Use of ultrasonography for the diagnosis of testicular injuries in blunt scrotal trauma

PURPOSE: We determined the use of scrotal ultrasonography in the initial diagnosis and management of testicular injuries due to blunt scrotal trauma. MATERIALS AND METHODS: We performed a retrospective review of 65 patients presenting to our Emergency Department with blunt scrotal trauma in the last 25 years. In 47 patients an inconclusive clinical examination prompted scrotal ultrasonography. A heterogeneous echo pattern of the testicular parenchyma with loss of contour definition was the basis for diagnosis of testicular rupture. The sensitivity and specificity of scrotal ultrasonography were determined by comparing this radiographic criterion with definitive intraoperative findings and the need for delayed orchiectomy due to undiagnosed testicular rupture. RESULTS: Of the 65 patients sustaining blunt scrotal trauma 44 (68%) underwent scrotal exploration, and 30 (46%) of these injuries involved rupture of the tunica albuginea. Among the 47 scrotal ultrasounds performed to supplement a nondiagnostic clinic examination, there were 32 suspected testicular ruptures. Thus, the 2 false-positives resulted in a specificity of 93.5% in those patients explored. No delayed orchiectomies were performed for missed testicular ruptures, resulting in 100% sensitivity. The majority of testicular ruptures were salvaged (83%), with only 5 of the 30 (17%) requiring orchiectomy (4 of these patients had delayed presentation greater than 48 hours). CONCLUSIONS: Scrotal ultrasonography, with the single radiographic finding of a heterogeneous echo pattern of the testicular parenchyma with loss of contour definition, is highly sensitive and specific in the diagnosis of testicular rupture in an otherwise equivocal scrotal examination. Accurate diagnosis and prompt repair led to a salvage rate for testicular rupture specifically of 83% and overall of 92%, with preservation of the testicular parenchyma and hormonal function, and avoidance of the delayed complications of chronic pain, atrophy and orchiectomy associated with missed testicular rupture.     

The use of ultrasound for evaluating subacute unilateral scrotal swelling

In 15 patients with subacute (longer than 8 hours) unilateral scrotal swelling in whom the etiology was in doubt scrotal ultrasound was used to determine whether the pathological condition was intratesticular and/or extratesticular. Surgical exploration confirmed intratesticular or intratesticular and extratesticular findings in 9 patients: 8 had torsion of the spermatic cord (including a testis rupture in 1 and epididymal ruptures in 2) and 1 had a mixed germ cell carcinoma. Of the 6 patients with extratesticular findings 3 had clinical epididymitis that resolved on antibiotic therapy and 2 had what appeared to be paratesticular hematomas with normal testes presumed to be secondary to minor trauma. The condition resolved with conservative therapy in the latter 2 patients. The remaining patient required surgical drainage because of the size and an epididymal rupture suspected by the ultrasound examination. Scrotal ultrasound is a quick, noninvasive, easily applied, accurate method to diagnose scrotal pathological conditions and should be used whenever the etiology of scrotal swelling is in doubt.     

Has ultrasound influenced the therapy concept of blunt scrotal trauma?

We present the ultrasonic diagnoses and treatment of 44 patients with blunt scrotal trauma (rupture of the testis, hematocele, intratesticular hematoma and hematoma of the scrotal layers). Purely intratesticular hematoma without any other accompanying injury also can be detected sonographically. When massive scrotal swelling is present ultrasound is valuable to determine the status of the underlying testis even if discrete fracture planes of the tunica cannot always be detected. To achieve best long-term results early surgical intervention should be performed in cases of rupture of the testicle and hematocele, while hematoma of the scrotal layers and purely intratesticular hematoma can be treated conservatively.     

肉膜蒂阴囊皮瓣修复阴茎皮肤完全撕脱伤

目的 探讨阴茎皮肤完全撕脱伤的修复方法。方法 采用肉膜蒂阴囊皮瓣或游离大腿皮瓣修复阴茎创面。急性创伤急诊一期修复，已感染伤口控制感染后二期修复。结果 8例术后勃起无限制，1例采用大腿中厚皮瓣修复阴茎皮肤敏感性下降。结论 肉膜蒂阴囊皮瓣血运及末梢神经丰富，弹性好，在阴囊皮肤没有破坏的情况下，应作为修复阴茎创面的首选.     

Diaphragmatic injuries: recognition and management in sixty-two patients.

Between 1979 and 1989, 62 patients were treated for traumatic injury of the diaphragm. Forty-five had penetrating injuries following stab wounds or gunshot wounds, and 17 had diaphragmatic tears from motor-vehicle and auto-pedestrian accidents. Forty-one patients sustained left-sided injuries; 20 patients sustained right sided injuries; and one patient sustained bilateral ruptures. All patients underwent exploratory laparotomy and diagnosis was confirmed at surgery. Diaphragmatic injury was suspected in only 17 (27%) patients preoperatively. The chest radiograph showed nonspecific abnormalities in 48 (77%) patients and was diagnostic in 15 (24%) patients. Six patients had diagnostic peritoneal lavage; five were positive and one was negative. Computerized tomography (CT) of the lower thorax and abdomen was performed on 11 (18%) patients, but not one scan was diagnostic. Fluoroscopy in two patients was helpful. All patients had other associated injuries. The liver, spleen, or stomach were frequently injured in association with penetrating diaphragmatic lacerations. Bony fractures, splenic injuries, and head trauma were more commonly found with blunt diaphragmatic ruptures. The average hospital stay for the penetrating injuries was 11 days and for blunt trauma was 16 days. The operative mortalities was 2 per cent for penetrating injuries and 12 per cent for blunt injuries.     

Does testicular mass always require orchiectomy?

Surgical exploration of a testicular mass should follow the basic principles of cancer surgery, including an inguinal approach, occlusion of the spermatic vessels, opening of the tunica vaginalis, and careful exploration of the testicle, epididymis, paratesticular structures, and spermatic cord. In a very few patients, when intratesticular lesion is small and moveable and can be seen through the tunica albuginea, and if there is a long history of scrotal mass, then the tunica albuginea should be opened and intratesticular exploration performed. The opening of the tunica albuginea does not violate the principles of cancer surgery, and for a few selected cases can prevent unnecessary orchiectomy. The incision of the tunica albuginea should no longer represent a surgical taboo to the urologist. Six cases of rare, benign intratesticular tumors are presented along with a rare indication for intratesticular exploration and testicle-preserving surgery.     

Inguinal lymph node metastases from germ cell testicular tumors

Between 1948 and 1982, 22 patients were seen with metastasis to the inguinal nodes from testicular germ cell tumors: 8 had a history of unilateral or bilateral orchiopexy with or without herniorrhaphy, 4 had nonsurgically corrected or uncorrected cryptorchidism, 9 had a history of herniorrhaphy, hydrocelectomy or transscrotal orchiectomy and 1 had no history of scrotal, iliac or inguinal surgery, or of tunica vaginalis or scrotal wall involvement by tumor. The histological type was pure seminoma in 5 patients, embryonal carcinoma in 7 and mixed tumor in 10. Treatment was individualized for tumor type and mode of presentation, and varied during the years according to the modalities available. At the time of this report 8 of 22 patients (36 per cent) are alive without evidence of disease from 2 to 29.5 years, 3 (16 per cent) have died without evidence of disease 10 to 17 years after treatment, 10 (45 per cent) have died of metastases 10 months to 6 years after treatment and 1 has been lost to followup. The over-all incidence of groin metastases from testicular carcinoma is low, even with a history of scrotal or inguinal surgery.     

Aerodigestive injuries of the neck

Cervical aerodigestive trauma is rare and most centers have a limited experience with its management. The purpose of this review was to study the epidemiology, diagnosis, and problems related to the early evaluation and management of these injuries. This was a retrospective study based on trauma registry and on chart, operative, radiological, and endoscopic reports. There were 1560 admissions with blunt or penetrating trauma to the neck. The overall incidence of aerodigestive trauma was 4.9 per cent (10.2% for gunshot wounds, 4.6% for stab wounds, and 1.2% for blunt trauma). All patients with aerodigestive trauma had suspicious signs or symptoms on admission. The most common life-threatening problem in the emergency room and directly related to the aerodigestive trauma was airway compromise. Twenty-nine per cent of patients with laryngotracheal trauma required an emergency room airway establishment because of threatened airway loss. Although rapid sequence induction was successful in the majority of cases, in 11.9 per cent there was loss of airway and a cricothyroidotomy was necessary. Overall, 9 per cent of cases with aerodigestive injuries were successfully treated nonoperatively. Thirty-six per cent of patients with laryngotracheal trauma and surgical repair were successfully treated without a protective tracheostomy. There was no mortality due to the aerodigestive injuries. Cervical aerodigestive trauma is rare. In conclusion, all patients with significant aerodigestive injuries requiring treatment had suspicious signs and symptoms. Airway compromise was a common problem in the emergency room. Loss of airway after rapid sequence induction is a potentially lethal complication and the trauma team should be ready for a surgical airway. Repair of laryngotracheal injuries without a protective tracheostomy is safe in selected cases.     

Accuracy of ultrasound diagnosis after blunt scrotal trauma (10 years experience)

Objectives  

To evaluate the role of ultrasonography (US) and its accuracy, sensitivity and specificity for the diagnosis of testicular rupture after blunt scrotal trauma. Moreover, tunica albuginea breach, testicular hematoma, testis avulsion, epididymal injuries and hematocele are particularly examined.     

Bilateral testicular injury from external trauma

Among 79 patients with testicular injury as a result of external trauma 5 had bilateral injury. Such injury occurred in only 1 of 66 patients (1.5 per cent) with blunt trauma versus 4 of 13 (31 per cent) with penetrating trauma. Bilateral ruptures were managed by bilateral partial orchiectomy in 2 cases, and orchiectomy with contralateral débridement and suturing in 1. Of 2 patients with unilateral rupture and contralateral contusion the contusions were treated by evacuation of the hematoma and the ruptures were managed by orchiectomy in 1 and partial orchiectomy in the other. Four patients were available for followup. One patient was hormonally anorchid but he obtained normal erections with testosterone cypionate, 1 had normal serum testosterone concentrations but borderline normal semen analysis, and 1 had reduced erections and borderline normal semen. The remaining patient had normal erections and no semen analysis was performed. The nature of the injury rather than the type of treatment appears to be the primary determinant of the outcome in these cases.     

Blunt bladder trauma: manifestation of severe injury

Twenty-nine patients with bladder injuries requiring operative treatment as a result of blunt trauma are presented. Motor vehicle accidents accounted for 86 per cent of the injuries. Hypotension and gross hematuria were the most prevalent clinical features, 68 per cent and 97 per cent, respectively. All patients had multiple associated injuries requiring operative treatment, average 2.9 per patient. Pelvic fractures occurred in 93 per cent and intra-abdominal injuries in 48 per cent of patients. The majority of ruptures (72%) were intraperitoneal. Mortality, related to associated injuries, was high (34%), attesting to the magnitude of injury sustained by the victim.     

A case of traumatic testicular torsion associated with a ruptured epididymis

To salvage the testis, most urological surgeons advocate early exploration of enlarging scrotal masses or suspected testicular ruptures resulting from trauma. A case of testicular torsion within a hematoma, following blunt testicular trauma is presented, and we suggest that another indication for exploring a scrotal mass following blunt injury is to help establish an early diagnosis of torsion of the testicle.     

Les traumatismes des bourses

Objective|To evaluate the epidemiological, clinical, laboratory and therapeutic features of scrotal trauma seen in the Department of Urology and Andrology of Brazzaville University Hospital, and to compare these results to the literature

Patients and Methods

This study included 18 patients hospitalized for scrotal trauma between January 1990 and December 2006. The parameters studied were: frequency, age, etiology, presenting symptoms, the time elapsed since the accident, the findings on clinical examination and ultrasonography, treatment and outcome.

Results

Scrotal trauma represented 0,4% of all hospital admissions to Brazzaville University Hospital. The mean age of the patients was 34.6 (range 9–64) years. The trauma was mainly due to traffic accidents (8 cases) and to work accidents (5 cases). The mean time elapsed between the accident and consultation was 3 days for blunt trauma and 1 hour for open trauma. The main presenting symptom was scrotal pain (n=10). Ultrasonography done in 8 patients revealed rupture of the tunica albuginea in 4, intra-testicular hematoma in 2 and hematocele in another 2 cases. Medical treatment was applied in 6 cases, while 12 patients were treated surgically by resection of the extruded testicular pulp and suturing of the tunica albuginea in 4, orchidopexy in 1, orchidectomy in 3, evacuation of the hematocele in 2 and drainage of the testicular hematoma in 2 cases. On longterm follow-up residual scrotal pain was observed in 3, oligoasthenozoo-spermia in 3, testicular atrophy in 2 and erectile dysfunction in 1 patient.

Conclusion

If hematocele is present, surgical exploration is mandatory. Ultrasonography can help to diagnose a rupture of the tunica albuginea, however this examination should not delay surgical treatment.     

睾丸损伤31例报告

目的:报告我院收治的31例32个睾丸损伤,总结诊治经验。方法:在31例睾丸损伤中,闭合性损伤26例,开放性损伤5例。保守治疗9例(其中2例改为手术治疗),直接手术治疗22例。结果:随访25例(26个睾丸),其中保守治疗9例,手术治疗16例。随访时间7个月~9年。保守治疗组和手术组各有2例睾丸萎缩;无1例睾丸硬化和慢性疼痛。结论:对任何阴囊、会阴外伤均应考虑睾丸损伤的可能,常规首选B超检查;在B超的密切监护下实施保守治疗;对手术探查应持积极的态度。     

Diagnostic and treatment problems in renal injuries

The case records of 112 patients with 116 renal injuries seen at Detroit Receiving Hospital (July 1980 to June 1985) were reviewed. Eighty-three (74%) of the injuries were caused by gunshot wounds, 18 (16%) by stab wounds, and 11 (10%) by blunt trauma. Of 102 patients who had a urinalysis (U/A) in the Emergency Department (ED), 12 had a normal U/A. Five of these 12 patients had severe renal pedicle injuries. Of 75 excretory urograms (IVPs) performed preoperatively, 21 (28%) were normal including seven in patients with major renal injuries requiring surgical treatment. The incidence of shock was 38 per cent in patients with injuries not requiring renal explorations, 69 per cent in patients with renal parenchymal injuries requiring surgery, and 93 per cent in patients with pedicle injuries requiring repair or nephrectomy. Although it is generally believed that traumatic perirenal hematomas should not be explored, there was an increased incidence of complications with this approach in this series. Of 65 stable renal injuries treated conservatively (without exploration of the renal parenchyma), there were nine (14%) complications including three reoperation for missed injuries and three perinephric abscesses. In 46 injuries that were explored (38 for bleeding and eight without bleeding), there were only two complications (5%), including a perinephric abscess.     

肉膜蒂阴茎阴囊联合皮瓣治疗重度或复杂性尿道下裂

目的：探讨重度或复杂性尿道下裂新尿道取材途径。方法：在单一皮瓣不够的情况下彩肉膜蒂阴茎阴囊联合皮瓣作新尿道。结果：47例中术后尿瘘2例。尿道狭窄1例。并发症发生率6.4%，结论：重度或复杂性尿道下裂可采用肉膜蒂阴茎阴囊联合皮瓣作新尿道。     

Solitary genital leiomyoma of the tunica dartos: a case report and review of the literature in Japan

We report a case of solitary genital leiomyoma arising from the tunica dartos of the scrotum. A 43-year-old man complained of a slightly tender left scrotal mass that had enlarged over approximately 17 years. On physical examination, the tumor was pedunculate and attached to the lower pole of the left scrotum. The tumor was clearly separate from scrotal contents such as the testis, epididymis, and spermatic cord. Ultrasonography showed the tumor to be 20.0 X 23.5 mm in diameter. Other laboratory examination findings were normal. Under local anesthesia, the tumor was resected at its base with overlying skin. On histopathological examination, the tumor consisted of interlacing bundles of smooth muscle cells, which were positive for vimentin, desmin, and a-actin. The tumor was diagnosed as leiomyoma arising from the scrotal tunica dartos. As solitary genital leiomyoma of the tunica dartos is rare, we have presented this case history and reviewed 23 cases that occurred in Japan.     

The etiology and management of genital injuries

In a 10-year period, we have seen and treated 70 patients with trauma to the genitalia. There were 42 penile, 38 scrotal, and 16 testicular injuries. Patients with severe multisystem or extensive genital wounds were successfully managed by early conservative debridement with delayed definitive repair.     

Case report: Traumatic unilateral testicular rupture

IntroductionTesticular trauma is classified aetiologically as blunt, penetrating or degloving. Blunt testicular trauma, caused by interpersonal violence, sporting injuries and RTAs account for the majority of cases, typically affecting males aged 15–40 [1]. Approximately 98.5% of blunt trauma resulted in unilateral testicular injury; about 12–15% involving cyclists or motorcyclists (Cass and Luxenberg, 1988) [2].Presentation of caseA 48-year-old male motorcyclist presented to the accident and emergency department with an acute scrotum following collision with an oncoming vehicle. On arrival, he was fully conscious, tachycardic and hypertensive. Examination of his genitalia revealed ecchymosis of the right hemi-scrotum and perineal bruising. The right hemi-scrotum was grossly swollen but the left testis was normal. Ultrasound revealed gross haematoma and ruptured capsule of the right testicle. Intraoperatively, emergency exploration of the right hemiscrotum revealed evidence of lower pole rupture. Clot evacuation and debridement of necrotic testicular tissue preceded closure of the tunica albuginea.DiscussionThe majority of all testicular ruptures are diagnosed secondary to sport-related injuries [3] and motor vehicle or motorbike accidents. However, analysis of the literature has revealed a total of five cases of rupture, which have been linked to testicular tumours, the most recent of which was reported in 2014 (Lunawat et al., 2014) [5]. In two out of these five cases, trivial trauma preceded the diagnosis. It raises the question whether the presence of malignancy decreases the threshold of suffering a blunt testicular injury hence increasing the likelihood of testicular rupture.ConclusionEmergency assessment and diagnosis as well as scrotal exploration are important components of the management of acute testicular rupture. Analysis of the literature proves that timely surgical intervention is crucial; early intervention results in higher rates of preservation and avoids the need for an orchidectomy.     

High resolution scrotal ultrasonography: a highly sensitive but nonspecific diagnostic technique

We compared surgical and pathological findings to those of preoperative scrotal ultrasonography in 50 consecutive patients undergoing surgical exploration for testicular trauma, tumors or benign atraumatic conditions. An inhomogeneous parenchymal echo pattern was the single most reliable predictor of a parenchymal abnormality. Large scrotal hematomas may preclude adequate visualization of the parenchyma and early testicular torsion may exhibit a normal parenchymal echo pattern. Except for early torsion, no false negative predictions of the state of the parenchyma were made.