Overview

Testicular trauma is considered to be damage to the testicles which are located outside of the body caused by either blunt force, penetrating injuries or degloving accidents. The testicles are usually a part of the anatomy for an individual assigned male at birth and their functions include the generation of sperm and hormones. They are enclosed in the scrotum, a skin pouch found outside the body. Testicular trauma can happen to anyone with one or two testicles and can affect normal physiology and function. The symptoms can be directly related to the scrotum such as pain, bruising and swelling or others such as fever, nausea and/or vomiting, adnominal pain and discomfort, testicular dislocation, hematuria and dysuria.¹ Testicular trauma has been shown to affect the fertility and sexual performance of persons assigned male at birth, resulting in infertility and erectile dysfunction

The common causes of testicular trauma are:¹

1. Penetration by weapons like knives or guns
2. Blunt force, such as hits, or things that can be thrown (e.g. balls)
3. Automobile, motorcycle or bicycle accidents
4. Machinery accidents
5. Animals’ bite

Initial assessment

History taking

Mechanism of injury

It is important to identify the cause of injury as trauma can be the result of blunt force, penetration or degloving (avulsion), which is when the skin is ripped.

Timing and progression of symptoms

The onset of the symptoms whether it is immediate or delayed, will be considered as well as how the symptoms develop as time goes by. Most cases usually present to the emergency room following an event which caused the injury with immediate symptoms. If severe cases do not improve within 48 hours, surgery may be required to diagnose the injury entirely.¹

Associated symptoms 

Symptoms such as nausea and/or vomiting, dysuria or hematuria and fever can be telltale signs of other conditions like testicular torsion, testicular rupture, and epididymitis.

Physical examination

Inspection, palpation and assessment for associated injuries 

The testicle/s will be assessed physically in a gentle manner to avoid aggravating the injury. The medical provider can determine if the testicle/s and surrounding areas are abnormal relating to their texture, tenderness, position, size and consistency. Typically, presentation is swollen, extremely delicate testicle/s with hematoma and possibly scrotal perineal ecchymosis (bruising)

Symptoms like pain, nausea and fainting are associated with testicular rupture while a lack of pain with scrotal swelling and hematoma is most likely related to testicular infarction or spermatic cord torsion. The perineal should also be checked for penetrating injuries.²

Diagnostic workup

Imaging modalities

Scrotal ultrasonography with Doppler 

If the initial physical exam is incomplete or inconclusive, further tests are usually recommended. An ultrasound is the first-line imaging diagnostic test for testicular trauma as it can determine and stage testicular injuries. This is a non-invasive procedure which produces Doppler images to show the extent of testicular integrity and vascular integrity like blood flow and scrotal content. The absence of blood flow may indicate testicular torsion or a revascularizing wound.³

Magnetic resonance imaging (MRI), nuclear imaging or CT scans 

These imaging tests may be necessary for further assessment to attain additional information. An MRI is useful in distinguishing between a posttraumatic hematoma and a testicular germ cell neoplasm.⁴

Laboratory tests 

Urinalysis 

A screening urinalysis is a critical adjunct test as it can exclude the possibility of urinary tract infection (UTI) or epididymal-orchitis. Urinalysis can either be non-invasively (spontaneous voiding) where the patient is advised to provide their urine (15mL or 30 mL) in a sterile container for examination or via an invasive method such as urethral catheterisation.

The best sample to collect is first void or ‘morning urine’ as it is more concentrated and allows for the detection of trace substances. However, other specific urine specimens may be requested based on the reason for testing. The sample should be tested within the first hour of being collected or stored properly for up to 24 hours. A complete urinalysis will give details about the physical, chemical and microscopical aspects specifically.⁵

• Physical - the volume, colour, clarity, odour, and specific gravity of urine
• Chemical - the pH, blood cell count (red and white blood cells), the presence of proteins, minerals and substrates 
• Microscopical - the presence of casts, cells, crystals, and microorganisms

Surgical approach 

Surgery can be used to diagnose testicular trauma and treat it if necessary.²

Differential diagnosis

It is important to differentiate between the numerous conditions that can present with the typical symptoms seen in testicular trauma like scrotal pain, bruising, swelling, and tenderness. The differential diagnoses consider traumatic or non-traumatic causes.

Traumatic causes

These disorders are due to external force or injury.

Testicular contusion

• Mild bruise with localised swelling and pain
• No structural damage to the testicle or scrotum

Testicular hematoma²

• Blood accumulates within or around the testis 
• Can be intratesticular (within the testicle) or extra-testicular (in the tunica vaginalis)
• Signs and symptoms: scrotal skin thickening, swelling
• A heterogeneous hypoechoic area without vascular disruption is seen in ultrasounds

Testicular rupture^2,6

• Severe trauma causes the tunica albuginea to fracture leading to the exposure of the seminiferous tubules 
• Signs and symptoms: extreme and consistent pain, swelling, bruising, abnormal testicle position and contour
• Ultrasound images show the discontinuity of tunica albuginea, heterogeneous echotexture

Testicular dislocation⁷

• Blunt testicular trauma can cause the testicle to shift from the scrotum into the superficial inguinal, pubic, canalicular, penile, intra-abdominal, perineal or crural regions
• Signs and symptoms: an empty hemiscrotum with a potential palpable tender mass

Hematocele^2,8,11,12

• The build-up of blood within the tunica vaginalis that surrounds each testicle
• Can be idiopathic or due to spontaneous bleeding
• Signs and symptoms: scrotal swelling (mass) and tenderness
• Small hematoceles are observed, while large or expanding ones require scrotal examination and surgery

Non-traumatic causes

These conditions are caused by other causes.

Testicular torsion

• The twisting of the spermatic cord inside the testicle, which can lead to ischaemia
• Signs and symptoms: sudden, extreme scrotal pain and swelling, fever, adnominal pain, nausea, vomiting, high-riding testis, frequent urination
• Ultrasound shows a lack of or decreased blood flow 

Epididymitis/orchitis^9,,15

• Causes include infections, trauma, autoimmune disorders and drug use 
• Signs and symptoms: Pain, swelling, and inflammation of the epididymis and/or testicle, fever, scrotal enlargement
• Increased blood flow with hypoechoic epididymis and/or testicle seen on Doppler images 

Hydrocele

• Abnormal serous fluid build-up within the tunica vaginalis
• Signs and symptoms: scrotal swelling that fluctuates in size, discomfort, pain, heavy feeling
• Ultrasound should show unusual fluid collection in the testicular area 
• Management: Usually observation; surgical drainage if symptomatic

Scrotal hernia (inguinal hernia)

• The intrusion of fatty tissue or a part of the bowel into the scrotum
• Signs and symptoms: feeling of pressure or heaviness in the groin area, pain when straining, lifting, coughing or bending over, a bulge or swelling in the groin or scrotum area
• The ultrasound images show the abdominal or pelvic content within the scrotum

Summary 

Testicular trauma refers to injuries affecting the testicles due to blunt force, penetrating wounds, or degloving incidents. These structures, crucial for sperm production and hormone regulation, are encased in the scrotum and exposed to external forces, making them vulnerable to injury. Symptoms of testicular trauma vary and may include localised pain, bruising, swelling, nausea, vomiting, fever, abdominal pain, and, in severe cases, testicular dislocation or urinary symptoms such as hematuria and dysuria. Beyond immediate physical consequences, testicular trauma can significantly impact fertility and sexual function, sometimes leading to infertility or erectile dysfunction. Common causes include blunt impacts, penetrating injuries from weapons, vehicular and machinery accidents, and animal bites.

A thorough initial assessment is essential, beginning with history-taking to determine the mechanism of injury, the progression of symptoms, and associated signs that may indicate complications such as testicular torsion or rupture. A physical examination follows, involving careful inspection and palpation to evaluate testicular position, texture, and tenderness while minimizing additional damage. The presence of hematomas, scrotal bruising, and extreme sensitivity often suggests severe trauma, while absent pain may raise concern for testicular infarction or spermatic cord torsion. Additionally, the perineal region is examined for potential penetrating injuries.

If physical examination findings are inconclusive, imaging studies play a pivotal role in diagnosis. Scrotal ultrasound with Doppler imaging is the primary modality, offering insight into testicular integrity, vascular perfusion, and scrotal contents. The absence of blood flow may indicate testicular torsion or vascular injury. In more complex cases, MRI, nuclear imaging, or CT scans provide additional details, particularly for distinguishing between hematomas and neoplastic changes. Laboratory tests, such as urinalysis, assist in identifying coexisting infections or urinary tract involvement, further guiding management decisions.

Surgical intervention may be necessary for both diagnostic and therapeutic purposes, particularly in cases of severe trauma or unclear diagnoses. It is crucial to differentiate testicular trauma from other conditions that present with scrotal pain and swelling. Traumatic causes include testicular contusion, hematoma, rupture, dislocation, and hematocele, each with varying degrees of severity and treatment requirements. Non-traumatic conditions, such as testicular torsion, epididymitis, orchitis, hydrocele, and inguinal hernias, can mimic testicular trauma but often have distinct clinical and imaging features. Proper differentiation ensures appropriate management and reduces the risk of complications, preserving testicular function and overall reproductive health.