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Rupture of the Testicle
THE JOURNAL OF UROLOGY
Vol. 66, No. 2, August 1951 Printed in U.S.A..
RUPTURE OF THE TESTICLE LOWRAIN E. McCREA
r
Traumatic rupture of the testicle without laceration of the scrotal skin is a rare condition. A review of the literature has revealed a total of 12 previously reported cases. The first case was presented by Cotton in 1906. Since that time the reports of the remaining 11 cases have sporadically appeared in the literature. A thirteenth case is herein reported. Little mention is made of the condition in our texts. No reference could be found as to what procedure was considered to be the proper method of surgical management. An analysis of the presented cases show that 8 were treated by orchiectomy and 4 were treated by closure of the tunica albuginea. Rupture of the testicle when mentioned in our texts is discussed under the subject of contusions. Terrillon and Suchard, in discussing the subject, divide testicular injury into three types: those in which there are disseminated capillary hemorrhages between the seminiferous tubules; those in which the hemorrhages are the size of a pea to that of a cherry, and lastly those in which the tunica albuginea itself is ruptured with bleeding into the tunica vaginalis. It is the last type that is to be considered. It is believed that the condition is of sufficient importance to be considered as an individual clinical entity. An analysis of the previously reported cases shows the defect in the tunica albuginea to be quite extensive. The testicular tubules are herniated within the tunica vaginalis. In some instances the testicular substance was completely shattered. In others the testicular substance was intact but protruded through a tear or rent in the tunica albuginea. The testicles, suspended and protected as they are, are seldom traumatized but occasionally are subject to direct force or sudden pressure. An analysis of the 13 cases to be found in the literature disclosed that all cases of trauma were caused by impacks of a direct nature. Further analyzing the nature of the accident of the reported cases, it would appear that in all the cases the blow was directed upward or obliquely upward. A blow directed in this manner would cause the testicle to be impinged between the symphysis pubis or the thigh and the striking object, regardless of its nature. This may be clearly seen in an analysis of table 1. In not a single instance in which rupture was reported was the scrotum or testicle struck by a soft object. In every instance pain was an immediate symptom. It is interesting to note that the age at which the accident occurred was during the span of life of greatest physical activity, the youngest being 8 years and the oldest 49 years of age. The average age was 23 years. It is recognized that the testes are remarkably sensitive to slight trauma. Trivial injuries to the testes (without rupture) are frequently associated with nausea, vomiting or even shock. It was surprising in an analysis of the cases presented to find only 3 instances of shock. It is interesting to note that shock when present in instances of rupture of the testicle was evident to a minor degree. The 27J
f
271
RUPTURE OF THE TESTICLE TABLE
1 ~-,
NAME
Cotton,
AGE
ACCIDENT
PAIN
SHOCK
47
Struck with baseball
Immediate then subsided
Immediate Slight
Increasing
Yes
Orchiectomy
17
Kicked by horse
Immedia1ie Severe
No
Hydrocele, 1 month
No
Bottle op .. era ti on
8
Fell astride foot board of bed
Marked
No
Yes
Not mentioned
Suture of tunica albuginea
30
Fell astride metal hand rail
Slight
No
Increasing
Not mentioned
Orchiectomy
27
Struck by belt buckle
Intense
No
Increasing
Not mentioned
Orchiectomy
16
Struck by knee playing football.
Severe radiating pain
No
Yes
No
Orchiectomy
27
Blow to scrotum while playing football
Severe pain
No
No
No
Orchiectomy
21
Kicked in scrotum
Immediate but subsided
Yes
Gradual
No
Orchiectomy
17
Struck during basketball game
Slight
No
Gradual swelling
No
Closure tunica albuginea
49
Struck by handle of sledge hammer
Immediate
Slight
Gradual
No
Closure tunica albuginea
1906 Malapert, 1916
Campbell,
1937
Navarrette
1937
Navarrette
1937 Castro,
194-0
Castro,
1940
Sejournet,
1944 Counseller and Pratt,
1944 "Wesson,
1946
I I
SWELLING
VOMITING
OPERATION
272
LOWRAIN E. McCREA TABLE
.NAME
Senger,
1950
SHOCK
28
Kicked in scrotum
Tenderness
No
Increasing
No
Orchiectomy
16
Kicked by horse
Severe
No
Gradual increase
No
Orchiectomy
16
Struck by baseball
Pain imNo mediatelylasted 1 hour
Gradual
No
Modified bottle operation
I
SWELLING
VOMITING
OPERATION
ACCIDENT
1947
McCrea,
PAIN
AGE
1947 Senger,
I-Continued
shock was immediate, slight, temporary. The case presented by Cotton is the only one which developed immediate shock and vomiting following trauma. The symptoms universally portrayed by patients having traumatic rupture of the testicles were immediate pain, which usually subsided, followed by gradual increasing swelling of the scrotum. The usual preoperative diagnosis made was that of an hematocele. Such a diagnosis was made due to continuous bleeding with increasing size of the scrotum. The diagnosis of hematocele has been made frequently by surgeons and urologists for many years. Any number of these cases could well have been rupture of the testicle but apparently stopped bleeding and were followed by gradual resolution. These cases were lost and the end results will never be known. ·whether atrophy of the testicle ultimately occurred or glandular acitivity normally continued cannot be ascertained. It is the writer's conviction, since observing the case to be presented and after having analyzed the previously reported cases, that the scrotum should be surgically opened and the testicle should be examined in every instance in which there is a history of trauma and in which a diagnosis of a hematocele is made. It is further interesting to note that in 4 instances the tunica albuginea was closed by suture and the testicle permitted to remain. Campbell stated that atrophy of the testicle was not apparent in his case 7 years following surgery. This is in direct contrast to the statement of Reclus who dogmatically stated that when the torn tunica albuginea was sutured and not removed, atrophy of the testicle occurred within 6 weeks. It is regrettable that the end results of the other 3 cases in the literature were not mentioned. CASE REPORT
T. R., a 16 year old white boy was struck by a thrown baseball on June 11, 1950. The ball struck the ground, bounced and struck the scrotum. The accident happened about 3 o'clock in the afternoon. He immediately became nauseated but did not vomit. There was no evidence of shock. He experienced slight pain in the right testicle, which pain continued for about 1 hour. He walked home without discomfort and ate a normal evening meal. He noticed that upon removal of his jockey shorts the pain recurred. He retired about 9:30 p.m., but
RUP'I'URE OF 'I'HE TESTICLE
273
was unable to sleep because of constant pain in the testicle. There was a slight swelling of the scrotum. He went to school as usual the next day. He stated he was comfortable as long as the testicles were supported or not compressed by his clothing in any way. He was unable to sleep that night because of dull, constant pain in the testicle. The swelling was relatively the same as 24 hours previously. He was seen 48 hours after the accident by his family physician. At that time there vrns a globular mass about the size of a small orange in the scrotum. The testicle was palpable above the mass and was somewhat tender to palpation. He ,vas treated by hot sitz baths and the use of a scrotal suspensory. He did not complain of any further pains. He played baseball on several occasions, was swimming and diving on 2 occasions and ,vorked as a janitor's assistant for several days. The swelling within the scrotum gradually increased. ·when first seen on June 27, 1950, there was a mass in the scrotum about the size of a large orange. The mass ·was not translucent. The testicle was palpable above the mass and tender to palpation. On July 10, 1950, one month following the accident, the scrotum was opened and a large quantity of blood was evacuated from the tunica vaginalis. An area of capillary bleeding on the wall of the tunica vaginalis was observed and ligated. The tunica albuginea presented a transverse rupture about 4 cm. in length. There was no evidence of bleeding from the testicle. It ,ms impossible to satisfactorily close the rent in the tunica albuginea without making excessive pressure on the testicular substance. The tunica vaginalis was partially resected and a modified "bottle operation" done. Recovery was uneventful. CONCLUSIONS
A case of traumatic rupture of the testicle is presented making the thirteenth case reported in the literature. Review and analysis of the 13 cases reflect the typical symptomatology of pain of varying degrees and swelling of the scrotum due to a hematocele. Severe shock is not a usual symptom of rupture of the testicle. Mild shock was noted in but 3 instances of the 13 cases reported in the literature. Atrophy of the testicle does not always follow conservative surgical measures in the treatment of rupture of the tunica albuginea. Exposure and examination of the testicle are advised in every instance of trauma to the scrotum or its contents in which a hematocele immediately or gradually occurs. 1930 Chestnut St., Philadelphia, Pa. REFERE:'\JCES CAMPBELL, M. F.: Pediatric Urology. New York: Macmillan Co., 1937, vol. 2, p. 188. CASTRO, H. D.: Rev. argent. de urol., 9: 32, 1940. COTTON, F. J.: Am. ,J. Urol., 2: 587, 1905-06. CouNSELLER, V. S. AND PRATT, J. H. JR.: J. Urol., 52: 334, 1944. lVIALAPERT: Gaz. l\fod. de Par., 87: 15, 1916. NAVARRETTE, E.: Rev. mid. Peruarm, 9: 271, 1937. SEJOURNET, M. P.: Bull. et mem. Soc. d.chirurgens de Paris, 35: 101, 1944. SENGER, F. L., BoTTONE, J. J. AND ITTNER, W. F.: J. Urol., 58: 453, 1947. WESSON, M. B.: Urol. & Cutan. Rev., 50: 16, 1946.
Vol. 66, No. 2, August 1951 Printed in U.S.A..
RUPTURE OF THE TESTICLE LOWRAIN E. McCREA
r
Traumatic rupture of the testicle without laceration of the scrotal skin is a rare condition. A review of the literature has revealed a total of 12 previously reported cases. The first case was presented by Cotton in 1906. Since that time the reports of the remaining 11 cases have sporadically appeared in the literature. A thirteenth case is herein reported. Little mention is made of the condition in our texts. No reference could be found as to what procedure was considered to be the proper method of surgical management. An analysis of the presented cases show that 8 were treated by orchiectomy and 4 were treated by closure of the tunica albuginea. Rupture of the testicle when mentioned in our texts is discussed under the subject of contusions. Terrillon and Suchard, in discussing the subject, divide testicular injury into three types: those in which there are disseminated capillary hemorrhages between the seminiferous tubules; those in which the hemorrhages are the size of a pea to that of a cherry, and lastly those in which the tunica albuginea itself is ruptured with bleeding into the tunica vaginalis. It is the last type that is to be considered. It is believed that the condition is of sufficient importance to be considered as an individual clinical entity. An analysis of the previously reported cases shows the defect in the tunica albuginea to be quite extensive. The testicular tubules are herniated within the tunica vaginalis. In some instances the testicular substance was completely shattered. In others the testicular substance was intact but protruded through a tear or rent in the tunica albuginea. The testicles, suspended and protected as they are, are seldom traumatized but occasionally are subject to direct force or sudden pressure. An analysis of the 13 cases to be found in the literature disclosed that all cases of trauma were caused by impacks of a direct nature. Further analyzing the nature of the accident of the reported cases, it would appear that in all the cases the blow was directed upward or obliquely upward. A blow directed in this manner would cause the testicle to be impinged between the symphysis pubis or the thigh and the striking object, regardless of its nature. This may be clearly seen in an analysis of table 1. In not a single instance in which rupture was reported was the scrotum or testicle struck by a soft object. In every instance pain was an immediate symptom. It is interesting to note that the age at which the accident occurred was during the span of life of greatest physical activity, the youngest being 8 years and the oldest 49 years of age. The average age was 23 years. It is recognized that the testes are remarkably sensitive to slight trauma. Trivial injuries to the testes (without rupture) are frequently associated with nausea, vomiting or even shock. It was surprising in an analysis of the cases presented to find only 3 instances of shock. It is interesting to note that shock when present in instances of rupture of the testicle was evident to a minor degree. The 27J
f
271
RUPTURE OF THE TESTICLE TABLE
1 ~-,
NAME
Cotton,
AGE
ACCIDENT
PAIN
SHOCK
47
Struck with baseball
Immediate then subsided
Immediate Slight
Increasing
Yes
Orchiectomy
17
Kicked by horse
Immedia1ie Severe
No
Hydrocele, 1 month
No
Bottle op .. era ti on
8
Fell astride foot board of bed
Marked
No
Yes
Not mentioned
Suture of tunica albuginea
30
Fell astride metal hand rail
Slight
No
Increasing
Not mentioned
Orchiectomy
27
Struck by belt buckle
Intense
No
Increasing
Not mentioned
Orchiectomy
16
Struck by knee playing football.
Severe radiating pain
No
Yes
No
Orchiectomy
27
Blow to scrotum while playing football
Severe pain
No
No
No
Orchiectomy
21
Kicked in scrotum
Immediate but subsided
Yes
Gradual
No
Orchiectomy
17
Struck during basketball game
Slight
No
Gradual swelling
No
Closure tunica albuginea
49
Struck by handle of sledge hammer
Immediate
Slight
Gradual
No
Closure tunica albuginea
1906 Malapert, 1916
Campbell,
1937
Navarrette
1937
Navarrette
1937 Castro,
194-0
Castro,
1940
Sejournet,
1944 Counseller and Pratt,
1944 "Wesson,
1946
I I
SWELLING
VOMITING
OPERATION
272
LOWRAIN E. McCREA TABLE
.NAME
Senger,
1950
SHOCK
28
Kicked in scrotum
Tenderness
No
Increasing
No
Orchiectomy
16
Kicked by horse
Severe
No
Gradual increase
No
Orchiectomy
16
Struck by baseball
Pain imNo mediatelylasted 1 hour
Gradual
No
Modified bottle operation
I
SWELLING
VOMITING
OPERATION
ACCIDENT
1947
McCrea,
PAIN
AGE
1947 Senger,
I-Continued
shock was immediate, slight, temporary. The case presented by Cotton is the only one which developed immediate shock and vomiting following trauma. The symptoms universally portrayed by patients having traumatic rupture of the testicles were immediate pain, which usually subsided, followed by gradual increasing swelling of the scrotum. The usual preoperative diagnosis made was that of an hematocele. Such a diagnosis was made due to continuous bleeding with increasing size of the scrotum. The diagnosis of hematocele has been made frequently by surgeons and urologists for many years. Any number of these cases could well have been rupture of the testicle but apparently stopped bleeding and were followed by gradual resolution. These cases were lost and the end results will never be known. ·whether atrophy of the testicle ultimately occurred or glandular acitivity normally continued cannot be ascertained. It is the writer's conviction, since observing the case to be presented and after having analyzed the previously reported cases, that the scrotum should be surgically opened and the testicle should be examined in every instance in which there is a history of trauma and in which a diagnosis of a hematocele is made. It is further interesting to note that in 4 instances the tunica albuginea was closed by suture and the testicle permitted to remain. Campbell stated that atrophy of the testicle was not apparent in his case 7 years following surgery. This is in direct contrast to the statement of Reclus who dogmatically stated that when the torn tunica albuginea was sutured and not removed, atrophy of the testicle occurred within 6 weeks. It is regrettable that the end results of the other 3 cases in the literature were not mentioned. CASE REPORT
T. R., a 16 year old white boy was struck by a thrown baseball on June 11, 1950. The ball struck the ground, bounced and struck the scrotum. The accident happened about 3 o'clock in the afternoon. He immediately became nauseated but did not vomit. There was no evidence of shock. He experienced slight pain in the right testicle, which pain continued for about 1 hour. He walked home without discomfort and ate a normal evening meal. He noticed that upon removal of his jockey shorts the pain recurred. He retired about 9:30 p.m., but
RUP'I'URE OF 'I'HE TESTICLE
273
was unable to sleep because of constant pain in the testicle. There was a slight swelling of the scrotum. He went to school as usual the next day. He stated he was comfortable as long as the testicles were supported or not compressed by his clothing in any way. He was unable to sleep that night because of dull, constant pain in the testicle. The swelling was relatively the same as 24 hours previously. He was seen 48 hours after the accident by his family physician. At that time there vrns a globular mass about the size of a small orange in the scrotum. The testicle was palpable above the mass and was somewhat tender to palpation. He ,vas treated by hot sitz baths and the use of a scrotal suspensory. He did not complain of any further pains. He played baseball on several occasions, was swimming and diving on 2 occasions and ,vorked as a janitor's assistant for several days. The swelling within the scrotum gradually increased. ·when first seen on June 27, 1950, there was a mass in the scrotum about the size of a large orange. The mass ·was not translucent. The testicle was palpable above the mass and tender to palpation. On July 10, 1950, one month following the accident, the scrotum was opened and a large quantity of blood was evacuated from the tunica vaginalis. An area of capillary bleeding on the wall of the tunica vaginalis was observed and ligated. The tunica albuginea presented a transverse rupture about 4 cm. in length. There was no evidence of bleeding from the testicle. It ,ms impossible to satisfactorily close the rent in the tunica albuginea without making excessive pressure on the testicular substance. The tunica vaginalis was partially resected and a modified "bottle operation" done. Recovery was uneventful. CONCLUSIONS
A case of traumatic rupture of the testicle is presented making the thirteenth case reported in the literature. Review and analysis of the 13 cases reflect the typical symptomatology of pain of varying degrees and swelling of the scrotum due to a hematocele. Severe shock is not a usual symptom of rupture of the testicle. Mild shock was noted in but 3 instances of the 13 cases reported in the literature. Atrophy of the testicle does not always follow conservative surgical measures in the treatment of rupture of the tunica albuginea. Exposure and examination of the testicle are advised in every instance of trauma to the scrotum or its contents in which a hematocele immediately or gradually occurs. 1930 Chestnut St., Philadelphia, Pa. REFERE:'\JCES CAMPBELL, M. F.: Pediatric Urology. New York: Macmillan Co., 1937, vol. 2, p. 188. CASTRO, H. D.: Rev. argent. de urol., 9: 32, 1940. COTTON, F. J.: Am. ,J. Urol., 2: 587, 1905-06. CouNSELLER, V. S. AND PRATT, J. H. JR.: J. Urol., 52: 334, 1944. lVIALAPERT: Gaz. l\fod. de Par., 87: 15, 1916. NAVARRETTE, E.: Rev. mid. Peruarm, 9: 271, 1937. SEJOURNET, M. P.: Bull. et mem. Soc. d.chirurgens de Paris, 35: 101, 1944. SENGER, F. L., BoTTONE, J. J. AND ITTNER, W. F.: J. Urol., 58: 453, 1947. WESSON, M. B.: Urol. & Cutan. Rev., 50: 16, 1946.