December 02, 2007

Testicular Trauma

Because the testicles are located within the scrotum, which hangs outside of the body, they do not have the protection of muscles and bones. This makes it easier for the testicles to be struck, hit, kicked or crushed. The following information should help explain why timely evaluation and proper management are critical for the best outcomes.

What happens under normal conditions?

As the producers of sperm and testosterone, the testicles are paired organs essential for every reproductive and sexual function enjoyed by men. But they are also prone to injuries that can leave damage to either the entire gland or essential parts of it.

Suspended in the scrotum, a skin pouch below the penis, each testicle is surrounded by the tunica albuginea, a tough, fibrous covering that often takes the hit of trauma to the gland. Like the shell of an egg, it can be easily "fractured" or shattered when confronted by a blunt or violent force.

But while this covering is injury-prone, other parts of the scrotal sac, most notably the adjacent epididymis, are also vulnerable. Lying along the backside of the testicle, this rubbery gland contains a single coiled tube formed by the merger of thousands of sperm-producing ducts, seminiferous tubules, originating inside the testicle.

Sperm stop briefly in the epididymis to mature before exiting in semen through the vas deferens, a tube that connects with the urethra. Unlike the vas, which is covered by a thick muscle wall, the epididymis has a coating that is both thin and fragile. As such, it puts the gland at higher risk for inflammation or injury.

What are the causes of testicular injury?

While testicular injuries can be from penetrating forces (e.g., stab wounds, gunshot wounds) or blunt forces (e.g., kick to the scrotum, baseball to the scrotum), they all have the potential of inflicting similar injuries: partial or complete ripping of the testicle as well as loss of the entire testicle. An injury sustained from a penetrating object such as a knife or bullet that punctures the scrotal sac, may cause a minor scrape to the skin or major impediment of the blood flow to the testicle itself. An injury can also be caused by a moving object — such as a kick or baseball to the groin — hitting the scrotal sac with a force so strong the energy causes injury.

What are the symptoms of testicular injury?

While trauma to the testicle or scrotal sac usually produces severe pain as a first symptom, it can also result in actual physical injury to any of its contents. When the testicle's hard covering is shattered or ripped, the blood flows from the injury, stretching the normally elastic scrotal sac until it is tense. While that collection of blood can trigger infection, there also may be additional fertility problems due to the ultimate loss of a testicle or immune system problems that affect the remaining testicle. In very severe cases of testicular injury, the entire testicle is ripped with either part of the testicle that cannot be saved or the entire testicle injured beyond repair.

Considerable pain not caused by a defect in the testicle's covering, may be due to epididymitis. Because the epididymis, the lengthy coil alongside the testicle, is a very thin-walled gland it easily becomes red and swollen either by infection or injury. If left untreated, the condition can lead to a loss of the testicle due to blockage of the blood supply to the testicle.

The symptoms mentioned above may indicate a very treatable, benign problem but they may also indicate testicular cancer. A substantial number of malignancies are discovered after minor injuries. But many men are not aware of the painless, solid lump, bulging from the smooth testicular covering, until they're injured in the groin and are examining themselves.

Do not make the mistake of many men who postpone medical care, thinking they are dealing with a simple bruise. This is a medical emergency! While testicular cancer caught early is generally curable, malignancies discovered late often require prolonged treatment involving surgery, radiation and chemotherapy.

Men who suffer anything more than a minor injury to the scrotum should seek an evaluation by a urologist. Reasons to seek medical care include:

swelling of the scrotal sac
any penetrating injury to the scrotal sac
prolonged pain in the scrotal sac
bruising and swelling of the scrotal sac
fevers after testicular injury
any other symptom that develops after injury to the scrotal sac

How are testicular injuries treated?

A urologist (particularly an expert in scrotal injury) can probably determine the extent of any injury to the testicle with a simple physical examination. After the urologist asks questions about how the injury occurred as well as other medical history questions, he will examine the contents of the scrotal sac. In doing so, the hard covering overlying the testicle can generally be easily felt as well as the narrow, soft epididymis. The structures that run into the testicle including the artery, vein and vas would then be felt to ensure that they are normal.

If everything appears normal, with no injury present, the urologist will probably prescribe pain medication such as acetaminophen or ibuprofen. A patient will also be advised to wear a jock strap, which provides good support for the scrotum.

If it is not clear that an injury has occurred, the urologist may request a scrotal ultrasound scan. Based on the same sonar sound waves that guide submarines, this device can safely and effectively image parts of the sac, including the testicle, epididymis and spermatic cord. More specialized versions can also track blood flow.

Although no imaging test is 100 percent perfect, ultrasound is an attractive alternative because it is easy to perform, uses no X-rays and clearly shows the physical structure of the scrotum. On rare occasions, the urologists may request an MRI, a more sophisticated imaging technique, if the ultrasound leaves more questions than answers.

If any imaging study reveals evidence of or suggests testicular injury, the usual course of action is an operation in which the urologists opens the scrotal sac and visually inspects as well as repairs any injury. Under anesthesia, an incision is made in the sac and the entire contents are examined. If a rip of the testicle has occurred and the testicle can be repaired (if it has good blood supply and the remaining testicle has sufficient covering available), the urologist will usually repair the defect with stitches and then close the scrotal sac skin. In some cases, the urologist will leave a drain in the scrotal sac to drain blood and other fluids. While it is removed in a few days, the patient can expect to wear a protective jock strap for several weeks.

On occasion, the injury is so severe that the testicle cannot be repaired. If this occurs, the urologist will remove the testicle. That does not mean the patient cannot father a child, however. If the patient's other testicle is normal, he should be able to impregnate his partner. Also, the patient's hormone levels should remain steady since only one testicle is required for either function

If the patient's physical examination and ultrasound suggest that the injury has caused epididymitis, he will probably be treated conservatively, placed on an anti-inflammatory medication (such as ibuprofen) and encouraged again to wear a jock strap. If necessary, the urologist may also prescribe an antibiotic. It generally takes six to eight weeks for the swelling to subside. The patient may have to have several follow-up visits with the urologist to chart his progress. Further, if conservative measures (medications and jock strap) do not work, surgery may be required and the testicle may have to be removed.

Frequently asked questions:

I have noticed pain in my scrotum and testicle but I do not remember any injury. What should I do?

There are many possible causes of scrotal or testicle pain including epididymitis, inflammation of the testicle and problems with other parts of the scrotum. Whatever the source, you should be examined by a urologist, a specialist trained in such problems.

I was hit by a knee during a basketball game and have since noticed a new lump in my scrotal sac. It does not hurt but should I do anything about it?

Like many young men, you are probably examining yourself for the first time now that you have had a sporting injury. There is a good chance that the lump or "new" mass you have just felt is a normal part of the anatomy (your epididymis). But it could be an injury or even testicular cancer. Any new lump should be checked immediately by a trained urologist. With his/her expertise, a urologist will ease your mind and point you to swift and accurate treatment.

I'm 55 years old and noticed a lump in my scrotum after being hit in the groin during pick-up game of baseball? Could this be testicular cancer or am I too old for that?

Testicular cancer can occur at any age, even though the most cases are between 15 and 35. Anyone with a new lump in the scrotum should see a urologist immediately. Often you will not need any further tests because the urologist can make a diagnosis with a physical examination. However, the urologist may also request an ultrasound. While some masses are not cancer (benign), many can be malignant. The good news, however, is that testicular cancer can be treated effectively (with initial surgical removal of the gland) if caught early. So do not be afraid to contact a urologist!

I noticed blood in my urine after being hit with a baseball. I do not feel any lumps. Should I still report this to my doctor?

Absolutely. Blood in the urine that is visible to the naked eye is almost always due to a urologic problem. You need to see a urologist immediately for evaluation to sort out the possibilities.

What can I do to prevent injury to my testicles?

There are many common-sense steps you can take to reduce your risk of testicular trauma. Wear a seat belt when driving a car. Make sure your clothes are tucked in and you are not exposing loose belts or other items to machinery that has exposed chains or belts. Wear a jock strap when playing sports. If the activity could produce severe contact (as in baseball, football or hockey) use a hard cup to reduce the risk. Finally, avoid any circumstances in which a moving object could hit your groin, particularly the scrotum.

Adapted from: American Urological Association Education and Research