What is the initial management for a patient with gross hematuria and blunt trauma of the scrotum?

Initial Management of Gross Hematuria with Blunt Scrotal Trauma

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

Immediate Evaluation for Urethral Injury

The presence of gross hematuria in the setting of scrotal trauma is a critical red flag that mandates evaluation for urethral injury. 1 This is a standard recommendation with Grade B evidence strength from the AUA guidelines.

Key diagnostic approach:

• Perform either retrograde urethrogram or urethroscopy—neither method is superior, and the choice depends on equipment availability and timing. 1
• Do not delay this evaluation, as urethral injuries require different management than isolated scrotal trauma. 1

Concurrent Scrotal Assessment

While evaluating for urethral injury, assess the scrotum for testicular rupture:

Physical examination findings suggesting rupture: 1, 2

• Scrotal ecchymosis and swelling
• Difficulty identifying normal testicular contours on palpation

Ultrasound imaging: 1, 2

• Perform urgent scrotal ultrasound
• Most specific findings are loss of testicular contour and heterogeneous echotexture of parenchyma
• These findings mandate surgical exploration

Surgical Decision-Making

If testicular rupture is confirmed or highly suspected, perform immediate scrotal exploration. 1, 2 This is a standard recommendation with Grade B evidence strength.

Surgical approach: 1, 2

• Debride non-viable tissue
• Close the tunica albuginea when possible
• Use tunica vaginalis grafts if primary closure of tunica albuginea is not feasible
• Perform orchiectomy only if the testis is non-salvageable

Early exploration prevents complications including: 2

• Ischemic atrophy of the testis
• Infection

Critical Pitfall to Avoid

The most common error is focusing solely on the scrotal injury and missing a concomitant urethral injury. 1 Gross hematuria in this setting is not simply from testicular trauma—it indicates potential urethral involvement that requires separate evaluation and management. The AUA guidelines explicitly state this evaluation "must" be performed (Standard recommendation, Grade B evidence). 1

Management Algorithm Summary

1. Recognize gross hematuria as a mandatory trigger for urethral injury evaluation 1
2. Perform retrograde urethrogram or urethroscopy to rule out urethral injury 1
3. Simultaneously obtain scrotal ultrasound looking for loss of testicular contour or heterogeneous parenchyma 1, 2
4. Proceed to scrotal exploration if ultrasound shows testicular rupture or clinical suspicion remains high 1, 2
5. Debride and repair the tunica albuginea, using grafts if needed 1, 2

This dual-track approach ensures neither the urethral nor testicular injury is overlooked, optimizing both immediate outcomes and long-term function.