Testicular rupture

 Testicular trauma is the third most common cause of acute scrotal pain1. Despite the vulnerable position of the testicles, testicular trauma is relatively uncommon. Mobility of the scrotum may be one reason severe injury is rare. Sporting activities account for more than half of all cases of testicular injury, and motor vehicle accidents account for another 9%–17% of testicular injuries2.

Testicular injuries can be divided into 3 broad categories based on the mechanism of injury. These categories include (1) blunt trauma, (2) penetrating trauma, and (3) degloving trauma. Injuries are typically seen in males aged 15-40 years.

Testicular trauma is defined as any injury sustained by the testicle. Types of injuries include blunt, penetrating, or degloving. Testicular rupture (also called fractured testis) is a rip or tear in the tunica albuginea resulting in extrusion of the testicular contents. It is a rare complication of testicular trauma. It may cause pain, scrotal swelling, nausea and vomiting (sometimes). Treatment consists of surgical exploration with repair of the defect. Blunt trauma refers to injuries sustained from objects applied with any significant force to the scrotum and testicles like kick to the groin or a sports injury. Penetrating trauma refers to injuries sustained from sharp objects or high-velocity missiles, e.g., gunshot and stab wounds. Degloving injuries (or avulsion injuries) are less common. With these, scrotal skin is sheared off, for example, when a testicle becomes trapped in heavy machinery. Testicular fracture refers to a break or discontinuity in the normal testicular parenchyma.

Intratesticular hematomas are a common occurrence in the traumatized scrotum and may manifest various features. They may occur singly or in multiples, may range in size from small to large, may range in age from hyperacute to chronic, and may or may not be associated with other testicular and extratesticular injuries. Extratesticular hematoceles, or collections of blood within the tunica vaginalis, are the most common finding in the scrotum after blunt injury. Blunt trauma accounts for approximately 85% of cases, and penetrating trauma accounts for 15%. As many as 80% of hematoceles (blood in the tunica vaginalis) are associated with testicular rupture

Patients typically present to the emergency department with a straightforward history of injury (eg, sports injury, kick to the groin, gunshot wound) soon after the event occurs. The majority of blunt testicular injuries are unilateral and isolated (i.e., without other associated injuries). The absence of scrotal swelling and hematoma may indicate a relatively benign injury. The complete absence of pain in a patient with scrotal swelling and hematoma raises the possibility of testicular infarction or spermatic cord torsion.
High-frequency ultrasonography (US) with a linear-array transducer is the modality of first choice for the evaluation of testicular trauma3. Additional imaging tests or scrotal exploration is required if testicular rupture is suggested because of clinical findings or when a patient experiences pain out of proportion to the physical examination findings. Surgical therapy is unnecessary in cases of minor trauma in which the testes are unequivocally spared and the scrotum has not been violated. Documented testicular injuries necessitate immediate repair. Inappropriately protracted expectant management promotes testicular infection, atrophy, and necrosis. Delay in repair may herald the loss of spermatogenesis and hormonal functions. More than 80% of ruptured testes can be salvaged, with a high success rate, if surgical repair is performed within 72 hours of testicular injury.

Anatomy:
The outermost layer of the scrotum is the scrotal skin. The next most superficial layer is the dartos muscle/fascia, which is contiguous with the Scarpa fascia of the abdomen, the Colles fascia of the perineum, and the dartos fascia of the penis. The dartos layer is followed by the external, middle, and internal spermatic fasciae, which are contiguous with the external oblique, internal oblique, and transversalis fasciae, respectively. The middle spermatic fascia forms the cremasteric muscle of the spermatic cord. The next layer is the tunica vaginalis, which is composed of an outer (parietal) layer and an inner (visceral) layer. The next layer is tunica albuginea which is a tough, white, fibrous, capsulelike layer. Next layer is tunica vascularis, which contains the arterial blood supply. Blood supply to the testes is threefold: testicular artery (principal artery, arises from the aorta on right side and renal artery on the left side), cremasteric artery (branch from inferior epigastric artery) and deferential artery (branch of the superior vesical artery).