Open injuries and injuries of scrotum and testis

Open injuries and injuries of the scrotum and testicles are most common between the ages of 15 and 40, but about 5% of patients younger than 10 years. Closed (blunt) injuries account for 80% of injuries of the vulva, open (penetrating) - 20%. The terms "blunt damage" and "penetrating damage" are characteristic of American and European professional literature. In this case, blunt damage occurs through external blunt strokes. And penetrating there are wounds of any depth that are inflicted by a sharp object in the area of impact and it is not necessary that the wound penetrates into any cavity of the body.

Damage to the external genitalia is noted in 2.2-10.3% of the injured, entering the hospital with various injuries, most often as a result of impact, compression, stretching, etc. Thermal, radiation, chemical damage, electric trauma are rare.

There is evidence that. That medical personnel treating patients with injuries to the external genitalia are more likely to be infected with hepatitis B and / or C. It has been shown that the contingent with penetrating wounds of the external genitalia is in 38% of cases of carriers of hepatitis B and / or C.

The damage to the external genital organs accounts for 30-50% of all damage to the genitourinary system, 50% of which are damage to the scrotum and its organs. In the case of blunt injuries, bilateral damage to the scrotal organs occurs in 1.4-1.5% of cases, with penetrating lesions in 29-31%. Blunt scrotal injury in 50% of cases is accompanied by its rupture. In closed injuries, bilateral damage to the scrotal organs occurs in 1.4-1.5% of cases, with penetrating lesions - in 29-31%.

ICD-10 codes

• S31.3. An open wound of the scrotum and testicles.
• S37.3. Injury of the ovary.

Causes of scrotal and testicle injury

Risk factors for damage to the vulva, including the scrotum and testicles:

• aggressive sports (hockey, rugby, contact sports);
• motorcycling;
• mental illness, transsexualism. And

Among them, the injuries that result from mine explosive wounds prevail (43%). The bullet wounds and shrapnel wounds, which in the previous wars XX in their main part, are presently occurring at 36.6 and 20.4%, respectively, respectively.

Isolated open lesions of the scrotum and its organs during wartime are quite rare and are detected in 4.1% of cases. The anatomical position of the scrotum determines her most frequent combined injuries with lower limbs, a small pelvis, and a stomach. In mine-explosive wounds, a large area of damage leads to combined injuries and organs and parts of the body that are more remote from the scrotum.

Damage of this kind is often combined with damage to other organs. In gunshot wounds, the size of the damage depends on the caliber of the weapon used and the speed of the bullet. How large are these parameters, so much more energy is transferred to the tissues and more traumatic is injury.

According to the statistics of recent wars, damage to the external genitalia is 1.5% of all injuries.

Damage resulting from the bite of animals is characterized by serious infections. In such observations, the most common infectious factors are Pasteurella multocida (50%), Escherichia coli, Streptococcus viridans, Staphylococcus aureus, Bacteroides, Fusobacterium spp. The drug of choice - semisynthetic penicillins, including protected, then cephalosporins or macrolides (erythromycin). Always need to be afraid of a rabies infection, so with such suspicions, vaccination is shown (immunoglobulin is an anti-rabies according to the standard scheme).

[1], [2], [3], [4], [5], [6]

Pathogenesis of open injuries and scrotal and testicle injuries

By the mechanism of application, the nature of the injured object and tissue damage, cut, chipped, torn, bruised, smashed gunshot and other scrotal injuries are distinguished. The main distinguishing feature of them is a different volume of tissue destruction at the time of injury. The most severe injuries of the scrotum and of its organs are gunshot. According to the materials of the Great Patriotic War, the combined wounds of the scrotum were much more often isolated and amounted to 62%.

In modern wars, combined wounds are observed with even greater frequency. The position of the scrotum determines its most frequent combined injuries with the lower limbs, but a large area of damage with mine-explosive wounds leads to combined injuries of the organs and parts of the body remote from the scrotum. Simultaneously with the scrotum, the urethra, penis, bladder, pelvis, limbs can be damaged. Gunshot wounds of the scrotum are almost always accompanied by damage to the testicle, and 50% of the wounded are observed to crush it. In 20% of the wounded, both testicles are damaged with a gunshot wound.

Gunshot wounds of the spermatic cord are usually accompanied by the destruction of the vessels, which serves as an indication for orchiectomy and bandaging of the vessels.

The share of open damage to the scrotum and testicles during peacetime does not exceed 1% of all injuries of the urogenital system. As a rule, open injuries of the scrotum and testicles are most often knife (stabbed) or bullet (gunshot). Drops on sharp objects can also lead to damage to the testicles, although they are much less common.

Symptoms of open injuries and scrotal and testicle injuries

Features of the structure of the skin of the scrotum and its blood supply lead to a pronounced divergence and tucking of the edges of the wound, to bleeding and the formation of extensive hemorrhages spreading to the anterior abdominal wall, penis, perineum, cellular spaces of the pelvis. Especially significant bleeding and hemorrhage in wounds of the root of the scrotum with damage to the spermatic cord. Bleeding from the testicular artery usually leads to significant blood loss and may endanger the life of the wounded. When a scrotum is injured, traumatic orchites and epididymitis often occur as a result of injuries to organs by a wounding projectile.

Gunshot wounds of the scrotum lead to the loss of one or both testicles in the wound. The wound of the testicle itself may be accompanied by shock, prolapse of the testicle parenchyma, the subsequent necrosis of which leads to its atrophy. Wounds of the scrotum and its organs have an unfavorable emotional and psychic effect on the victim, therefore, starting with the pre-medical and ending with specialized medical care, the principle of maximum anatomical preservation and functional restoration of damaged organs should be observed.

When the testicles are injured, shock is noted in all cases. The stage of shock is determined by the severity of the combined injuries. With superficial wounds of the skin, the scrotum was limited to 36% of the cases by the application of an aseptic bandage, while the others underwent initial surgical treatment of the wounds.

At the stages of medical care, 30.8% of the wounded made removal of non-viable tissues of damaged testicles with suturing their belly coat. In 20% of the wounded, an orchiectomy was performed (3.3% of the injured were bilateral).

Classification of scrotal and testicle injury

The classification of the injuries of the testicle and scrotum of the European Urological Association (2007) is based on the classification of the organ damage classification committee of the American Association for Trauma Surgery and makes it possible to distinguish between patients with severe trauma, which is indicated by surgical treatment, and patients whose trauma can be treated conservatively. PC

The degree of damage to the scrotum (protocol of the European urological association 2006)

Group	Description
I	Shake
II	Rupture <25% of scrotum diameter
III	Rupture> 25% of scrotum diameter
IV	Avalanche (separation) of scrotal skin <50%
V	Avalanche (detachment) of scrotal skin> 50%

The severity of damage to the testicle (protocol of the European Urological Association, 2006)

Group	Description
I	Concussion or bruising
II	Subclinical rupture of the protein membrane
III	Rupture of the gall bladder with loss of parenchyma <50%
IV	Rupture of parenchyma with loss of parenchyma> 50%
V	Complete destruction of the testicle or avulsion (separation)

By type, traumatic injuries of the testicle and scrotum are classified as closed, or obtuse (bruise, rupture, and infringement), and open, or penetrating (ripped-bruised, stabbed, cut, gunshot), as well as frostbites and thermal damage to the scrotum and its organs. Both can be isolated and combined, as well as single and multiple, one- or two-way. According to the conditions of occurrence, damage to civil and military time is identified.

Open injuries or wounds to the scrotum and its organs predominate in wartime. In the conditions of everyday and industrial conditions of peacetime, their casual injuries are rare. During the Great Patriotic War, injuries to the scrotum and its organs accounted for 20-25% of the injuries of the genito-urinary organs. The increased number of open scrotal injuries in modern local wars in comparison with the data of the Great Patriotic War, the war in Vietnam is explained by the prevalence of mine-explosive wounds, their relative amount has increased significantly (90%). Open lesions of the scrotum during military operations in the territory of the Republic of Afghanistan and Chechnya were found in 29.4% of the total number of wounded with damage to the urogenital system. Isolated lesions of the scrotum and its organs are rare (in 4.1% of cases).

Modern data from local wars show that there is no significant difference in the side of scrotal injury: left lesions occurred in 36.6% of cases, on the right - in 35.8%; 27.6% of injuries are bilateral. Damage to the spermatic cord was observed in 9.1% of the wounded, they were more often combined with crushing of the testicles. Two-sided crushing of the testes occurred in 3.3% of the wounded.

[7], [8], [9]

Complications of open injuries and scrotal and testicle injuries

Equal complications of wounds of the scrotum and its organs are purulent infection of wounds, necrotic orchitis, gangrene of the scrotum. Their prevention consists of careful hemostasis, drainage of wounds and the use of antibacterial drugs. Treatment of complications of gunshot and other injuries is carried out at the stage of specialized medical care.

Thus, in the provision of medical care for wounds of the scrotum and its organs, in most cases the tactic of maximally sparing surgical treatment of open wounds of the scrotum and its organs is authorized. In this case, extreme caution must be observed when it is necessary to catheterize the bladder of the wounded with a single preserved testicle. So in 1.6% of the wounded, the cause of epididymitis of a single testicle was a permanent catheter, established for a long period (more than 3-5 days). Inadequate drainage of the scrotum wound, suturing tightly on its own testicle shell (without the operations of Bergmann or Winckelmann), the use of silk threads when suturing the testicles can lead to suppurations, epididymitis, and dropsy requiring repeated surgical interventions in the postoperative period.

[10], [11],

Diagnosis of open injuries and injuries of scrotum and testis

[12], [13]

Clinical diagnosis of open injuries and scrotal and testicle injuries

Diagnosis of open injuries (gunshot wounds) of the scrotum is not of diagnostic complexity. As a rule, an external examination is enough. The entrance wound holes are almost always located on the skin of the scrotum, but their dimensions do not determine the severity of the lesions. The presence in the scrotum of a well-developed vasculature and loose connective tissue causes, in addition to external bleeding, also internal, and the latter leads to the formation of hematomas of considerable size. Hematomas with wounds of the scrotum are found in modern combat conditions in 66.6% of the wounded. In 29,1% of observations in the wound of the scrotum, the testicle falls, including with small wounds due to a reduction in her skin.

More attention requires timely recognition of the combined damage of nearby organs: the urethra, the bladder, etc. Extensive hemorrhagic infiltration usually makes it difficult or impossible to palpate the testicles in the scrotum. In such cases, the injury of the scrotum organs is detected during the initial surgical treatment of the wounds.

[14], [15]

Instrumental diagnosis of open injuries and scrotal and testicle injuries

In the case of gunshot, especially shrapnel wounds of the scrotum, an X-ray examination is performed to reveal the localization of foreign bodies.

With penetrating wounds, ultrasound and urinalysis are always shown . In addition, CT scan of the abdominal cavity with or without cystography should be performed.

Treatment of open injuries and injuries of scrotum and testis

General principles of treatment of open injuries and injuries of scrotum and testis

First aid for wounds of the scrotum and its organs consists in applying a pressing aseptic bandage, carrying out the simplest anti-shock measures, applying antibacterial agents.

At the stage of the first medical care, if necessary, the bandage is replaced by a stoppage of bleeding by ligation of the vessels. Introduce painkillers, antibiotics, tetanus toxoid.

Qualified medical care consists in the operative treatment of the wounded with continued bleeding.

Surgical treatment of open injuries and scrotal and testicle injuries

Operations, depending on the severity of injury, the presence of combined injuries, are performed under local anesthesia or under anesthesia. In the initial surgical treatment of the scrotal wounds by economical excision of the edges of the wound, obviously the non-viable tissues and foreign bodies are removed. Conduct a final stop of bleeding, remove the spilled blood and its clots. Perform a revision of the scrotum organs. The intact testicle that has dropped into the wound is cleaned of contamination by washing with a warm isotonic solution of sodium chloride, hydrogen peroxide or nitrofural (furacilin). After the treatment of the wound is completed, such an egg is immersed in the scrotum.

The wound of the scrotum is drained and sutured. If, for whatever reason, the testicle has not been duly immersed in the scrotum, then after liberation from the scars, excess granulations and determination of viability, they are immersed in a bluntly formed bed in the scrotum. After the primary surgical treatment of the gunshot wound of the scrotum, the joints are not applied to the wound. With a significant margin discrepancy, wounds are sutured with sparse guiding sutures. All operations complete with thorough drainage of the scrotal wounds. With her extensive lacerations, when the testicles are hanging on the bare seminal cords, if possible, "mobilize" and connect the remaining scraps of scrotal skin with the sutures over the testicles.

With complete separation of the scrotum, one- or two-stage operations are performed to form the scrotum. The first stage of the two operations at the stage of qualified medical care consists in immersion of each testicle in the subcutaneous pockets made on the wound side of the anterior-internal surface of the thighs and in the primary surgical treatment of the wound with mandatory drainage. The second stage of scrotal formation is performed after 1-2 months. From the skin of the hips above the subcutaneous pockets containing the testicles, tongue-shaped flaps with a feeding leg are cut out. A scrotum is created from these flaps.

Simultaneous formation is possible from two tongue-shaped skin-fat flaps cut out on the posterior-inner surface of the thighs. Additional cuts at the base and tops of the flaps achieve better fit of the spermatic cord and testicles and better closure of wound defects on the hips. Operations of scrotal formation are carried out at the stage of specialized medical care.

The severity of injury significantly increases. If simultaneously with the wound of the scrotum, one and especially both of the testes or other organs of the scrotum are injured. With penetrating damage to the testicles, surgical intervention is almost always performed, during which small wounds of the white shell without shedding of the testicle tissue are sutured with nodular catgut sutures, and with more serious lesions, unviable tissues are removed, the existing hematomas are drained, and active bleeding is stopped. In most cases it is possible to restore the scrotum and testicles, however, both in military and in peace conditions, the number of orchiectomies can reach 40-65%.

Defect of the egg white shell can be replaced by a flap taken from the vaginal membrane. With significant lesions of the gallbladder and testicle parenchyma, apparently nonviable tissues are excised, after which by overlapping the catgut sutures restore the integrity of the belly over the remaining testicle tissue. With significant damage to the testicle, the most gentle surgical treatment is recommended. If the testicle is fragmented into several fragments, they are wrapped in a warm solution of procaine (novocain) with biotics, after which the testicle is reconstituted by stitching the gallbladder with rare catgut sutures.

The testicle is removed if it is completely crushed or completely detached from the spermatic cord. Loss of one testicle does not lead to endocrine disorders. With cosmetic and psychotherapeutic and after removal of the testicle, it is possible to insert a prosthesis imitating the testicle into the scrotum. If you detach or crush both testicles, you need to remove. With the passage of time (3-5 years), the wounded patients experience a decline in sexual functions, psychic depression appears and grows, signs of feminization, which require the introduction of male sex hormones, better prolonged action.

It is proved that even with bilateral gunshot damage to the testicles, early surgical intervention in 75% of the observations can contribute to the maintenance of fertility. If bilateral removal of the testicles is mandatory, then in such cases, conservation of spermatozoa is always indicated. The necessary material for this is extracted by testicular or microsurgical extraction of spermatozoa.

According to studies in people of post-pubertal age, the method of restoring testicular damage does not matter, the spermogram index decreases to some extent, and in the restored or cured conservative testicle the nonspecific inflammatory process develops, tubular atrophy, suppression of spermatogenesis. Biopsy of the opposite testicle, pathological changes, including autoimmune character, are not detected.

In the first hours after injury, it is impossible to establish exactly the extent and boundaries of organ damage. In these cases, resection of the testicle is impractical. It should be very economical to excise clearly crushed tissues, ligate bleeding vessels and sew the rare catgut sutures with an envelope for free rejection of necrotic parenchyma sites. Prolonged unclosed fistula associated with the course of necrotic orchitis, may require further removal of the testicle.

When the spermatic cord is injured, it is necessary to uncover and revise it for as long as the dissection of the scrotal is performed. Remove the poured blood, find and separately bandage the bleeding vessels. The problem of dressing or stitching the vas deferens is decided individually. With small defects, it is possible to restore it by applying an end-to-end anastomosis, although with complete damage (separation) of the spermatic cord, its restoration is possible without vasovazostomy.

A difficult task for andrologists and surgeons is also self-castration, which is quite rare and is usually performed by mental patients or transsexuals. Here we consider three tactical options, depending on the type of damage and the patient's mental and sexual disposition:

• timely performed reimplantation of the testicle can lead to a brilliant result;
• the appointment of substitute androgen treatment;
• transition to the use of estrogenic drugs - transsexual.