What is the approach to managing gross hematuria with blunt trauma to the testicles?

Approach to Gross Hematuria with Blunt Testicular Trauma

In patients with blunt testicular trauma and gross hematuria, you must immediately evaluate for concomitant urethral injury with retrograde urethrography or urethroscopy, while simultaneously performing scrotal ultrasound to assess for testicular rupture. 1

Initial Assessment and Diagnostic Priorities

Evaluate for Urethral Injury First

The presence of gross hematuria in the setting of scrotal trauma raises immediate concern for urethral injury, which occurs in 10-29% of penetrating genital injuries and can occur with blunt trauma. 1

You must perform evaluation for concomitant urethral injury in patients presenting with gross hematuria, blood at the urethral meatus, or inability to void. 1 The AUA guidelines classify this as a Standard recommendation with Grade B evidence strength.

• Diagnostic options include:
  • Retrograde urethrography
  • Urethroscopy
  • Neither method is superior; choose based on equipment availability and timing 1

Assess for Testicular Rupture

Perform scrotal ultrasound to evaluate for testicular rupture, looking specifically for loss of testicular contour and heterogeneous echotexture of parenchyma. 1

Physical examination findings suggesting testicular rupture include: 1

• Scrotal ecchymosis and swelling
• Difficulty identifying testicular contours on palpation
• Large hematocele

Management Algorithm

If Testicular Rupture is Confirmed or Highly Suspected

Perform immediate scrotal exploration and debridement with tunical closure (when possible) or orchiectomy (when non-salvageable). 1 This is an AUA Standard recommendation with Grade B evidence.

• Early exploration and repair prevents complications including ischemic atrophy and infection 1
• Debride non-viable tissue and close the tunica albuginea when possible 1
• Use tunica vaginalis grafts for closure when primary closure of tunica albuginea is not feasible 1
• Blunt scrotal trauma leads to testicular rupture in 50% of cases presenting for evaluation, and early exploration is associated with higher testicular salvage rates 1

If Urethral Injury is Identified

Manage urethral injuries based on location and severity:

• Anterior urethral injuries: immediate direct surgical repair if clinical conditions allow and experienced surgeon available 1
• Posterior urethral injuries: primary repair only if clinical conditions allow; otherwise urinary drainage and delayed urethroplasty 1

If Bladder Injury is Suspected

While less common with isolated testicular trauma, gross hematuria with pelvic trauma warrants bladder evaluation. 2, 3

Perform retrograde cystography with minimum 300 mL contrast via retrograde gravity filling to achieve maximal bladder distention if there is:

• Pelvic fracture (29% incidence of bladder injury with gross hematuria) 2, 3
• Inability to void
• Suprapubic pain or distention 2, 3

Critical Pitfalls to Avoid

Do not miss concomitant urethral injury: The presence of gross hematuria in genital trauma mandates urethral evaluation before assuming the bleeding is solely from testicular injury. 1

Do not delay surgical exploration for testicular rupture: Early exploration (within 72 hours) is associated with higher testicular salvage rates compared to delayed or conservative management. 1 While one retrospective study suggested conservative management may be safe 4, this contradicts established AUA guidelines which are based on Grade B evidence showing improved outcomes with early exploration. 1

Do not rely on microscopic hematuria alone: Gross hematuria has 100% sensitivity and 98.5% specificity for bladder injury in blunt trauma, whereas microscopic hematuria is unreliable. 5 However, in the context of testicular trauma with gross hematuria, you must still evaluate the entire genitourinary tract systematically.

Do not perform inadequate imaging: If cystography is indicated, ensure proper technique with retrograde filling to at least 300 mL; clamping a Foley catheter and relying on IV contrast accumulation is inadequate. 2, 3

Imaging Recommendations for Stable Patients

For hemodynamically stable patients with gross hematuria and blunt trauma:

• Perform IV contrast-enhanced CT of abdomen/pelvis with immediate and delayed images to evaluate kidneys and ureters 1
• Add CT cystography if pelvic fracture present or bladder injury suspected 1, 2
• Perform scrotal ultrasound for testicular evaluation 1
• Consider retrograde urethrography if blood at meatus or inability to void 1