Scrotal trauma: A case report and review of the literature

Genitourinary (GU) injury is present in approximately 10% of cases of abdominal trauma.1 Of those GU injuries, up to 67% involve the external genitalia.2,3 GU trauma is more common in males, especially in the instance of genital injury. This increased incidence in males is secondary to both anatomical considerations and increased participation in activities such as contact sports, violent interaction, and war activities.2 The lower urinary tract is susceptible to traumatic injury by way of various mechanisms. These injuries, and their sequelae, can affect patients of any age or background. Though lower urinary tract trauma rarely results in life-threating pathology, appropriate management of these injuries is pivotal in decreasing long-term morbidity.4 Although the external genitalia in males are at high risk of injury in trauma because of their extracorporeal location, the scrotum and testes are relatively well-protected from severe damage for the following reasons: 1) the testes are inherently mobile within the scrotum; 2) the scrotal skin provides reasonable elasticity allowing for internal structures to slip away from the point of contact in blunt trauma; 3) the cremasteric reflex offers a protective reflex mechanism; and 4) the tunica albuginea serves as a tough fibrous physical defense with its tensile strength.4–6 Resultantly, the incidence of scrotal or testicular injury in a trauma activation is generally considered to be less than one percent. However, the associated morbidity to the patient (including psychological effects of testicular injury or loss) and health system costs associated with these injuries warrant special attention.5,7–9 In general, there are two broad domains to consider when evaluating scrotal trauma: blunt vs. penetrating injury. Historically, blunt injury has been thought to comprise the significant majority (i.e., 75–80%) of genital trauma.2,4 A recent analysis of the National Trauma Data Bank in the U.S. described a more balanced distribution of penetrating vs. blunt scrotal trauma, with both representing nearly half of all injuries.5 However, this significant difference in reported mechanism may be attributable to input biases and geopolitical determinants (e.g., increased incidence of gunshot wound [penetrating] injuries in the U.S. compared to other nations). The importance of categorizing these these types of injuries into broad classes lies in the special diagnostic and management considerations for each type of injury (Fig. 2). For example, while just 1.5% of blunt testicular injury involves the gonads bilaterally, approximately 30% of penetrating scrotal injury will involve both testes. Additionally, penetrating injury occurs with associated injuries in approximately 70% of patients, decreasing the threshold of suspicion of damage to neighboring structures, such as the penis, bladder, urethra, and femoral vessels.2,4 However, workup for associated injury should not be neglected in the setting of blunt trauma either, and nearby structures should be appropriately investigated when clinical suspicion is present (e.g., blood at the urethral meatus suggesting urethral injury).4 Other domains of scrotal trauma, including thermal and degloving/scrotal wall avulsion injuries, are described in the literature as well and will be discussed here briefly. Open in a separate window Fig. 2 Simplified diagnostic and management pathway in blunt and penetrating scrotal trauma.

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