Testicular Trauma Treatment

Testicular Trauma Treatment: Medical therapy Institute conservative treatment for patients with minor trauma in which the testes are unequivocally spared and the scrotum has not been violated. The usual treatment consists of scrotal support, nonsteroidal anti-inflammatory medications, ice packs, and bed rest for 24-48 hours.

Scrotal support decreases scrotal mobility and the likelihood of aggravating the injury. Anti-inflammatory medications decrease scrotal edema and provide nonsedating analgesia. Ice packs applied to the groin at least every 3-4 hours decrease swelling in the acute phase.

If associated epididymitis is suggested or if urinary tract infection is present, administer appropriate antibiotic therapy. Failure of medical management after an appropriate period of observation warrants imaging of the scrotum with ultrasound and Doppler studies. In the case of testicular dislocation, manual reduction has been used successfully in 15% of cases. Future elective orchiopexy should still be performed to minimize the risk of torsion.

Attempts have been made to apply injury severity scales, such as that of the American Association for the Surgery of Trauma (AAST), to dictate if nonoperative management is appropriate in certain cases of testicular trauma. However, prospective validation and long-term outcome data are lacking

Surgical therapy With the possible exception of a superficial skin injury, explore penetrating testicular trauma in the operating room. Patients with a history of blunt trauma and associated hematoceles often undergo surgical exploration for earlier resolution of pain and shorter convalescence. However, some institutions defer surgical exploration of nonexpanding hematoceles following blunt trauma if they are smaller than 5 cm.

Documented testicular injuries command immediate repair. Inappropriately protracted expectant management promotes testicular infection, atrophy, and necrosis. Delay in repair may herald the loss of spermatogenesis and hormonal functions.

Proper operative management is adequate debridement of necrotic or devitalized tissue, copious irrigation, meticulous attention to hemostasis, and closure of the tunica albuginea. This is true even if 50% of the parenchyma is destroyed. A small, dependently placed drain and broad-spectrum antibiotic coverage are also indicated.

Injury to the vas deferens or epididymis may be repaired using microsurgical techniques. This is usually performed as a staged procedure several months later to avoid operating in a potentially contaminated field.

Orchiectomy is rarely indicated, unless the testis is completely infarcted or shattered. Testicular injuries may be associated with significant loss of scrotal covering. Loss of scrotal skin from degloving injuries most commonly is the result of industrial or large machinery accidents and may be treated in 1 of 3 ways, as follows:

The preferred method is primary closure of the testis using the remaining scrotal skin. A minimum of 20% of the original scrotal skin provides adequate coverage of the scrotal contents. Adequate debridement and copious irrigation are required before attempting primary closure. If the amount of remaining scrotal skin is insufficient, mobilize the testis to adjacent areas to obtain coverage. The optimal locations are subcutaneous thigh pouches, with delayed scrotal reconstruction in 4-6 weeks. The temperature of the thigh is approximately 10° lower than core body temperature, favoring spermatogenesis. As a last resort, allow the testicles to remain exposed and apply daily moist-to-dry normal saline dressings until adequate granulation tissue forms. Within 1 week, follow this with a split-thickness skin graft, preferably harvested from the inner thigh.

Bilateral or unilateral testicular amputation treated within 8 hours with microvascular reimplantation techniques may allow successful revascularization. Do not place a testicular prosthesis until complete healing has occurred. If reimplantation is not possible, the ductus deferens should be cleaned and ligated with subsequent primary closure. It is important to note that in the case of psychotic and transsexual men, 20-25% will reattempt autoemasculation following reconstruction after genital self-mutilation.

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