Viva Practice for the FRCS(Urol) and Postgraduate Urology Examinations, 2nd ed.

Genital Trauma

Q. A 21-year-old university student is kicked in the groin during an intercollegiate football match. He is brought to hospital because he has a swollen painful scrotum. He is otherwise well. How would you assess this patient and what injuries may have been sustained?

A. He should have a focussed history and examination. It is important to rule out the possibility of other major injuries prior to concentrating on the genitalia. The possible injuries include scrotal bruising with localised haematoma formation, haematocele, testicular, epididymal and spermatic cord injury (including torsion).

Q. How may testicular injuries be classified?

A. Tunica albuginea disruption (testicular rupture) or contained intratesticular haematoma or testicular dislocation.

Q. Is there any role for imaging?

A. Yes. An adequate physical examination is often difficult due to the presence of bruising, swelling, haematoma and pain. Scrotal ultrasound is the imaging method of choice for detecting intrascrotal injury - the primary goal being to assess the integrity (intact tunica albuginea) and vascularity of the testis. It has a specificity of 75% and a sensitivity of 64% in detecting testis rupture (although the sensitivity may be higher in more experienced hands). A combination of clinical and ultrasound findings will guide management.

Q. What may be seen on ultrasound of an injured testis?

A. Disruption of the tunica albuginea may be detected. However, more commonly the diagnosis is made by a combination of findings including the presence of a haematocele, a contour abnormality of the testis indicating disruption of the tunica albuginea and heterogenous echotexture of the testis (the latter suggestive of associated parenchymal bleeding).

Q. What does this intraoperative scrotal image in Figure 8.11 show?

Figure 8.11

A. Figure 8.11 shows testicular rupture.

Q. How would you manage this patient?

A. This patient should be counselled for urgent scrotal exploration. Extruded or necrotic seminiferous tubules should be debrided and the tunica albuginea closed with fine (4-0) absorbable sutures. A small drain may be left to drain dependently and the patient put on broad-spectrum antibiotics for 7 days. For reproductive, endocrine and psychological reasons, every effort should be made to preserve the testis but in the presence of gross injury, orchidectomy should be performed.

Q. Is there a role for delayed (>48 hours) scrotal exploration?

A. Studies have shown that testicular salvage after blunt trauma decreased from 80% to 30% if exploration was delayed by more than 3 days.

Q. How would you manage a haematocele?

A. Prompt drainage is recommended for large haematoceles to prevent infection, testicular ischaemia, and prolonged pain. Scrotal haematomas, bruising and smaller haematoceles can be treated conservatively with ice, rest and elevation.

Q. How does the management of bilateral testicular injury differ?

A. The consequences include loss of fertility, hypogonadism and significant psychosexual issues. Sperm banking should be considered in the early post-injury phase and testosterone levels monitored.



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