What is the recommended treatment for a young to middle-aged man with a suspected testicular fracture due to recent trauma to the groin area?

Testicular Fracture Treatment

Perform urgent scrotal ultrasound immediately upon presentation, and if testicular rupture is confirmed or strongly suspected based on clinical findings (scrotal ecchymosis, swelling, inability to identify testicular contours), proceed directly to surgical exploration and repair—this approach achieves approximately 86% testicular salvage rates and prevents long-term complications including testicular atrophy and infertility. 1

Immediate Diagnostic Approach

Clinical Assessment

• Look specifically for scrotal ecchymosis, swelling, and difficulty identifying testicular contours on physical examination—these findings indicate likely testicular rupture 1
• Check for blood at the urethral meatus, gross hematuria, or inability to void, as these indicate possible concomitant urethral injury requiring additional evaluation 1

Urgent Imaging

• Perform scrotal ultrasound urgently (same day, within hours) to identify loss of testicular contour and heterogeneous echotexture of parenchyma, which mandate immediate surgical exploration 1
• Contrast-enhanced ultrasound can clearly depict testicular fracture lines, tunica albuginea interruption, and hematoma presence 1
• Do not delay surgical exploration if clinical findings are highly suspicious, even if ultrasound is equivocal—proceed directly to surgery in uncertain cases 1

Surgical Management

Indications for Immediate Surgery

• Any suspected or confirmed testicular rupture requires urgent scrotal exploration 1, 2
• Testicular fracture with complete rupture of the tunica albuginea requires surgical repair 2
• Presence of large haematocele or very large intratesticular hematoma warrants surgical intervention 3

Surgical Technique

• Perform scrotal exploration with hematoma evacuation 1
• Close the tunica albuginea when possible 1
• Perform orchiectomy only when the testicle is non-salvageable 1

Conservative Management (Limited Role)

Conservative management may be considered only in mild fracture cases without rupture of the tunica albuginea, consisting of rest, anti-inflammatory drugs, and testicular support with close surveillance 2, 3. However, this approach requires:

• Absence of clinical and ultrasonographic criteria of severity (no haematocele, no very large intratesticular haematoma, no rupture of tunica albuginea) 3
• Regular surveillance to detect any deterioration 3

Critical Timing Considerations

• Prompt surgical exploration at the time of presentation provides the best outcomes—testicular salvage rates reach approximately 86% when explored urgently 1
• Delayed diagnosis leads to worse outcomes including ischemic atrophy and reduced fertility potential 1
• Even in cases with doubtful clinical or ultrasound findings, surgical exploration must be performed as soon as possible 3

Long-Term Complications to Prevent

• Testicular atrophy (volume <12ml) can result from untreated or inadequately treated trauma, leading to impaired spermatogenesis and reduced fertility 1
• Testicular volumes below 12ml correlate with reduced total sperm count and sperm concentration 1
• Ischemic atrophy can occur as a complication of delayed or conservative management 1

Common Pitfalls to Avoid

• Do not delay imaging or surgical exploration when testicular rupture is suspected—early intervention is critical for testicular salvage 1
• Do not assume normal fertility based on testicular size alone after trauma—semen analysis is necessary if atrophy develops 1
• Do not rely solely on ultrasound sensitivity, which can be low for diagnosing testicular rupture—when in doubt, explore surgically 3