Scrotal
trauma remains a relatively uncommon condition in urology, as reflected in our
study, which identified only 34 cases over a four-year period. The literature
similarly reports a low incidence, with the largest series not exceeding 86
cases collected over 15 to 28 years, corresponding to an annual incidence of 1
to 5.6 cases [1]. This rarity is likely underestimated, since many patients
with minor injuries are managed in emergency departments or by general
practitioners, while others do not seek medical care and are therefore not
included in urological series [1]. The predominant age group for this type of
trauma lies between 20 and 30 years [2-4], consistent with our findings, where
39% of patients were aged 25–34 years. This overrepresentation of young adults
is also highlighted by other authors [2], and can be explained by the higher
exposure of this population to occupational hazards, sports activities, and
interpersonal violence. The mean number of annual cases and the mean age in our
series are comparable to those reported in the literature [3]. Closed scrotal
trauma is the most common presentation. The main causes include physical
assaults, which accounted for 75% of cases in our study; road traffic
accidents, representing 29%; workplace accidents (falls, crushing, machinery
injuries); and sports injuries. Open scrotal trauma is less frequent,
representing approximately 15% of cases in France; in our series, open trauma
accounted for 40% of the 11 patients affected. Their incidence may be higher in
countries where firearms are widely accessible—no longer the case in our
context—while in our population, etiologies mainly included road traffic
accidents, dog bites, and one stab wound.
The
diagnosis of scrotal trauma is generally based on clinical history. However, it
may be more challenging in polytrauma or in patients with altered
consciousness. Scrotal swelling or ecchymosis should raise suspicion.
Associated injuries must also be assessed, as these occur in 20–30% of cases
[3,4], including penile or urethral trauma, perineal or thigh skin lesions,
fractures, or abdominal visceral injuries. In our series, two patients had
concomitant thigh wounds. The delay between trauma and consultation is often
significant. The mean delay in our study was one day (range 0–5 days), whereas
some series report delays up to four days [3-5]. This may result from patient
embarrassment, the illicit nature of the trauma, or spontaneous pain reduction
after the initial hyperalgesic phase [5].
Clinical
presentation depends on the timing of care
In
recent trauma, pain is the most constant symptom [4], often radiating to the
groin and iliac fossa, and may be accompanied by nausea or vomiting. Clinical
examination is frequently limited by pain and edema, making assessment of
testicular integrity difficult. Two classical patterns are described:
hematocele and scrotal hematoma [4,6]. In hematocele, the scrotum is enlarged,
non-transilluminable, and testicles are impalpable. In scrotal hematoma, the
scrotum is enlarged, ecchymotic, and dark red, with the test is difficult to
palpate [7]. Our clinical findings are consistent with the literature. In
neglected trauma, symptoms become less specific: worsening edema, bluish
discoloration, extension of the hematoma beyond the scrotum, or low-grade
fever. Diagnosis may be confused with orchiepididymitis, delayed torsion, or
post-traumatic hydrocele [8]. No neglected trauma was found in our study.
Most
authors agree that a large inflammatory scrotum or hematocele should prompt
urgent surgical exploration even if ultrasound findings are normal [5]. Sellem
emphasized the role of ultrasound in moderate trauma, showing that among 20
moderate cases, 10 had ultrasonographic testicular lesions 7 of which were
confirmed as fractures during surgery. Conversely, Anderson [9-12] found that
among 12 ultrasound-detected testicular lesions, only 5 corresponded to
fractures at exploration. These findings highlight the problem of false
positives, particularly when scrotal edema hinders ultrasound interpretation
[10]. Nevertheless, this does not alter management, as surgery would be
indicated based on clinical findings alone. In our study, scrotal ultrasound
was performed in 75% of cases and detected scrotal hematoma in two patients and
albuginea rupture in six patients, yielding a specificity of 100%.
Magnetic
resonance imaging (MRI), although rarely available in emergency settings, has
shown promising results for identifying tunica albuginea rupture [11]. In a
prospective study of seven patients, MRI reliability reached 100% [12-14].
While MRI may become an important diagnostic tool in the future, it was not
performed in any case in our series. Treatment decisions depend primarily on
the presence of hematocele, hematoma, or ultrasound abnormalities. In the
absence of hematocele and with a normal ultrasound, medical management
(analgesics, NSAIDs, scrotal support) is sufficient [2], as illustrated by
15/56 patients in the series by Kleinclauss [3]. Conversely, hematocele
mandates emergency exploration [15,3], even without tunica albuginea rupture
[6], as early intervention reduces the rate of orchiectomy from 45% to 9% [14].
Early surgery (<72 h) preserves the testicle in 80% of ruptures versus 32%
when delayed beyond 3 days [16]. Hospital stays are also shorter in
early-treated patients [14]. In our series, all patients underwent surgical
exploration (Table 1).
Complications of scrotal
trauma are not well documented in the literature [17]
Infectious
complications include abscesses, perineal cellulitis, and Fournier’s gangrene,
especially in extensive hematomas or associated urethral injury. Although some
advocate prophylactic antibiotics, no consensus exists outside of open trauma
[17]. Long-term complications include: testicular atrophy, reported in up to
50% of cases [5,18,19], attributed to microvascular injury, compression from
edema/hematoma, or autoimmune mechanisms. Contralateral testicular atrophy has
also been described [17]; persistent testicular pain, also reported by
Kleinclauss [3], with poorly understood mechanisms [14]; infertility, estimated
at 5% [3], primarily due to antisperm antibodies after tunica albuginea
rupture. However, several studies suggest that surgical preservation does not
significantly affect semen parameters, whereas orchiectomy does [20]. In our
study, clinical outcomes were favorable in 80% of cases, with only two
complications reported: one testicular atrophy and one case of persistent
testicular pain [21-28].
