Pediatric emergency medicine trisk 3330 3330
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When inspection of the scrotum and its contents is obscured by local swelling and
pain, ultrasonography is helpful to define the extent of the injury. An
intratesticular hematoma may show as an echogenic or hypoechoic testicular
mass. A hematocele produces a complex extratesticular fluid collection.
Sonographic findings of rupture include the presence of hematocele, parenchymal
heterogeneity, intraparenchymal hemorrhage, and disruption of the tunica
albuginea or parenchyma. If the ultrasound examination is inconclusive,
radionuclide scanning may provide additional information. Both ultrasonography
and nuclear scintigraphy help in the diagnosis of testicular torsion (see Chapter
119 Genitourinary Emergencies ).
Patients who sustain small intrascrotal hematomas, skin ecchymosis, or minor
skin and dartos injury without evidence of injury to the testes can be managed
conservatively. Treatment consists of ice packs and scrotal support. Minor
testicular injuries such as contusions or hematomas can also be treated
conservatively. Large testicular hematomas (>3 to 5 cm) or testicular disruption
may require surgical management. Delay in surgery may lead to ischemic
necrosis, pain, secondary infections, and disruption of testicular function.
Initial Assessment, Management, and Diagnostic Testing
Superficial lacerations of the scrotum can be repaired using absorbable sutures.
Local infiltration with lidocaine plus epinephrine provides adequate anesthesia.
Urologic consultation should be obtained if the laceration extends through the
dartos. Physical examination of the scrotal contents determines the need for
debridement and primary closure. All penetrating testicular injuries require
surgical exploration.
Degloving injuries of the scrotum can be seen after motor vehicle (particularly
motorcycle), industrial, or farm machinery accidents. Scrotal injuries are
associated with varying degrees of penile skin loss. The underlying penile and
scrotal structures are usually spared. Management involves debridement with
primarily closure or coverage of the defect by skin flaps or grafting if more than
50% to 70% of the scrotal skin is lost.
Testicular rupture is a surgical emergency. It is characterized by a tear of the
tunica albuginea and extravasation of testicular contents into the scrotal sac. Such
injuries require early surgical exploration and repair to avoid the potential
complications of atrophy and persistent pain. Ultrasonography has been
demonstrated to be sensitive in the diagnosis of testicular rupture by informing
the clinician of the integrity of the scrotal contents early. The high specificity of
the ultrasonography may also provide information to guide the clinician on the
necessity of surgical exploration. Testicular salvage is more likely when
