What is the appropriate treatment for a young to middle-aged man with a recent history of trauma to the groin area and suspected testicular fracture?

Treatment of Testicular Fracture

Perform immediate scrotal exploration with debridement and tunical closure in all patients with suspected testicular rupture following trauma. 1

Diagnostic Approach

Clinical Presentation

• Suspect testicular rupture when the patient presents with scrotal ecchymosis, swelling, or difficulty identifying testicular contours on physical examination after blunt or penetrating scrotal trauma 1
• Persistent severe pain that doesn't resolve within minutes, along with nausea or vomiting, suggests significant testicular injury requiring urgent evaluation 2

Imaging Evaluation

• Ultrasound is the primary imaging modality to evaluate suspected testicular rupture, though it has limited sensitivity for detecting tunica albuginea disruption 3
• The most specific ultrasonographic findings are loss of testicular contour and heterogeneous echotexture of parenchyma, which should prompt immediate surgical repair 1
• Perform ultrasound urgently (same day or within hours) as delayed diagnosis leads to worse outcomes including ischemic atrophy and infection 4, 2
• If ultrasound findings are equivocal or diagnosis remains uncertain, proceed directly to surgical exploration rather than delaying treatment 1, 3

Surgical Management

Indications for Immediate Exploration

• All cases of suspected or confirmed testicular rupture require prompt surgical exploration and repair 1, 5, 6
• Early exploration and repair prevents complications such as ischemic atrophy of the testis, infection, chronic pain, and testicular loss 1, 2, 5

Surgical Technique

• Perform scrotal exploration with debridement of non-viable tissue and primary closure of the tunica albuginea whenever possible 1
• When primary closure of the tunica albuginea cannot be achieved, use tunica vaginalis grafts to provide coverage 1
• Orchiectomy should only be performed when the testis is non-salvageable 1
• For penetrating scrotal injuries, immediate exploration with debridement and repair is mandatory to prevent complications 1

Important Distinction: Fracture vs. Rupture

• Testicular fracture refers to a "break" in the testicular parenchyma, while testicular rupture is disruption of the tunica albuginea with extrusion of testicular contents 7
• Despite this technical distinction, both conditions typically require surgical exploration, as fractures are often accompanied by complete rupture of the tunica albuginea 7

Critical Pitfalls to Avoid

• Do not delay surgical exploration: Prompt repair within hours significantly reduces complications including testicular loss, chronic pain, and permanent organ damage 2, 5, 6
• Do not rely solely on ultrasound: Ultrasound has low sensitivity for testicular rupture; when clinical suspicion is high despite equivocal imaging, proceed to surgical exploration 3
• Do not attempt conservative management in adults: While one study reported success with conservative treatment in select adolescent boys with delayed presentation 8, the AUA guideline standard of care remains surgical exploration for suspected testicular rupture in the general population 1

Conservative Management Exception

• Conservative management (scrotal support, antibiotics, rest, analgesics, serial ultrasound) has been reported only in highly select adolescent boys with delayed presentation (1-5 days post-injury) and preserved blood flow 8
• This approach contradicts standard guideline recommendations and should not be applied to the general adult population 1