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Traumatic Rupture of the Testicle
THE JOURNAL OF UROLOGY
Vol. 96, July Printed in U.S.A.
Copyright @ 1966 by The Williams & Wilkins Co.
TRAUMATIC RUPTURE OF THE TESTICLE J. L. McCORMACK, A. W. KRETZ
AND
R. TOCANTINS
From· the Department of Urology, The Swedish Medical Center,Seattle, Washington
Testicular rupture by blunt trauma has been considered rare. Bronk and Ben-y suggest that one reason for the paucity of reported cases is that surgical exploration does not necessarily follow the diagnosis of hematocele.1 Only 27 cases of traumatic rupture of the testis have been reported in the literature.2 - 3 Five additional instances of testicular rupture have been treated in two Seattle hospitals during the past 10 years. In more than half of the cases previously reported injury occurred during participation in athletics.None of the reported injuries occurred in ectopic or undescended testes. In only 1 man (who had a seminoma) was testicular disease found to antedate the injury. None of the 5 patients to be described had pre-existing disease and all five were injured during sporting recreation. Direct blunt trauma to the scrotum is required to rupture the tough, inelastic tunica albuginea. There may be two types of kinetic force which produce this injury. Three of the patients to be described experienced a crushing force to the scrotum where the testis was undoubtedly impinged against a ramus of the pubic bone. The other 2 patients were struck by missiles traveling at moderate velocity. In these latter instances one wonders if the testes were hanging loosely in the scrotum and literally exploded on contact or if the testis was forced against the ramus of the pubic bone allowing crushing to occur. In all cases the basic injury was rupture of the tunica albuginea. CASE REPORTS
Case 1. While scuffling with a friend a 17-yearold boy was struck in the right groin and immediately experienced severe pain and swelling in the right testicle. Fifteen hours later examination showed a swollen, firm, red, tender mass in the Accepted for publication July 9, 1965. Read at annual meeting of Western Section, American Urological Association, Inc., San Francisco, California, April 26-29, 1965. 1 Bronk, W. S. and Berry, J. L.: Traumatic rupture of the testicle: Report of a case and a review of the literature. J. Urol., 87: 564, 1962. 2 Counseller, V. S. and Pratt, J. H., Jr.: Rupture of the testicle: Report of cases and review of literature. J. Urol., 62: 334, 1944. 3 Senger, F. L., Bottone, J. J. and Ittner, W. F.: Traumatic rupture of the testicle. J. Urol., 68: 451, 1947.
80
right scrotum which did not transilluminate. The preoperative impression was acute torsion of the testis or testicular appendage or rupture of the testis. Immediate surgical exploration revealed a hematocele and a laceration of the tunica albuginea through which testicular tubules extruded. A portion of the tubules was excised permitting closure of the tunica albuginea. This reduced the total testicular mass by about 30 per cent. One year later the injured testis felt smaller than the left but firm and viable. Case 2. Three days following a fall from a bicycle a 13-year-old boy was seen by his family physician because of continued painful swelling in the left testis and fever of 104F. For a presumptive diagnosis of acute epididymitis he was treated with penicillin and chloramphenicol. The fever subsided and the scrotal swelling seemed to decrease during the 7 days of his hospital care. After discharge the acute process recurred but did not respond to additional antibiotic therapy. A few hours prior to his second hospital admission, 22 days after injury, the large, swollen, scrotal mass spontaneously drained seropurulent matter. A culture of the drainage was sterile and no sperm cells were seen on smear. Surgical exploration through an extensively thickened and indurated scrotal wall showed a laceration of the tunica albuginea. The extruding tubules appeared macerated and the epididymis was indurated. An orchiectomy was performed and the microscopic study showed necrosis of all the testicular tubules. Convalescence was uneventful. Case 3. A 19-year-old boy suffered an injury to the groin when his motor boat struck a piling and he was thrown across the gunwhale. He felt immediate pain and noted swelling with discoloration of the scrotal skin. During the next 8 days the swelling increased and the ecchymosis extended into the suprapubic and perinea! areas. Surgical exploration 9 days after injury showed an extensive laceration of the tunica albuginea. There was a large hematoma in the scrotum containing an estimated 200 ml. blood with blood extravasating along the cord. It was assumed that the laceration had extended into the tunica vaginalis allowing the extensive extravasation of blood. An orchiectomy was done. Convalescence was uneventful.
TRAUMATIC RUPTURE OF TESTICLE
Case 4, A 23-year-old college football player ,ms struck in the right scrotum with a baseball and immediately experienced moderately severe pain, Swelling soon developed, With conservative treatment, including a scrotal wspensory and ice packs, the patient was able to continue his usual school activities (no football) but after 8 days there was no reduction in the pain or scrotal turgor, Surgical exploration revealed a tense hematocele and a 2 cm, laceration of the tunica albuginea TABLE
L S11,mmary of testicular rupture
i Constant I Pain and , Turgor
Hematocele
1
Delay in Treatment
I !
Result
--~1---i--I
17 13 19
23 23
X X X X
X
Yes
I No I
No Yes
I Yes
15 hrs, I Salvage 22 days Orchiectomy 9 days Orchiectomy 8 days Salvage 3 Slonghed
81
with protrusion of some of the testicular tubnlef, The tubules were replaced and the tunica albu, ginea was closed, The tunica vaginalis was everted. Followup examination showed a testis normal to palpation. Case 5, A 23-year-old medical student ,rn,S struck in the left scrotum by a golf ball and experienced immediate pain with ,;crotal swelJ., ing and nausea. Despite conservative treatment, including ice packs and scrotal support, the pain continued, On the third day following the injury he had a swollen, red, tense, tender maKs in the left scrotum, Surgical exploration revealed a htimatocele and laceration of the tunica albuginea about 2 cm. long. The protruding testicular tn, bules were excised, the laceration was closed anc\ the scrotum was drained, During the next 2 months he had constant drainage from the scrotum, At the end of this time no testicular tissue could be felt, He has subsequently married and has 2 children,
F'w. l. A, diagram of hemalocele, B, rupture of tunica a.lbuginea. C, surgical
82
MCCORMACK, KRETZ AND TOCANTINS DISCUSSION
All 5 patients in the cases herein reported complained of testicular pain and turgor following trauma (table 1). Ecchymosis was a prominent finding in 1 patient while in another, where exploration was delayed 22 days, systemic signs of inflammation were present. Acute epididymitis was the provisional diagnosis in four of the 5 cases and undoubtedly this erroneous impression led to the significant delay in definitive surgical treatment. Despite this delay a good result was ultimately obtained in one of the 4 patients. The remaining patient was seen and operated upon by a urologist 15 hours after injury. This testicle was salvaged and a good result was obtained. Orchiectomy was the procedure chosen in 2 cases. In one the laceration of the tunica albuginea extended to involve the tunica vaginalis resulting in extravasation of blood along the spermatic cord and into the suprapubic and perinea! areas. It is unlikely that the 9-day delay in his treatment altered the decision for orchiectomy. In the other patient who had an orchiectomy definitive treatment was delayed for 22 days. More immediate surgical treatment may have allowed salvage of the testicle rather than spontaneous evacuation of the infected hematocele. In the other 3 patients who developed typical hematoceles an attempt was made to save the testicle. The technique used was surgical closure of the tunica albuginea after excision of the exposed and necrotic testicular tubules (fig. 1). In 2 cases the maneuver was successful while in 1 case the remaining testicular tissue sloughed. In none of the 5 patients did the generally accepted measures for conservative treatment of testicular disease seem to alter the course of the process. To be considered in the differential diagnosis of testicular rupture are those dirnases which produce a painful, swollen, scrotal mass. When it is possible to exclude disease which pre-exists external trauma the remaining causes of this syndrome include acute epididymitis, torsion of either the testicle or a testicular appendage, or rupture of thetunicaalbuginea. Identification of bloody fluid by the aspiration of the hydrocele cavity should make surgical exploration mandatory. Sargent describes the result of neglect: "The delicacy of the spermatogenic tissue is such that severe injury almost inevitably terminates in complete testicular atrophy. Here secondary infection with abscess and sloughing is more prone to occur than in those injuries without frank rupture." 4 4 Sargent, J. C.: Injuries of genital tract. In: Urology. Edited by M. F. Campbell, vol. 2: chapt.
However, of particular interest was Wesson's report in 1946 of his management of a patient with a traumatic rupture of a solitary testicle. 5 On 3 occasions he aspirated the hematocele. When surgical exploration was carried out on the twenty-third day yellow fluid filled the cavity and the necrotic slough was easily removed making closure of the lacerated tunica albuginea possible. The testicle was salvaged. We have had no experience with multiple aspirations of a hematocele. Undoubtedly the extent of the injury influences the recovery of the damaged testis. Atwell and Ellis mention 3 patients with minor hematoceles in whom recovery was spontaneous, presumably by reabsorption of the blood and necrotic testicular tissue. 6 This may explain the atrophic testis sometimes found in older men during routine examination where there is only a vague history of testicular trauma. One possible consequence of this type of injury to be considered is an auto-immune reaction to one's own sperm. Whether spermatic cells after extravasation of testicular tissue act as antigens and produce antibodies under these circumstances is not known. One patient of this group conceived 2 children after his injury. The fertility status of the other 4 patients is unknown. CONCLUSION
Testicular rupture requires a non-penetrating external force to the testis to produce a tear of the tunica albugi.nea. Usually the laceration, limited to the tunica albuginea, produces a hematocele. The more promptly this condition is recognized and specific surgical repair of the laceration is effected, the less is the chance of complication and the greater is the opportunity for salvage of the testicle. The recognition of a hematocele by aspiration is suggested as one method of diagnosing testicular rupture. Early surgical exploration of the scrotum is recommended. SUMMARY
The cases of 5 patients who had traumatic rupture of the tunica albuginea are described. When this condition is suspected surgical exploration of the testicle is recommended. 4, pp. 926-951. Philadelphia: W. B. Saunders Co. 1954. I 6 Wesson, M. B.: Traumatism of the testicle· report of a case of traumatic rupture of a solitary testicle. Urol. & Cutan. Rev., 50: 16-19 1946. 6 Atwell, J. D. and Ellis, H.: Ruptu;e of the testis. Brit. J. Surg., 49: 345, 1961.
Vol. 96, July Printed in U.S.A.
Copyright @ 1966 by The Williams & Wilkins Co.
TRAUMATIC RUPTURE OF THE TESTICLE J. L. McCORMACK, A. W. KRETZ
AND
R. TOCANTINS
From· the Department of Urology, The Swedish Medical Center,Seattle, Washington
Testicular rupture by blunt trauma has been considered rare. Bronk and Ben-y suggest that one reason for the paucity of reported cases is that surgical exploration does not necessarily follow the diagnosis of hematocele.1 Only 27 cases of traumatic rupture of the testis have been reported in the literature.2 - 3 Five additional instances of testicular rupture have been treated in two Seattle hospitals during the past 10 years. In more than half of the cases previously reported injury occurred during participation in athletics.None of the reported injuries occurred in ectopic or undescended testes. In only 1 man (who had a seminoma) was testicular disease found to antedate the injury. None of the 5 patients to be described had pre-existing disease and all five were injured during sporting recreation. Direct blunt trauma to the scrotum is required to rupture the tough, inelastic tunica albuginea. There may be two types of kinetic force which produce this injury. Three of the patients to be described experienced a crushing force to the scrotum where the testis was undoubtedly impinged against a ramus of the pubic bone. The other 2 patients were struck by missiles traveling at moderate velocity. In these latter instances one wonders if the testes were hanging loosely in the scrotum and literally exploded on contact or if the testis was forced against the ramus of the pubic bone allowing crushing to occur. In all cases the basic injury was rupture of the tunica albuginea. CASE REPORTS
Case 1. While scuffling with a friend a 17-yearold boy was struck in the right groin and immediately experienced severe pain and swelling in the right testicle. Fifteen hours later examination showed a swollen, firm, red, tender mass in the Accepted for publication July 9, 1965. Read at annual meeting of Western Section, American Urological Association, Inc., San Francisco, California, April 26-29, 1965. 1 Bronk, W. S. and Berry, J. L.: Traumatic rupture of the testicle: Report of a case and a review of the literature. J. Urol., 87: 564, 1962. 2 Counseller, V. S. and Pratt, J. H., Jr.: Rupture of the testicle: Report of cases and review of literature. J. Urol., 62: 334, 1944. 3 Senger, F. L., Bottone, J. J. and Ittner, W. F.: Traumatic rupture of the testicle. J. Urol., 68: 451, 1947.
80
right scrotum which did not transilluminate. The preoperative impression was acute torsion of the testis or testicular appendage or rupture of the testis. Immediate surgical exploration revealed a hematocele and a laceration of the tunica albuginea through which testicular tubules extruded. A portion of the tubules was excised permitting closure of the tunica albuginea. This reduced the total testicular mass by about 30 per cent. One year later the injured testis felt smaller than the left but firm and viable. Case 2. Three days following a fall from a bicycle a 13-year-old boy was seen by his family physician because of continued painful swelling in the left testis and fever of 104F. For a presumptive diagnosis of acute epididymitis he was treated with penicillin and chloramphenicol. The fever subsided and the scrotal swelling seemed to decrease during the 7 days of his hospital care. After discharge the acute process recurred but did not respond to additional antibiotic therapy. A few hours prior to his second hospital admission, 22 days after injury, the large, swollen, scrotal mass spontaneously drained seropurulent matter. A culture of the drainage was sterile and no sperm cells were seen on smear. Surgical exploration through an extensively thickened and indurated scrotal wall showed a laceration of the tunica albuginea. The extruding tubules appeared macerated and the epididymis was indurated. An orchiectomy was performed and the microscopic study showed necrosis of all the testicular tubules. Convalescence was uneventful. Case 3. A 19-year-old boy suffered an injury to the groin when his motor boat struck a piling and he was thrown across the gunwhale. He felt immediate pain and noted swelling with discoloration of the scrotal skin. During the next 8 days the swelling increased and the ecchymosis extended into the suprapubic and perinea! areas. Surgical exploration 9 days after injury showed an extensive laceration of the tunica albuginea. There was a large hematoma in the scrotum containing an estimated 200 ml. blood with blood extravasating along the cord. It was assumed that the laceration had extended into the tunica vaginalis allowing the extensive extravasation of blood. An orchiectomy was done. Convalescence was uneventful.
TRAUMATIC RUPTURE OF TESTICLE
Case 4, A 23-year-old college football player ,ms struck in the right scrotum with a baseball and immediately experienced moderately severe pain, Swelling soon developed, With conservative treatment, including a scrotal wspensory and ice packs, the patient was able to continue his usual school activities (no football) but after 8 days there was no reduction in the pain or scrotal turgor, Surgical exploration revealed a tense hematocele and a 2 cm, laceration of the tunica albuginea TABLE
L S11,mmary of testicular rupture
i Constant I Pain and , Turgor
Hematocele
1
Delay in Treatment
I !
Result
--~1---i--I
17 13 19
23 23
X X X X
X
Yes
I No I
No Yes
I Yes
15 hrs, I Salvage 22 days Orchiectomy 9 days Orchiectomy 8 days Salvage 3 Slonghed
81
with protrusion of some of the testicular tubnlef, The tubules were replaced and the tunica albu, ginea was closed, The tunica vaginalis was everted. Followup examination showed a testis normal to palpation. Case 5, A 23-year-old medical student ,rn,S struck in the left scrotum by a golf ball and experienced immediate pain with ,;crotal swelJ., ing and nausea. Despite conservative treatment, including ice packs and scrotal support, the pain continued, On the third day following the injury he had a swollen, red, tense, tender maKs in the left scrotum, Surgical exploration revealed a htimatocele and laceration of the tunica albuginea about 2 cm. long. The protruding testicular tn, bules were excised, the laceration was closed anc\ the scrotum was drained, During the next 2 months he had constant drainage from the scrotum, At the end of this time no testicular tissue could be felt, He has subsequently married and has 2 children,
F'w. l. A, diagram of hemalocele, B, rupture of tunica a.lbuginea. C, surgical
82
MCCORMACK, KRETZ AND TOCANTINS DISCUSSION
All 5 patients in the cases herein reported complained of testicular pain and turgor following trauma (table 1). Ecchymosis was a prominent finding in 1 patient while in another, where exploration was delayed 22 days, systemic signs of inflammation were present. Acute epididymitis was the provisional diagnosis in four of the 5 cases and undoubtedly this erroneous impression led to the significant delay in definitive surgical treatment. Despite this delay a good result was ultimately obtained in one of the 4 patients. The remaining patient was seen and operated upon by a urologist 15 hours after injury. This testicle was salvaged and a good result was obtained. Orchiectomy was the procedure chosen in 2 cases. In one the laceration of the tunica albuginea extended to involve the tunica vaginalis resulting in extravasation of blood along the spermatic cord and into the suprapubic and perinea! areas. It is unlikely that the 9-day delay in his treatment altered the decision for orchiectomy. In the other patient who had an orchiectomy definitive treatment was delayed for 22 days. More immediate surgical treatment may have allowed salvage of the testicle rather than spontaneous evacuation of the infected hematocele. In the other 3 patients who developed typical hematoceles an attempt was made to save the testicle. The technique used was surgical closure of the tunica albuginea after excision of the exposed and necrotic testicular tubules (fig. 1). In 2 cases the maneuver was successful while in 1 case the remaining testicular tissue sloughed. In none of the 5 patients did the generally accepted measures for conservative treatment of testicular disease seem to alter the course of the process. To be considered in the differential diagnosis of testicular rupture are those dirnases which produce a painful, swollen, scrotal mass. When it is possible to exclude disease which pre-exists external trauma the remaining causes of this syndrome include acute epididymitis, torsion of either the testicle or a testicular appendage, or rupture of thetunicaalbuginea. Identification of bloody fluid by the aspiration of the hydrocele cavity should make surgical exploration mandatory. Sargent describes the result of neglect: "The delicacy of the spermatogenic tissue is such that severe injury almost inevitably terminates in complete testicular atrophy. Here secondary infection with abscess and sloughing is more prone to occur than in those injuries without frank rupture." 4 4 Sargent, J. C.: Injuries of genital tract. In: Urology. Edited by M. F. Campbell, vol. 2: chapt.
However, of particular interest was Wesson's report in 1946 of his management of a patient with a traumatic rupture of a solitary testicle. 5 On 3 occasions he aspirated the hematocele. When surgical exploration was carried out on the twenty-third day yellow fluid filled the cavity and the necrotic slough was easily removed making closure of the lacerated tunica albuginea possible. The testicle was salvaged. We have had no experience with multiple aspirations of a hematocele. Undoubtedly the extent of the injury influences the recovery of the damaged testis. Atwell and Ellis mention 3 patients with minor hematoceles in whom recovery was spontaneous, presumably by reabsorption of the blood and necrotic testicular tissue. 6 This may explain the atrophic testis sometimes found in older men during routine examination where there is only a vague history of testicular trauma. One possible consequence of this type of injury to be considered is an auto-immune reaction to one's own sperm. Whether spermatic cells after extravasation of testicular tissue act as antigens and produce antibodies under these circumstances is not known. One patient of this group conceived 2 children after his injury. The fertility status of the other 4 patients is unknown. CONCLUSION
Testicular rupture requires a non-penetrating external force to the testis to produce a tear of the tunica albugi.nea. Usually the laceration, limited to the tunica albuginea, produces a hematocele. The more promptly this condition is recognized and specific surgical repair of the laceration is effected, the less is the chance of complication and the greater is the opportunity for salvage of the testicle. The recognition of a hematocele by aspiration is suggested as one method of diagnosing testicular rupture. Early surgical exploration of the scrotum is recommended. SUMMARY
The cases of 5 patients who had traumatic rupture of the tunica albuginea are described. When this condition is suspected surgical exploration of the testicle is recommended. 4, pp. 926-951. Philadelphia: W. B. Saunders Co. 1954. I 6 Wesson, M. B.: Traumatism of the testicle· report of a case of traumatic rupture of a solitary testicle. Urol. & Cutan. Rev., 50: 16-19 1946. 6 Atwell, J. D. and Ellis, H.: Ruptu;e of the testis. Brit. J. Surg., 49: 345, 1961.