Management of Scrotal Trauma and Testicular Rupture

Clinical Presentation Requiring Investigation

Scrotal hematoma after trauma should raise suspicion for an associated urethral injury and warrants further evaluation. 1
Patients may present with scrotal ecchymosis and swelling, which are common signs of blunt scrotal trauma. 2
Physical examination may be limited by difficulty visualizing testicular contours, especially when swelling is present. 2
Persistent severe pain, nausea, or vomiting after scrotal injury indicates the need for urgent imaging and possible surgical intervention. 2
Blood at the urethral meatus suggests a concomitant urethral injury and should prompt urethral assessment. 3

In all blunt scrotal injuries without an obvious hematocele, an urgent scrotal ultrasound with Doppler flow assessment should be performed on the same day, ideally within a few hours of presentation. 2
Ultrasound findings that mandate immediate surgical exploration include:

The American Urological Association recommends urgent surgical exploration for any suspected testicular rupture based on clinical assessment and ultrasound findings. 1
Immediate exploration is also required when a clinical hematocele is evident on examination, even without imaging. (Note: this recommendation is derived from guideline consensus; no specific citation provided in the source material.)

Technique: All confirmed or strongly suspected testicular ruptures should be explored promptly, with the following steps:
Timing: Surgical repair performed within hours of injury yields a testicular salvage rate of approximately 86 %; delays significantly reduce salvage and increase complications. 4

When scrotal hematoma coexists with blood at the urethral meatus, gross hematuria, or inability to void, retrograde urethrography should be performed before any urethral catheterization. 1
In hemodynamically unstable patients, placement of a suprapubic catheter is recommended, with definitive urethrography deferred until the patient is stabilized. 1
A digital rectal examination is advised because associated rectal injuries occur in up to 5 % of severe scrotal trauma cases. 1

All penetrating scrotal wounds require immediate surgical exploration, thorough debridement, and repair due to the high likelihood of testicular rupture. 2

For conservatively managed intratesticular hematomas, interval scrotal ultrasound is recommended to confirm resolution. (Citation not provided; omitted per instructions.)
A three‑month follow‑up ultrasound should be performed to detect testicular atrophy; a volume < 12 mL suggests impaired spermatogenesis. 4
If atrophy is identified, a semen analysis is indicated to assess fertility potential. 4