Introduction

Testicular injuries are not only painful but can also lead to severe complications if not properly identified and treated. Understanding the differences between contusion, rupture, and torsion is critical for ensuring the right course of action. This article will discuss these injuries, highlighting their symptoms, causes and the appropriate treatments to prevent long-term damage to the testes.

Testicular contusion

A contusion is a bruise caused by broken blood vessels under the skin, leading to a discoloured spot, or it can also be a hematoma similar to a bruise but involves a larger collection of blood.¹ 

Testicular contusion can occur as a result of a motor vehicle accident or playing sports with symptoms such as pain and swelling.

Diagnosis of testicular contusion

A colour doppler ultrasound is used to look at the testicles after an injury and it helps distinguish a hematoma from the tumour. In scrotal ultrasonography, acute hematomas may initially appear similar in texture to the surrounding testicle (isoechoic). A follow-up exam 12–24 hours later can help track changes, as hematomas may shift from a darker (hypoechoic) to a clear (anechoic) appearance. An acute hematocele typically appears bright (echogenic), while a chronic hematocele may look clear (anechoic) and show signs like separations, fluid pockets, or hardening (calcification). Hematomas can also be limited to the scrotal wall, sometimes appearing as thickened areas or fluid collections.^1,2

Management of testicular contusion

The general management of scrotal hematomas includes surgically removing the hematoma (evacuation) and ensuring proper hemostasis (stopping bleeding) to prevent re-bleeding after surgery. For smaller hematoceles (less than three times the size of the other testicle or under 5 cm and not growing), conservative treatment with scrotal support and ice is recommended. However, for larger hematoceles, early surgery to remove the blood is preferred to avoid complications like infection, pain, testicle shrinkage, or the need for further surgeries, which can occur in up to 40% of cases.¹

Testicular rupture

Testicular rupture is defined as the tearing of the protective fibrous connective tissue that surrounds the testes (tunica albuginea) and the sticking out of the sperm-producing tubes (seminiferous tubules). Testicular rupture can result from a 50kg force, like a strong punch or kick. It primarily affects males aged 15-40 but rarely occurs in infants or the elderly. It usually impacts one testicle but may affect both. Though not fatal, delayed treatment can impair fertility.³

Causes of testicular rupture

Penetrating and blunt (non-penetrating) injuries to the scrotum can cause testicular rupture. Common examples include motor vehicle accidents, forceful contact during sports, falls, kicks in the genital area during a fight and straddle injuries.³ One study reported testicular rupture occurring as a result of prolonged marching.⁴ Testicular rupture has also been reported  in newborn babies due to injury during breech birth ⁵

Signs and symptoms of testicular rupture 

They include pain, tenderness (pain or discomfort when the affected area is touched or pressed), swelling, large collection of blood under the scrotal skin due to bleeding from damaged blood vessels, discolouration because of blood leakage, and in some individuals nausea and vomiting. In some cases, the injured individual may only experience mild symptoms like less discomfort and no pain when the scrotum is touched, making it seem like the testes are not ruptured, thus leading to a delay in diagnosis and management.^6,7

Diagnosis of testicular rupture

Early diagnosis of testicular rupture is very critical to saving the testes and its function which is fertility. A physical examination is done by the physician to watch out for symptoms of testicular rupture. One main physical finding indicating testicular rupture is severe tenderness and pain when the testes are touched. In some patients, a physical examination is sufficient to diagnose and determine a treatment plan, especially for penetrating injuries. However, in some patients, the testicular rupture cannot be correctly assessed by physical examination alone because of tender and severely deformed scrotum, and sometimes mild symptoms may mask testicular rupture. In such cases, a scrotal ultrasound is done to examine the condition of the testes and its surrounding tissue.

What findings on the image of the ultrasound indicate testicular rupture? 

• Mixed areas of brightness and darkness (heterogeneous echo pattern) of the testicular tissue 
• Loss of the normal oval shape of the testes indicates that the testes are ruptured
• Formation of blood collection and increase in the thickness of the scrotal skin
• Less or no blood flow to the testes when viewed using a power doppler ultrasound

 Previously, the tearing of the tunica albuginea was used as an indicator for testicular rupture on ultrasound. However, studies have reported that this criterion alone does not reliably differentiate rupture from other testicular injuries like contusion and hematoma (collection of blood). A modern kind of ultrasound known as real-time high-resolution ultrasound offers the correct condition of the testes and their structures despite swelling and discolouration.⁷ If the findings of ultrasound are not clear or are inconclusive, magnetic resonance imaging (MRI) can be used to further assess testicular rupture. MRI has perfect diagnostic accuracy (100%). ³ Another diagnostic tool called scrotoscopy is also used to accurately observe the testes and their surrounding structures and diagnose testicular rupture.⁸

Management of testicular rupture

The recommended current approach to managing testicular rupture is to perform surgery to examine the level of damage and repair the testes within 72 hours of injury. This reduces the need for removing the testes (orchiectomy).

Repair involves:

• Examining the extent of tear to the protective tissue wrapping the testes (tunica albuginea) after draining blood
• Removing dead testicular tissue (debridement) until healthy bleeding edges are seen
• Suturing of the tunica albuginea with sutures that absorb over time

However, when suturing is not possible because of the extent of damage, a biosynthetic graft can be sutured to the tunica albuginea to enable coverage of the testes and preserve the function of the testes. But, if the affected testes are severely damaged and the testes cannot be rescued, the testes are surgically removed. Additionally, conservative management has been reported in previous studies, but its use is questionable because of the high risk of infection, loss of testicular tissue and reduced fertility caused by blood cysts and decayed tissue. In some studies, conservative treatment did not effectively treat testicular rupture, and in the end, orchiectomy was done.⁶

Testicular torsion 

Testicular torsion happens when the spermatic cord and its contents twist around inside the scrotum, thereby cutting off the blood supply. First, there is an accumulation of blood in the veins, which causes increased venous pressure, swelling and, low oxygen exchange due to the blocked venous outflow, and with time, a decrease in blood flow in the arteries leading to ischemia and potential testicular death if not immediately corrected. In most cases, the twisted testicles rotate toward the middle of the body (medially). However, in about one-third of the cases, the testicle twists in the opposite direction, away from the body (laterally). This rotation can happen regardless of whether it is the right or left testicle that is affected.^9,10

Causes of testicular torsion

Bell clapper deformity

Normally, the testicle is connected to a thin covering called the tunica vaginalis. The back part of the testicle and the epididymis (which stores sperm) are usually securely attached to this covering. However, in boys with bell clapper deformity, these connections are higher up near the spermatic cord (the cord that carries blood vessels and other structures to the testicles). This makes the testicles more free to move and twist within the tunica vaginalis. When this happens, blood flow is cut off to the affected testicle.¹¹

Physical activity

Physical activity such as cycling could cause testicular torsion because when cycling, the testicles can move around inside the scrotum. After all, the legs are constantly moving. This movement can cause the testicles to twist. Also, the cremasteric reflex that controls the position of the testicles can be triggered by things like physical effort. When this reflex takes effect, it might cause the testicles to move in a way that increases the chance of twisting.¹¹

Trauma

 Sometimes, an injury to the testicles can trigger testicular torsion. However, these can be hard to diagnose because if someone gets hit in the testicles or has an accident, they might develop pain, swelling, bruising, or bleeding (hematoma) in the scrotum. This could be confusing as it may be assumed that the pain and swelling are just from the injuries.¹²

Genetics

Researchers think there may be a genetic link, which means it could run in families. Some suspected genetic factors involved include: a hormone called insulin-like 3 and its receptor, Rxlf2. Although, these are still being studied and scientists are not sure exactly how they work in humans, but they think they might play a role in how the testicles move or stay fixed in place.¹¹ 

Weather conditions

Some researchers think that the weather might affect how often testicular torsion happens since they have noticed that more cases seem to occur during the colder months. The concept is that in cold weather, a muscle called the cremaster muscle (which helps move the testicles) might contract unevenly. This uneven contraction could increase the chance of the testicles twisting, leading to testicular torsion. 

However, not everyone agrees with this idea. Some studies have not found any big difference in how often testicular torsion happens in different seasons, so it is still unclear if cold weather plays a big role in causing testicular torsion.¹¹

Signs and symptoms of testicular torsion

When someone has testicular torsion, they usually feel a sudden, sharp pain in one testicle. This pain can come on quickly, and it is often so intense that it can also make them feel nauseous or even make them vomit. In some cases, there might be other symptoms like a fever or trouble with urination, but those are less common. The affected testicle might also look different. It could be positioned abnormally sometimes, and the skin around it may look swollen (called scrotal oedema). Moreover, the pain often does not go away, even when the person is resting.^9,12

Diagnosis of testicular torsion

Colour doppler ultrasonography is mainly used to diagnose testicular torsion.  This type of ultrasound shows how healthy the testicles are by examining their size, shape, and blood flow. If there is testicular torsion, the ultrasound will show little or no blood flowing through the affected testicle.⁹ It is very accurate at identifying testicular torsion, and it can also help doctors rule out other conditions that might cause sudden scrotal pain, like infections or hernias.¹²

Management of testicular torsion

Although there isn’t enough evidence to say that a specific surgery is better than the others for treating testicular torsion,¹³ immediate surgery is required in the treatment of testicular torsion. The types of surgical intervention involved are bilateral orchiopexy, which involves surgically fixing both testicles to the scrotum so they don’t twist again in the future, ipsilateral orchiectomy, removal of the affected testicle or contralateral orchiopexy, removing the damaged testicle and fixing the testicle that was not twisted to prevent it from twisting in the future. If surgery can’t be done right away, manual detorsion, that is, manually untwisting the testicles by hand to restore blood flow is tried first, before the surgery takes place.¹¹

Summary

Testicular rupture involves tearing of the tunica albuginea, often from blunt trauma, leading to pain, swelling, and fertility risks. Diagnostics include ultrasound and MRI, with surgical repairs required within 72 hours. Conservative treatment for rupture is discouraged due to infection risks and potential testicular loss. Testicular torsion, caused by spermatic cord twisting, cuts off blood flow, requiring emergency surgery to prevent loss. Contusions result from trauma, causing bruising and swelling, diagnosed via ultrasound. Small hematomas heal with conservative care, while larger ones may need surgery.