What is a testicular injury?

Testicular trauma is caused by injuring one or both testicles, and the aftermath can range from temporary pain to compromised functionality. The testicles are responsible for producing sperm and hormones, and testicular trauma may interfere with those biological functions.¹

Testicular injuries can affect a male individual at every stage of life, but they are mostly commonly observed in males aged 15 to 40 years due to sports, physical activities, and high-risk jobs (e.g., military service). Depending on how the injury occurred and which part of the testicles it has affected, testicular injuries are split into the following categories: blunt trauma, penetrating trauma, and degloving trauma.²

Untreated testicular injuries may affect sex hormones (e.g. testosterone) and subsequently fertility (the ability to have biological children). It is important to consult a healthcare physician for an accurate diagnosis and the right guidance on managing the injury and ensuring optimal reproductive health.^1,2

Causes and types of testicular trauma 

The way the injury occurred, as well as the depth of it, allows us to classify testicular injuries into three main categories:

Blunt trauma 

This is the most common type of testicular injury, observed in 85% of cases.³
It is mostly caused by:

• A kick in the area
• A sports ball hitting the area
• Vehicle accidents with a motorcycle or bike 
• Machinery accidents 

Penetrating trauma 

A more serious but less common injury. It damages the inner part of the testicles, and it can be caused by invasive forces to the testicular microenvironment⁴ such as: 

• Stabbing 
• Gunshot

Degloving trauma 

A more serious but the least common injury that results in the removal of the skin that covers the testicles.⁵ It may be caused by: 

• Agricultural accidents
• Industrial accidents (using machines)
  

After your healthcare provider clinically evaluates your condition, you will be advised about the best treatment for your injury (surgical or non-surgical). 

How serious is a testicular injury?

As with any injury, the immediate response of your body will likely be pain and/or swelling. But what is happening on the inside? Ischemia (inadequate blood supply) may occur at the moment of the incident. This is a critical condition and it requires immediate clinical care, as it can lead to the rupture of the testicles. Seeking medical attention within 72 hours of injury can save up to 80% of ruptured testicles. Untreated conditions may result in testicular atrophy (shrinking of the testes), infection, and infertility.⁶ 

A testicular injury can also have delayed complications, such as testicular necrosis (irreversible tissue death). This can result from inadequate oxygen supply to the area. Not enough oxygen means not enough nutrients, and therefore, the tissue can irreversibly get damaged. Additionally, the loss of blood supply to the affected testis may cause testicular atrophy and eventually require surgical removal (orchiectomy). Other complications may be nerve damage and chronic inflammation.¹

Your hormones may also be affected by testicular trauma. “Uncoordinated” hormones can have a negative impact on sperm production and, subsequently, on the ability to have children. If the seminiferous tubules (the sperm-production factories) are damaged, there will be a low sperm count (oligospermia) or absence of sperm (azoospermia) observed. At the same time, the cells that produce testosterone (Leydig cells) and surround the seminiferous tubules will also be affected. The overall cause of hormonal imbalances may lead to reduced libido, ultimately affecting reproductive health.¹⁹

How is a testicular injury diagnosed?

A healthcare provider will get your thorough history and perform a physical examination to assess the severity of the injury and suggest the best course of action. A scrotal ultrasound is usually the first step of the diagnosis.⁷

Additionally, imaging technologies such as Doppler ultrasonography may be used in patients with blunt trauma. Doppler ultrasonography involves an ultrasound device sending sound waves to a screen that produces an image of the inner environment of the testicles. For more serious cases, MRI will be performed to create a more detailed image to visualise the testicular environment in more detail.^2,3

Your healthcare provider may also recommend laboratory tests to assess your hormonal profile by detecting the activity of inflammation biomarkers.²⁰ A semen analysis may also be required to assess if the injury has affected the production of sperm cells. 

How to respond after a testicular injury

If you experience pain and discomfort, you may consider the following to manage the pain momentarily:

• Cover ice with a towel and press against the scrotum
• Get pain-relief medication
• Offer extra support to the area (e.g. wearing a jockstrap)³

You should then arrange to see a healthcare provider, as surgical interventions may be needed. The most common surgical interventions can be:

• Debridement: This is a minimally invasive surgery in which a small incision is made in the testicles to remove the damaged/infected tissue⁸
• Tunica albuginea repair: this is a connective tissue layer that covers other important tissues in your penis, like the one that transports blood flow to cause an erection, and your urethra. Testicular injuries may tear the tunica albuginea and stitches may be needed⁹
• Vascular repair: Microvascular anastomosis or vascular grafting may be performed to restore blood flow in a damaged artery¹⁰
• Orchiectomy: In the case of severely damaged testicles, your healthcare provider may suggest removing the affected testicle(s)¹¹

Advanced preservation strategies for mild to severe damage

One of the biggest challenges a severe testicular injury may pose is compromised fertility. The cryopreservation of sperm cells, also known as sperm freezing, is a reliable way to store sperm cells for future use with the help of assisted reproductive technologies (ART).¹²

Additionally, testicular tissue cryopreservation is another resort. In this case, a small incision is made in the testicles to remove part of the tissue that makes sperm cells. The tissue is frozen and stored, “pausing” time for your sperm cells. At a later stage, it can be thawed and sperm cells can be retrieved.¹³

Preserving fertility using regenerative medicine is currently being explored. Some promising methods include: (i) the transplantation of spermatogonial stem cells (SSCs) in patients with impaired sperm production. SSCs are cells found in the testicles that are not yet sperm cells, but can become sperm cells. This is a promising method to restore continuous sperm production.¹⁴ (ii) Bioprinting and tissue engineering advancements are also promising methods that will allow 

the “duplication” of the testicular microenvironment outside of the body. This way, sperm cells will be generated in the laboratory and can be later used in ART.¹⁵

Post-Treatment: What to consider 

Hormone complications

Some testicular injuries may affect the levels of hormone production in your body. For example, testosterone, one of the most talked-about hormones, is critical for reproductive health but also overall health. Lack or inadequate production of testosterone can have a great impact on the body, such as a drop in lean body mass and bone density. Your healthcare provider might recommend Hormone Replacement Therapy (HRT) to restore the right balance of hormones in the body.¹⁶

Fertility complications

If you experience fertility complications after a testicular injury, fertility counseling can help you navigate your options for having children. Today, ARTs are widely used and offer great possibilities of having biological children.¹⁷

Psychological complications

Navigating a testicular injury alone can be a significant emotional and physical challenge. It is important to have access to counseling, support groups, and medical support to help you cope with the impact and explore your options for fertility and recovery. 

Future Directions

The field of fertility preservation is constantly and rapidly evolving, and new therapies emerge that offer promising possibilities.¹⁵

The already-existing approaches, including sperm and testicular tissue freezing, together with surgical techniques like debridement, continue to improve as scientists strive to enhance these techniques for even better outcomes. Emerging therapies using alternative approaches, such as Artificial gametogenesis, will allow new possibilities for patients who were unable to store their sperm, as their sperm will be generated in the laboratory using primordial germ cells (PGCs).¹⁸

Summary

Testicular injuries may occur in every male individual at some point in their lives, either from sports or other types of accidents. An injury can range from mild to extreme, and apart from the momentary discomfort, it can lead to greater complications. Have you experienced a testicular injury? If so, seek medical attention to get the right diagnosis and advice. A testicular injury may cause fertility problems if it affects your hormones and sperm production. It is important to seek guidance and fertility counselling to understand where you are standing. Nonetheless, there are promising possibilities to maintain your reproductive potential and physically recover from the injury.