Management of Testicular Fracture
All cases of suspected or confirmed testicular rupture require immediate surgical exploration and repair to prevent permanent complications including testicular loss, chronic pain, and erectile dysfunction. 1, 2
Diagnostic Approach
Clinical Presentation
- Suspect testicular rupture when the patient presents with scrotal ecchymosis, severe swelling, or difficulty identifying testicular contours on physical examination after blunt scrotal trauma 1, 2
- Persistent severe pain that doesn't resolve within minutes, accompanied by nausea or vomiting, indicates significant testicular injury requiring emergency evaluation 1
Imaging
- Ultrasound with Doppler is the first-line imaging modality for evaluating suspected testicular rupture 2
- The most specific ultrasonographic findings are loss of testicular contour and heterogeneous echotexture of testicular parenchyma 1, 2
- If ultrasound findings are equivocal or diagnosis remains uncertain, proceed directly to surgical exploration rather than delaying treatment 1
Surgical Management Algorithm
Timing
- Perform surgical exploration within hours of presentation—delayed repair significantly worsens outcomes 1, 2
- Early exploration and repair prevents complications such as ischemic atrophy of the testis, infection, chronic pain, and testicular loss 1, 2
Surgical Technique
- Perform scrotal exploration with debridement of non-viable tissue and primary closure of the tunica albuginea whenever possible 1, 2
- When primary closure of the tunica albuginea cannot be achieved, use tunica vaginalis grafts to provide coverage 1, 2
- Orchiectomy should only be performed when the testis is non-salvageable 1, 2
Concomitant Injuries
- Evaluate for urethral injury if there is blood at the urethral meatus, gross hematuria, or inability to void 2
- For extensive genital skin loss, perform exploration and limited debridement of clearly non-viable tissue 2
Critical Pitfalls to Avoid
- Do not delay seeking emergency care or surgical exploration—testicular rupture requires surgical intervention within hours to prevent permanent complications 1, 2
- Do not rely solely on ultrasound sensitivity, which can be low for testicular rupture; when clinical suspicion is high, proceed to surgical exploration even with equivocal imaging 1, 3
- Do not attempt conservative management in cases of confirmed or suspected rupture of the tunica albuginea, as this is the standard of care requiring surgical intervention 1, 2
Evidence Nuances
While one small case series 4 reported successful conservative management in 7 adolescent boys with delayed presentation (1-5 days post-injury), this contradicts established guideline recommendations. The American Urological Association clearly recommends prompt surgical exploration for all suspected testicular ruptures 1, 2, as this approach prevents the serious complications of ischemic atrophy, infection, chronic pain, and testicular loss that can occur with delayed or conservative management.