Open injuries and trauma to the scrotum and testicle

Open injuries and trauma to the scrotum and testicle are most common in patients aged 15 to 40 years, but about 5% of patients are under 10 years old. Closed (blunt) injuries account for 80% of injuries to the external genitalia, open (penetrating) injuries - 20%. The terms "blunt injuries" and "penetrating injuries" are typical for American and European professional literature. Blunt injuries occur through external blunt blows. Penetrating wounds are wounds of any depth that are inflicted by a sharp object precisely in the impact zone and it is not necessary for the wound to penetrate any cavity of the body.

Damage to the external genitalia is observed in 2.2-10.3% of victims admitted to hospital with various types of injuries, most often as a result of impact, compression, stretching, etc. Thermal, radiation, chemical injuries, and electrical trauma are rare.

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

Damage to the external genitalia accounts for 30-50% of all damage to the genitourinary system, of which 50% are damage to the scrotum and its organs. In blunt injuries, bilateral damage to the scrotum organs occurs in 1.4-1.5% of cases, in penetrating injuries - in 29-31%. Blunt injuries to the scrotum are accompanied by rupture in 50% of cases. In closed injuries, bilateral damage to the scrotum organs occurs in 1.4-1.5% of cases, in penetrating injuries - in 29-31%.

ICD-10 codes

• S31.3 Open wound of scrotum and testicles.
• S37.3. Injury of ovary.

Causes of Scrotum and Testicle Injury

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

• aggressive sports (hockey, rugby, contact sports);
• motorsport;
• mental illness, transsexualism and

Among them, the most common are injuries caused by mines and explosives (43%). Bullet and shrapnel wounds, which made up the bulk of the previous wars of the 20th century, are now encountered in 36.6 and 20.4% of cases, respectively.

Isolated open injuries to the scrotum and its organs are quite rare in wartime and are detected in 4.1% of cases. The anatomical position of the scrotum predetermines its most frequent combined injuries with the lower extremities, small pelvis, and abdomen. In mine-explosive wounds, a large area of damage leads to combined injuries to organs and body parts more distant from the scrotum.

Damage of this kind is often combined with damage to other organs. In case of gunshot wounds, the size of the damage depends on the caliber of the weapon used and the speed of the bullet. The greater these parameters are, the more energy is transferred to the tissues and the more pronounced the injury is.

According to statistics from recent wars, injuries to the external genitalia account for 1.5% of all injuries.

Damage resulting from animal bites is prone to 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 is semisynthetic penicillins, including protected ones, then cephalosporins or macrolides (erythromycin). Rabies infection should always be feared, therefore, in case of such suspicions, vaccination is indicated (anti-rabies immunoglobulin according to the standard scheme).

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Pathogenesis of open injuries and trauma of the scrotum and testicle

According to the mechanism of infliction, the nature of the wounding object and tissue damage, there are cut, stab, lacerated, bruised, crushed gunshot and other wounds of the scrotum. Their main distinguishing feature is the different volume of tissue destruction at the time of injury. The most severe wounds of the scrotum and its organs are gunshot. According to the materials of the Great Patriotic War, combined wounds of the scrotum were much more common than isolated ones and accounted for up to 62%.

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

Gunshot wounds to the spermatic cord are usually accompanied by vascular destruction, which serves as an indication for orchiectomy and vascular ligation.

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

Symptoms of open injuries and trauma to the scrotum and testicle

The peculiarities of the structure of the skin of the scrotum and its blood supply lead to a pronounced divergence and turning in of the edges of the wound, to bleeding and the formation of extensive hemorrhages spreading to the anterior abdominal wall, penis, perineum, and pelvic cellular spaces. Bleeding and hemorrhages are especially significant in wounds to the root of the scrotum with damage to the spermatic cord. Bleeding from the testicular artery usually leads to significant blood loss and can threaten the life of the wounded person. In wounds to the scrotum, traumatic orchitis and epididymitis often occur due to contusion of the organs by the wounding projectile.

Gunshot wounds to the scrotum result in one or both testicles falling into the wound. Wounds to the testicle itself may be accompanied by shock, loss of testicular parenchyma, subsequent necrosis of which leads to its atrophy. Wounds to the scrotum and its organs have an adverse emotional and mental impact on the victim, therefore, starting with pre-hospital and ending with specialized medical care, the principle of maximum anatomical preservation and functional restoration of damaged organs should be observed.

In case of testicular injuries, shock is observed in all cases. The stage of shock is determined by the severity of combined injuries. In case of superficial wounds of the skin of the scrotum, in 36% of cases, the application of an aseptic bandage was limited, in the rest, primary surgical treatment of the wounds was performed.

At the stages of providing medical care, 30.8% of the wounded underwent removal of non-viable tissues of damaged testicles with suturing of their protein membrane. Orchiectomy was performed in 20% of the wounded (bilateral in 3.3% of the injured).

Classification of scrotum and testicle injuries

The European Urological Association Classification of Testicular and Scrotal Injuries (2007) is based on the classification of the Organ Injury Classification Committee of the American Association for the Surgery of Trauma and makes it possible to differentiate between patients with severe injuries who are indicated for surgical treatment and patients whose injury can be treated conservatively.

Degrees of scrotal injury (European Urological Association protocol 2006)

Group	Description
I	Shake
II	Rupture <25% of scrotal diameter
III	Rupture >25% of scrotal diameter
IV	Avulsion (tearing) of scrotal skin <50%
V	Avulsion (tearing) of scrotal skin >50%

Severity of testicular injury (European Urological Association protocol, 2006)

Group	Description
I	Concussion or hematoma
II	Subclinical rupture of the tunica albuginea
III	Rupture of the tunica albuginea with parenchyma loss <50%
IV	Parenchymal rupture with parenchymal loss >50%
V	Complete destruction of the testicle or avulsion (tearing off)

By type, traumatic injuries of the testicle and scrotum are divided into closed or blunt (bruise, rupture, and strangulation), and open or penetrating (lacerated-bruised, stab-cut, gunshot), as well as frostbite and thermal injuries of the scrotum and its organs. Both can be isolated and combined, as well as single and multiple, unilateral or bilateral. By the conditions of occurrence, injuries are divided into peacetime and wartime.

Open injuries or wounds of the scrotum and its organs predominate in wartime. In everyday and industrial conditions of peacetime, their accidental injuries occur quite rarely. During the Great Patriotic War, wounds of the scrotum and its organs accounted for 20-25% of wounds of the genitourinary organs. The increased number of open injuries of the scrotum 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 number has increased significantly (90%). Open injuries of the scrotum during military actions in the territory of the Republic of Afghanistan and Chechnya occurred in 29.4% of the total number of wounded with damage to the genitourinary organs. Isolated injuries of the scrotum and its organs are quite rare (in 4.1% of cases).

Modern data from local wars show that there is no significant difference in the side of the scrotum injury: injuries occurred on the left in 36.6% of cases, on the right - in 35.8%; 27.6% of injuries were bilateral. Injuries to the spermatic cord were observed in 9.1% of the wounded, they were often combined with crushing of the testicles. Bilateral crushing of the testicles occurred in 3.3% of the wounded.

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Complications of open injuries and trauma to the scrotum and testicle

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 wounds is carried out at the stage of specialized medical care.

Thus, when providing medical care for wounds of the scrotum and its organs, in most cases the tactics of the most gentle surgical treatment of open wounds of the scrotum and its organs are justified. At the same time, extreme caution must be observed when catheterization of the bladder of wounded patients with a single surviving testicle is necessary. Thus, in 1.6% of the wounded, the cause of epididymitis of a single testicle was a permanent catheter installed for a long period (more than 3-5 days). Insufficient drainage of the scrotum wound, tight suturing of the proper testicular membrane (without Bergmann or Winkelmann operations), the use of silk threads when suturing testicular wounds can lead to suppuration, epididymitis, dropsy in the postoperative period, requiring repeated surgical interventions.

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Diagnosis of open injuries and trauma to the scrotum and testicle

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Clinical diagnostics of open injuries and trauma of the scrotum and testicle

Diagnosis of open injuries (gunshot wounds) of the scrotum does not present any diagnostic difficulty. As a rule, an external examination is sufficient. Entry wound holes are almost always located on the skin of the scrotum, but their size does not determine the severity of the damage. The presence of a well-developed vascular network and loose connective tissue in the scrotum causes, in addition to external bleeding, also internal bleeding, and the latter leads to the formation of hematomas of significant size. Hematomas in scrotal wounds occur in 66.6% of wounded in modern combat conditions. In 29.1% of cases, a testicle falls into the scrotal wound, including in small wounds due to contraction of its skin.

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

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Instrumental diagnostics of open injuries and traumas of the scrotum and testicle

In case of gunshot wounds, especially shrapnel wounds to the scrotum, an X-ray examination is indicated to identify the location of foreign bodies.

In case of penetrating wounds, ultrasound and urine analysis are always indicated. In addition, CT of the abdominal cavity with or without cystography should be performed.

Treatment of open injuries and trauma to the scrotum and testicle

General principles of treatment of open injuries and trauma of the scrotum and testicle

First aid for injuries to the scrotum and its organs consists of applying a pressure aseptic bandage, performing simple anti-shock measures, and using antibacterial agents.

At the first aid stage, if necessary, the bandage is replaced and bleeding is stopped by ligating the vessels. Painkillers, antibiotics, and tetanus toxoid are administered.

Qualified medical care consists of prompt treatment of wounded people with ongoing bleeding.

Surgical treatment of open injuries and trauma to the scrotum and testicle

Depending on the severity of the injury and the presence of associated injuries, operations are performed under local anesthesia or general anesthesia. During primary surgical treatment of scrotal wounds, obviously nonviable tissues and foreign bodies are removed by economical excision of the wound edges. Bleeding is finally stopped, and the spilled blood and its clots are removed. The scrotal organs are inspected. The intact testicle that has fallen into the wound is cleaned of contamination by washing with a warm isotonic solution of sodium chloride, hydrogen peroxide or nitrofural (furacilin). After the wound is treated, the testicle is immersed in the scrotum.

The scrotum wound is drained and sutured. If for some reason the testicle that has fallen into the wound was not promptly immersed in the scrotum, then after it has been released from scars, excess granulations and viability has been determined, it is immersed in a blunt-formed bed in the scrotum. After the initial surgical treatment of a gunshot wound of the scrotum, no sutures are applied to the wound. If the edges of the wound are significantly separated, it is sutured with rare guide sutures. All operations are completed with careful drainage of the scrotum wounds. In the case of extensive lacerated wounds, when the testicles are hanging on the exposed spermatic cords, the remaining flaps of scrotal skin should be "mobilized" and sutured above the testicles.

In case of complete scrotum detachment, one- or two-stage operations of scrotum formation are performed. The first stage of the two-stage operation is performed at the stage of qualified medical care and consists of immersion of each testicle in subcutaneous pockets made on the side of the wound on the anterior-inner surface of the thighs and primary surgical treatment of the wound with its obligatory drainage. The second stage of scrotum formation is performed after 1-2 months. From the skin of the thighs above the subcutaneous pockets containing the testicles, tongue-shaped flaps with a feeding stalk are cut out. The scrotum is created from these flaps.

One-stage formation is possible from two tongue-shaped skin-fat flaps cut on the posterior-inner surface of the thighs. Additional incisions at the base and tops of the flaps achieve better fit of the spermatic cords and testicles and better closure of wound defects on the thighs. Scrotum formation operations are performed at the stage of specialized medical care.

The severity of the injury increases significantly if, simultaneously with the injury to the scrotum, one or even more so both testicles or other organs of the scrotum are injured. In case of penetrating injuries to the testicle, surgical intervention is almost always performed, during which small wounds of the protein membrane without prolapse of testicular tissue are sutured with interrupted catgut sutures, and in case of more serious injuries, non-viable tissue is removed, 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 peaceful conditions, the number of orchiectomies can reach 40-65%.

The defect of the tunica albuginea of the testicle can be replaced with a flap taken from the vaginal membrane. In case of significant damage to the tunica albuginea and testicular parenchyma, clearly nonviable tissues are excised, after which the integrity of the tunica albuginea is restored over the remaining testicular tissue by applying catgut sutures. In case of significant damage to the testicle, the most gentle surgical treatment is recommended. If the testicle is crushed into several fragments, they are wrapped in a warm solution of procaine (novocaine) with biotics, after which the testicle is restored by suturing the tunica albuginea with rare catgut sutures.

The testicle is removed when it is completely crushed or completely torn from the spermatic cord. The loss of one testicle does not lead to endocrine disorders. For cosmetic and psychotherapeutic reasons, and after the removal of the testicle, it is possible to insert a prosthesis into the scrotum that imitates the testicle. If both testicles are torn or crushed, removal is necessary. Over time (3-5 years), the injured experience a decrease in sexual function, mental depression appears and increases, signs of feminization, for the treatment of which it is necessary to administer male sex hormones, preferably prolonged action.

It has been proven that even with bilateral gunshot injury to the testicles, early surgical intervention in 75% of cases can help preserve fertility. If bilateral removal of the testicles is necessary, then in such cases sperm preservation is always indicated. The necessary material for this is obtained by testicular or microsurgical sperm extraction.

According to studies, in post-pubertal individuals, the method of testicular repair is irrelevant, spermogram indices decrease to varying degrees, and a non-specific inflammatory process, tubular atrophy, and suppression of spermatogenesis develop in the repaired or conservatively treated testicle. Biopsy of the opposite testicle does not reveal pathological changes, including those of an autoimmune nature.

In the first hours after injury, it is impossible to accurately determine the extent and boundaries of organ destruction. In these cases, testicular resection is inappropriate. It is necessary to excise obviously crushed tissues extremely sparingly, ligate bleeding vessels, and suture the protein membrane with rare catgut sutures to ensure free rejection of necrotic areas of the parenchyma. A long-term unclosed fistula associated with the course of necrotic orchitis may require subsequent removal of the testicle.

In case of spermatic cord injuries, it is necessary to expose and inspect it along its length, for which purpose the scrotum wound is dissected. The spilled blood is removed, the bleeding vessels are found and separately ligated. The question of ligation or suturing of the vas deferens is decided individually. In case of minor defects, it is possible to restore it by applying an end-to-end anastomosis, although in case of complete damage (tearing) of the spermatic cord, its restoration is possible without vasovasostomy.

Self-castration, which is quite rare and usually performed by mentally ill or transsexuals, also presents a difficult task for andrological surgeons. Three tactical options are considered here, depending on the type of injury and the patient's mental and sexual disposition:

• If testicular reimplantation is performed in a timely manner, it can lead to a brilliant result;
• appointment of androgen replacement therapy;
• transition to the use of estrogen drugs - transsexual.