AAST Guidelines for Scrotal Trauma
Primary Recommendation
The WSES-AAST 2019 guidelines do not provide specific recommendations for scrotal trauma management; however, they address urethral injuries that may present with scrotal hematoma, and the American Urological Association recommends urgent surgical exploration for suspected testicular rupture based on clinical and ultrasound findings. 1, 2, 3
Clinical Presentation Requiring Investigation
Patients with scrotal trauma may present with:
- Scrotal hematoma (which may indicate underlying urethral injury) 1
- Scrotal ecchymosis and swelling 2, 3
- Difficulty identifying testicular contours on physical examination 2, 3
- Persistent severe pain, nausea, or vomiting 2
- Blood at the urethral meatus (suggesting concomitant urethral injury) 3
Critical pitfall: Testicular rupture can occur without tenderness—three patients with operatively confirmed rupture had only swelling on examination. 4
Diagnostic Algorithm
Immediate Assessment
- If clinical hematocele is present on examination, proceed directly to surgical exploration without imaging. 4
- For all other presentations, obtain scrotal ultrasound with Doppler urgently (same day, ideally within hours). 2, 3
Ultrasound Findings Mandating Exploration
Proceed to immediate surgical exploration if ultrasound demonstrates: 2, 3, 4
- Loss of testicular contour
- Heterogeneous echotexture of testicular parenchyma
- Disruption of the tunica albuginea
- Extrusion of seminiferous tubules
- Large hematocele
Conservative Management Candidates
Patients can be managed conservatively if ultrasound shows: 4, 5
- No hematocele
- Clearly distinct tunica albuginea
- Absence of fracture planes within the testis
- Isolated intratesticular hematoma without other injuries
Important caveat: One retrospective study suggested conservative management even for testicular rupture may be safe, with only 4/23 patients developing atrophy. 6 However, this contradicts established AUA guidelines and should not guide practice, as early surgical repair prevents ischemic atrophy, infection, chronic pain, and testicular loss. 2, 3
Surgical Management
Operative Technique
All suspected or confirmed testicular ruptures require prompt surgical exploration: 2, 3
- Evacuate hematoma
- Debride non-viable tissue
- Achieve primary closure of tunica albuginea whenever possible
- Use tunica vaginalis flap or graft when primary closure is not feasible 3
- Perform orchiectomy only when testis is non-salvageable 2, 3
Timing
Surgical repair must occur within hours of injury—testicular salvage rates reach approximately 86% with prompt exploration. 7 Delayed presentation significantly worsens outcomes. 2
Concomitant Urethral Injury Evaluation
If scrotal hematoma is present with blood at the urethral meatus, gross hematuria, or inability to void: 1, 3
- Perform retrograde urethrography before any urethral catheterization
- In hemodynamically unstable patients, place suprapubic catheter and defer urethrography
- Rectal examination should be performed to assess for associated rectal injuries (present in up to 5% of cases) 1
Penetrating Scrotal Injuries
Immediate surgical exploration with debridement and repair is mandatory for all penetrating scrotal injuries due to high incidence of testicular rupture. 2, 8
Follow-Up Considerations
- Interval ultrasound is recommended for conservatively managed intratesticular hematomas to assess resolution 4
- Three-month follow-up to evaluate for testicular atrophy (volume <12ml indicates impaired spermatogenesis) 7
- Semen analysis is necessary if atrophy develops, as testicular size alone does not predict fertility 7