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The patient was a 15-year-old male. Four months prior to his visit to our department, he was hit in the right scrotum by a baseball, which caused right scrotal swelling and pain. He visited a urologist who prescribed analgesics. During follow up observation, right scrotal hydrocele appeared and a puncture procedure was performed two times. Four months later, while climbing a rope for strength training, his scrotum became entangled by the rope. He immediately felt right scrotal pain and visited a urologist. Two days later, he was referred to our department for a thorough examination. Scrotum ultrasound revealed right scrotal hydroceles and swollen right cauda epididymis. The patient was treated conservatively with pain control. The next day, the pain did not improve, and surgery was decided since testicular rupture could not be completely ruled out. Surgery was performed on the third day. The caudal portion of the right epididymis was injured approximately 2cm, the tunica albuginea had been ruptured and the testicular parenchyma had escaped. The surface of the testicular parenchyma was covered with a thin film, suggesting that 4 months had elapsed since the tunica albuginea injury. The injured area of the epididymis tail was sutured. Subsequently, we removed the remaining testicular parenchyma and restored the tunica albuginea. Twelve months postoperatively, right hydrocele and testicular atrophy were not observed.

The patient was a 15-year-old male. Four months prior to his visit to our department, he was hit in the right scrotum by a baseball, which caused right scrotal swelling and pain. He visited a urologist who prescribed analgesics. During follow up observation, right scrotal hydrocele appeared and a puncture procedure was performed two times. Four months later, while climbing a rope for strength training, his scrotum became entangled by the rope. He immediately felt right scrotal pain and visited a urologist. Two days later, he was referred to our department for a thorough examination. Scrotum ultrasound revealed right scrotal hydroceles and swollen right cauda epididymis. The patient was treated conservatively with pain control. The next day, the pain did not improve, and surgery was decided since testicular rupture could not be completely ruled out. Surgery was performed on the third day. The caudal portion of the right epididymis was injured approximately 2cm, the tunica albuginea had been ruptured and the testicular parenchyma had escaped. The surface of the testicular parenchyma was covered with a thin film, suggesting that 4 months had elapsed since the tunica albuginea injury. The injured area of the epididymis tail was sutured. Subsequently, we removed the remaining testicular parenchyma and restored the tunica albuginea. Twelve months postoperatively, right hydrocele and testicular atrophy were not observed.

Blast testicular injury from gunshot may result in severe testicular damage and rupture, which is seen very rarely in the pediatric population. The management of these wounds is difficult and most of them result in orchiectomy. A patient with bilateral severe testicular rupture and large tunica albuginea defects due to gunshot that was repaired with tunica vaginalis flaps was presented in this study. A 16-year-old boy was administered with both ruptured testes that are located out of the scrotum. He was a sheep-man in the field and fired to kill the fox but shot himself. The first examination revealed both tunica albuginea defects and unviable tissues but normal blood supply in testes. He was taken to the operating theatre and the exploration revealed a bullet hole in the cranial portion of the scrotum on the left side of the penis. Tunica albuginea defects were severe and primer closure could not be achieved; however, defects were minimized with a few primer sutures on the tunica albuginea edges. Not to sacrifice the viable testicular tissue for closing the tunica albuginea, tunica vaginalis flaps were prepared and sutured to the remaining edges with absorbable sutures. At his fourth-month follow-up, Doppler ultrasound revealed normal blood supply of both testes. Severe testicular rupture with tunica albuginea defect sometimes could not be closed primarily without excision of viable testicular tissue. In these cases, the vascularized tunica vaginalis flaps provide an alternative method of closure for bilateral testicular injury in pediatric patients.

Antecedentes: El trauma testicular y escrotal ocurre principalmente en jóvenes entre 15 y 40 años. El 50% de las heridas testiculares por arma de fuego terminan en orquiectomía. La presentación clínica es con dolor, edema, equimosis y hematoma; laceración de piel o exposición de tejido. El diagnóstico es clínico. La evidencia o sospecha de una ruptura testicular es una urgencia y requiere exploración quirúrgica inmediata. El manejo quirúrgico recomendado es con cierre primario de la túnica albugínea cuando es posible y orquiectomía cuando no es posible. Caso clínico: Presentamos el caso de un masculino de 20 años con trauma testicular por arma de fuego; condicionándole trauma izquierdo grado V y derecho grado IV. Se realizó orquiectomía simple izquierda y orquiectomía parcial derecha con reconstrucción testicular por medio de injerto de túnica albugínea contralateral. El paciente cursó con una evolución satisfactoria; al estudio ultrasonográfico Doppler de control se observó vascularidad conservada y hormonalmente niveles de testosterona en aumento. Discusión: La meta en el tratamiento del trauma testicular es preservar el tejido viable y reparar el testículo. El cierre primario está descrito ante una laceración de la túnica albugínea con bordes fácilmente identificables, lo cual no fue posible en este caso. Dentro de las reparaciones descritas existen injertos de túnica vaginalis, mallas de material reabsorbible y biológicas con resultados no concluyentes. El uso de túnica albugínea como reparación y protección del testículo contralateral, permitió una reconstrucción óptima; evitando el aumento de presión que se produce al usar la túnica ipsilateral y permitiendo la preservación del parénquima y fisiología testicular.

Introduction Testicular injury with a tunica albuginea tear is typically reconstructed by primary closure. We herein describe the successful use of a tunica vaginalis flap for reconstruction of a ruptured testis for which primary closure was not possible. Case presentation A 21-year-old man visited our hospital with scrotal swelling after a baseball struck his left testis. Magnetic resonance imaging and ultrasonography indicated a left tunica albuginea tear, and emergency surgery was performed. Primary closure of the tunica albuginea was impossible since a tight closure could cause secondary damage. A vascular pedicle flap was prepared by shaping the tunica vaginalis to replace the tunica albuginea. He was discharged 2 days postoperatively. Ultrasonography showed normal size and blood flow in the ruptured testis at the 2-week and 3-month follow-up. Conclusion A testicular vaginalis flap should be considered when primary closure is difficult in cases of testicular rupture with tunica albuginea damage.

Following civil unrest during 2020, physicians began to notice a variety of injuries resulting from crowd control weapons. While prior research emphasized ocular trauma, genitourinary complications of injuries have yet to be investigated. A previously healthy 27-year-old male presented to the emergency department due to sudden onset of severe left testicular pain following rubber bullet trauma. Physical exam showed extreme tenderness, abrasion, contusion, and edema of the left testicle with normal right testicle. Doppler ultrasound showed minimal blood flow to the superior pole with irregularity of the tunica albuginea. Surgery confirmed testicular rupture with a large tunical violation and extruded spermatic tubules. The testicle was thoroughly irrigated, non-viable tubules were debrided, and intraoperative ultrasound confirmed restoration of blood flow. Patient was discharged and instructed to follow-up should he face any fertility concerns in the future. Current crowd control guidelines state projectiles should be aimed at the lower abdomen or extremities; however, projectiles can cause testicular trauma which may lead to hypogonadism, infection, and psychological impact. Until there are changes to methods of crowd control, attendees should consider the use of athletic cups.

Objective: To review the use of ultrasound imaging in the diagnosis of testicular rupture and in relation to current guidelines. Methods: Data was retrospectively collected for all patients diagnosed with testicular rupture at a major trauma centre between 2011 and 2018. Data included patient demographics, mechanism of trauma, specific findings on ultrasound and outcomes. On review of ultrasound imaging, specific findings identified include a breach in the tunica albuginea (currently advised in guidelines), heterogenicity and contour loss. Results: Eight patients were identified with average age 37 years old, mechanism of trauma was 50%, 37.5% and 12.5% for motorcycle road traffic collision, sporting injury and workplace injury respectively. A breach of tunica albuginea was identified on ultrasound in 65% of cases, compared with 100% of cases showing contour loss and heterogenicity. Of the 87.5% patients who were managed surgically one needed orchidectomy (and later testosterone replacement). Conclusion: Guidelines have varied on how to use ultrasound imaging in diagnosing a clinically difficult condition. Our case series demonstrates that diagnosing testicular rupture by looking for more easily identifiable characteristics (heterogenicity and contour loss) than currently recommended in the guidelines (breech in the tunica albuginea) will aid diagnosis and patient pathway and improve outcomes. Level of evidence: 5

A case report of mototrauma of scrotum with rupture of the testis and bilateral traumatic dislocation of testes and literature data on this topic are presented.

Blunt testicular trauma with rupture of albuginea is one of the rarest emergencies in children. Medical history and Testicular Doppler Ultrasound lead to diagnosis. Appropriate management is necessary to preserve the testis. Follow-up to adulthood is recommended to assess the impact on fertility.

Scrotal and testicular injuries are uncommon injuries, accounting for only a fraction of all trauma. Blunt scrotal trauma is accompanied by testicular rupture in up to 50% of cases. We present a rare case of scrotal rupture with evisceration of a viable, intact testicle after a motor vehicle accident. The patient's presentation, associated injuries, operation, and post-operative course are described. In brief, this is a case of a 69-year-old male who sustained multiple rib, pelvic, and right femur fractures in addition to scrotal injury after a motor vehicle accident. He was taken quickly to the operating room for the scrotal rupture, and his testicle was successfully replaced and scrotal laceration repaired. He did well post-operatively. This case represents one of the few accounts of this particular injury in the literature.

Traumatic testicular rupture is a rare yet serious condition most commonly seen in penetrating trauma victims (e.g. gunshot wounds or motorcycle collisions) that requires immediate surgical management given its potential complications of hypogonadism and infertility. While ultrasound is the most established modality for diagnosing testicular rupture, trauma patients are usually first evaluated with a trauma protocol computed tomography (CT) exam including the chest, abdomen, and pelvis upon presentation, so it is important to recognize CT findings of testicular injury. We present a novel case in which the suspicion for testicular injury was initially raised based upon CT findings of scrotal hematoma/fluid. These findings were then further characterized with ultrasound and confirmed at surgery. In this case, we provide intraoperative imaging that corresponds clearly to findings seen on both CT and ultrasound.

Bilateral testicular injuries are rare. However, the incidence of these injuries has been increasing in wartime. We describe the case of gunshot wound of the both testicle caused by high velocity bullets. The patient was managed by surgical exploration, debridement and repaired of both testis using tunica vaginalis. During the follow up, the left testis was not viable and there was a need for orchiectomy; in a follow-up of 4 months, ultrasonography showed a viable right testis with minimal atrophic change and the patient reported to have normal erection with borderline hormonal function. We describe this case of bilateral testicular rupture, which was repaired using tunica vaginalis as graft, with attention to the management and outcome of this injury process.

Testicular rupture after blunt scrotal trauma is characterized by rupture of the tunica albuginea and extrusion of seminiferous tubules. This is a serious injury and appropriate evaluation and management are necessary both for symptom control, but also for preservation of the testicle. Clinical examination of the scrotum following trauma is difficult and may result in incorrect triage of patients for surgical exploration. This case study describes the assessment and management of blunt testicular trauma in an adolescent lacrosse player.

Management of testicular rupture with a large tunical defect may not be feasible without excision of viable tissue. This study describes the use of a vascularized tunica vaginalis flap, without debridement of viable tissue, in four adolescents. Postoperative ultrasound showed good blood flow and 80% volume of the contralateral testis in two cases. Postoperative exam revealed normal exam and ultrasonographic appearance in three patients, the fourth was demonstrated to be small and undescended during evaluation of contralateral testicular torsion. This approach is recommended in cases of large tunical defects, as it avoids the debridement of viable testicular tissue.

The objectives of this study were to investigate patients treated for scrotal trauma at our institute for the last three decades to describe our experience with an emphasis on the etiologies and ultrasonographic findings in these patients. We reviewed medical records of patients who underwent scrotal ultrasonography for evaluation of testicular trauma at our institutes from 1986 to 2015. Trends regarding the etiology of scrotal trauma were evaluated during each decade. The echo pattern and contour definition of the testicular parenchyma and the pattern of hematoma development were recorded to evaluate radiographic findings of testicular injury. The correlation between ultrasonographic and intraoperative findings was assessed. A total of 115 patients were analyzed. Most patients (92.2%) presented with blunt trauma. The most common etiology of testicular trauma was assault during the first and second decades, while injury related to a fall was most common during the third decade. Of the 77 patients (67.0%) who underwent urgent exploration, 46 patients (59.7%) had testicular rupture. Loss of contour definition, heterogeneous echo pattern of the testicular parenchyma, and testicular hematoma showed a moderate to strong degree of correlation with testicular rupture (Spearman correlation co-efficient: 0.5-0.8). Over the past 30 years, the etiology of testicular injury changed from assault to falls or athletic injury and the severity of injury has decreased. Our findings demonstrate the importance of ultrasonography for determining an appropriate management strategy in scrotal trauma. Surgical exploration should be considered in patients with abnormal ultrasonographic findings.

We present 2 patients found to have ovotesticular disorder of sexual development (otDSD) in late adolescence. Two 15-year-old phenotypically male patients presented to a large pediatric hospital with different complaints: 1 with concern for testicular rupture after a straddle injury; 1 with gynecomastia. Further workup, including imaging and laboratory tests, was performed before surgical exploration. The first patient had unilateral ovotestis, contralateral testis, and SRY-negative 46,XX karyotype. The second patient with gynecomastia had unilateral ovotestis with hemi-uterus and fallopian tube, contralateral ovarian tissue, and 46,XX/47,XXY Klinefelter mosaic karyotype. Although rare, phenotypically normal male patients may present later with ovotesticular disorder of sexual development.

We present a case of testicular rupture after blunt scrotal trauma requiring surgical exploration and repair with salvage of the injured testicle. Testicular rupture is a true urological emergency and early diagnosis and surgical exploration maximized testicular salvage. Ultrasonography proves useful in evaluating the scrotal contents and allowing for early diagnosis of testicular injury.

Testicular trauma is a rare emergency. While penetrating injuries need surgical revision, blunt injuries may be treated conservatively. However, in case of testicular rupture early surgical intervention increases the chance of testicular preservation. Therefore, a meticulous urological diagnosis is important to avoid complications and to reduce rates of secondary orchiectomy.

Imaging of the scrotum in the setting of acute symptoms such as pain or swelling is commonly performed emergently to differentiate between patients who require immediate surgery and those that do not. Acute scrotal symptoms are generally caused by infectious, traumatic or vascular etiologies. Rapid diagnosis and initiation of treatment is vital for testicular salvage in cases of acute testicular torsion, testicular rupture, and Fournier gangrene. Epididymitis, epididymo-orchitis, torsed testicular appendage, segmental testicular infarction, scrotal hematomas, testicular neoplasms, and acute idiopathic scrotal edema can have similar clinical presentations, but these conditions do not require immediate surgery. Ultrasound is the well-established first-line imaging modality for the acute scrotum. Contrast-enhanced ultrasound and magnetic resonance imaging can be useful as problem-solving tools when ultrasound studies are inconclusive or equivocal. This review describes normal scrotal anatomy and a wide range acute scrotal disorders, with emphasis on the imaging and clinical features that can minimize the risk of misdiagnosis.

To examine whether scrotoscopy could be used to diagnose testicular rupture (TR) with accuracy. This retrospective study included all patients receiving scrotoscopy followed by immediate open exploration (OE) for suspected TR at two Chinese tertiary care centers between March 2014 and March 2018. Fifteen patients suspected of having TR were included. TR was considered in 8 patients (8/15) via emergency scrotal ultrasound (ESU) examination. Of these 8 patients, 6 cases as well as 3 other cases, a total of 9 cases (9/15) were confirmed TR by scrotoscopy and OE; the remaining 6 patients (6/15) were found disease free. The presence/absence of TR was identified correctly with scrotoscopy in all 15 cases. The rupture size of the testicular tunica albuginea (TTA) varied from 0.5 to 2 cm. Only 3 cases (3/15) had scrotal wall edema and all quickly recovered. The testis was normal in size and blood flow at 6-month follow-up visit. Scrotoscopy accurately diagnoses TR, and may avoid unnecessary OE, especially for the patients confirmed free of disease.

Sao Paulo State Univ UNESP, Sch Agr & Veterinarian Sci, Dept Vet Clin & Surg, Jaboticabal, Brazil

Epididymo-orchitis is a medical condition characterised by inflammation of epididymis and testis which is a common urological diagnosis encountered by healthcare professionals. Misdiagnosis and under treatment can lead to poor outcome such as infarction and abscess formation. We presented a 33-year-old man, with no known medical illness, presented with one-week history of left testicular pain, swelling and fever. He was commenced on Amoxicillin by his general practitioner. Physical examination showed left swollen and tender testis and normal right testis. Investigations showed an elevated white cell count (WCC) 41.3x103 /L and colour doppler ultrasound (USG) testes showed left epididymo-orhitis. He was admitted and treated with IV Unasyn® (Ampicillin+Sulbactam) for 5 days. His symptoms improved, and he discharged home well with one week oral Unasyn®. He represented 2 weeks later with worsening left scrotal swelling and pain. Clinical examination found a swollen, tender and erythematous scrotum with 1x1cm defect in the left scrotum with purulent discharge. He underwent operation incision and drainage of left scrotum and left orchidectomy. Post-operatively he recovered well. Histopathology reported as epididimoorchitis with abscess, necrosis and perforation. As a conclusion, testicular rupture and abscess formation secondary to epididymo-orchitis is an uncommon reported complication. Immediate recognition and treatment is crucial as a delayed diagnosis can lead to sepsis and infertility.

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