensitive Considerations
While testicular torsion is the primary concern in younger patients with acute scrotal pain, in elderly trauma patients, the key distinction is between testicular rupture (requiring emergency surgery) versus contusion or hematoma (managed conservatively). 1, 2
- Testicular torsion is rare in patients over 35 years of age, making traumatic injury the more likely diagnosis in elderly patients with scrotal pain following trauma. 3, 4
Physical Examination Findings
- Assess for severe swelling that prevents adequate palpation of testicular contents - this mandates imaging rather than clinical observation alone. 1
- Look for visible testicular deformity, loss of normal contour, or palpable irregularity - these suggest rupture rather than simple contusion. 1, 2
- Evaluate for expanding hematocele or hematoma - rapid expansion suggests ongoing bleeding requiring surgical intervention. 2
Imaging Protocol
Ultrasound with color Doppler is the first-line imaging modality for all scrotal trauma except degloving injuries. 2
Key Ultrasound Findings
- Discontinuity of the echogenic tunica albuginea indicates testicular rupture - this is the critical finding requiring emergent surgery. 2
- Testicular fracture appears as linear hypoechoic bands through the parenchyma. 2
- Hematocele (blood in tunica vaginalis) and intratesticular hematoma can be differentiated from simple hydrocele. 2
- Color Doppler assessment of testicular perfusion determines viability - absent flow suggests severe vascular injury or complete disruption. 2
Management Algorithm
Testicular Rupture (Tunica Albuginea Disruption)
Emergent surgical exploration is mandatory when rupture is identified, as surgery within hours results in testicular salvage in 80-90% of cases. 2
- Do not delay surgery for additional imaging or observation - the window for salvage is time-dependent. 2
- Surgical debridement of nonviable tissue and primary closure of the tunica albuginea is the standard approach. 2
Simple Contusion or Hematoma Without Rupture
Conservative management is appropriate when ultrasound confirms intact tunica albuginea: 1
- Bed rest with scrotal elevation until swelling and pain subside. 5, 1
- Oral analgesics for pain control - NSAIDs are typically sufficient. 1
- Spermatic cord block may be considered for severe pain that is not controlled with oral medications. 1
- Ice application in the acute phase (first 24-48 hours). 1
Indeterminate Cases
If scrotal swelling makes examination difficult and ultrasound is equivocal or unavailable, prompt urological referral is appropriate. 1
- Transillumination can help differentiate fluid collections from solid masses, though ultrasound is far superior. 1
- Aspiration of the scrotum is rarely indicated for diagnostic purposes and should not delay definitive imaging or surgical consultation. 1
Critical Clinical Pitfalls
- Do not assume all scrotal trauma in elderly patients is benign - testicular rupture can occur from relatively minor trauma, especially in patients with underlying testicular pathology. 2
- Expanding hematoceles require surgical exploration even if initial ultrasound does not show clear rupture, as ongoing bleeding may indicate vascular injury or delayed rupture. 2
- Color Doppler is essential to assess for vascular injuries including pseudoaneurysms, which may require intervention beyond simple observation. 2
- In elderly patients, consider that decreased testicular perfusion may be baseline rather than acute, making comparison to the contralateral side critical. 3