Adverse Effects and Complications of Testicular Tunica Albuginea Tear
A tear in the testicular tunica albuginea leads to testicular rupture with extrusion of seminiferous tubules, and without prompt surgical repair within hours, results in ischemic atrophy, testicular loss, infection, chronic pain, and potential infertility. 1, 2, 3
Immediate Pathophysiological Consequences
When the tunica albuginea ruptures, the following cascade occurs:
- Extrusion of testicular contents: Seminiferous tubules herniate through the tear, becoming exposed to the scrotal environment 2, 4
- Hematocele formation: Blood accumulates around the testis, creating a compressive effect that further compromises testicular perfusion 2, 3
- Vascular compromise: Severe swelling and hematoma formation compress testicular blood supply, initiating ischemic injury 4
Major Complications Without Timely Surgical Repair
Testicular Loss and Atrophy
- Ischemic atrophy is the most common complication when repair is delayed beyond a few hours, as the compromised blood supply leads to irreversible testicular tissue death 1, 2, 3
- Testicular salvage rates drop dramatically with delay: Surgical repair within hours yields approximately 86% salvage rates, but delays significantly reduce this outcome 2
- Testicular atrophy is defined as volume less than 12 mL on follow-up ultrasound at three months, indicating impaired spermatogenesis 2
- Orchiectomy becomes necessary when the testis is non-salvageable due to extensive necrosis from delayed treatment 1, 3
Infectious Complications
- Infection risk increases when extruded seminiferous tubules and hematoma provide a medium for bacterial growth, particularly when surgical debridement is delayed 1, 3
- Abscess formation can occur as a secondary complication of untreated testicular rupture 1
Fertility Impairment
- Impaired spermatogenesis results from testicular atrophy, requiring semen analysis when atrophy is identified on follow-up imaging 2
- Bilateral injury risk: In penetrating trauma, there is potential for concomitant contralateral testicular injury that must be evaluated 1
Chronic Pain and Functional Disability
- Chronic scrotal pain develops as a long-term sequela when testicular rupture is inadequately treated 4
- Erectile dysfunction can occur as a complication of severe testicular injury 4
Critical Timing Factor
The evidence strongly emphasizes that timing of surgical intervention is the single most important determinant of outcome:
- Immediate exploration (within hours) prevents the cascade of ischemic injury 2, 3
- Delayed presentation worsens all outcomes, including higher rates of orchiectomy, infection, and chronic complications 4
- Even in cases where spontaneous epithelialization across extruded tubules has been documented at 6 weeks, this is not recommended management as it represents an exceptional case rather than standard outcome 5
Surgical Management Prevents Complications
The American Urological Association guidelines make clear that prompt surgical exploration with debridement of non-viable tissue and primary closure of the tunica albuginea is the standard of care to prevent these adverse effects 1, 2, 3:
- Evacuation of hematocele relieves vascular compression 2
- Debridement of non-viable tissue prevents infection and removes necrotic material 1, 2
- Primary tunical closure restores testicular integrity and prevents ongoing extrusion 1, 2
- Tunica vaginalis flap coverage can be used when primary closure is impossible, providing an alternative to orchiectomy 1, 3
Clinical Pitfall to Avoid
Do not rely on ultrasound sensitivity alone to rule out testicular rupture, as ultrasound has limited sensitivity for detecting tunica albuginea tears, particularly in penetrating trauma where exploration rates exceed 50% for testicular injury despite imaging 1, 6. When clinical examination reveals scrotal ecchymosis, severe swelling, or inability to identify testicular contours, proceed directly to surgical exploration rather than delaying for equivocal imaging 1, 3, 6.