Diagnosis and Management of Blunt Testicular Trauma
Diagnostic Approach
Scrotal ultrasound with Doppler is the first-line imaging modality for evaluating blunt testicular trauma, and should be performed urgently to identify testicular rupture, which requires immediate surgical exploration. 1, 2
Key Clinical Features to Assess
- Scrotal ecchymosis, severe swelling, and inability to palpate normal testicular contours on physical examination strongly suggest testicular rupture 2
- History of direct impact to the scrotum from sports injuries, motor vehicle accidents, or assault 1, 3
- Presence of blood at the urethral meatus, gross hematuria, or inability to void indicates potential concomitant urethral injury requiring additional evaluation 2
Ultrasound Findings
The most specific ultrasound findings indicating testicular rupture include:
- Loss of testicular contour or disruption of the tunica albuginea 1, 2
- Heterogeneous testicular echotexture 1, 2
- Visualization of a fracture line through the testicular parenchyma 1
- Hematocele (blood collection around the testis) 4
Important caveat: Ultrasound has high sensitivity but imperfect specificity—it can show nonspecific abnormalities without clearly demonstrating rupture, yet testicular rupture is universally associated with an abnormal ultrasound 5. When clinical suspicion is high based on mechanism of injury and physical exam findings, proceed to surgical exploration even if ultrasound findings are equivocal 5.
Management Algorithm
When Testicular Rupture is Confirmed or Highly Suspected
Immediate surgical exploration with debridement and tunical repair should be performed, as early intervention (within hours to days) maximizes testicular salvage rates and prevents complications including ischemic atrophy and infection. 1, 2
Surgical technique:
- Explore the scrotum and evacuate hematoma 2
- Debride non-viable testicular tissue 2
- Close the tunica albuginea primarily when possible 2
- Use tunica vaginalis flap or graft if primary closure is not feasible 2
- Perform orchiectomy only when the testis is completely non-salvageable 1, 2
Testicular salvage rates approach 100% with early exploration, even in cases of true rupture 5. Studies demonstrate that early surgical intervention provides superior long-term outcomes compared to conservative management 1, 4.
When Ultrasound Shows Only Intratesticular Hematoma Without Rupture
Conservative management is appropriate for isolated intratesticular hematomas without tunica albuginea disruption 4. This includes:
- Pain control with analgesics 6
- Scrotal support 6
- Rest and ice application 6
- Serial ultrasound examinations to monitor resolution 6
When Ultrasound Shows Hematoma of Scrotal Layers Only
Conservative management without surgical exploration is appropriate 4.
Critical Pitfalls to Avoid
Do not delay surgical exploration when testicular rupture is suspected clinically, even if ultrasound is equivocal 5. High-energy mechanisms (motorcycle accidents, direct kicks) warrant a low threshold for exploration 5, 6.
Do not miss concomitant urethral injury—evaluate with retrograde urethrogram or urethroscopy if blood at meatus, hematuria, or voiding difficulty is present 2. Urethral injury occurs in 10-22% of genital trauma cases 1.
Do not miss testicular rupture in polytrauma patients—scrotal injuries may be triaged below more obvious injuries, leading to delayed diagnosis and worse outcomes 6. Obtain scrotal ultrasound early in the evaluation sequence 6.
Special Considerations
For penetrating scrotal injuries, surgical exploration is mandatory as over 50% will have testicular rupture 1. The threshold for exploration should be lower than with blunt trauma 1.
MRI is not routinely indicated but may serve as a problem-solving tool when ultrasound findings are unclear 1, 3. However, it should not delay surgical exploration when clinical suspicion is high 1.
CT imaging is not routinely used for isolated scrotal trauma evaluation 1.