Editing Lower Urinary Tract Trauma (section)

=== Testicular trauma ===
* '''<span style="color:#ff0000">Testicular rupture must be considered in all cases of blunt scrotal trauma</span>'''
** '''Blunt scrotal trauma may lead to rupture of the tunica albuginea of the testicle'''.

==== <span style="color:#ff0000">Diagnosis and Evaluation</span> ====

===== <span style="color:#ff0000">History and Physical Exam</span> =====
* '''History'''
** Most patients complain of exquisite scrotal pain and nausea.
*** '''≈5% of spermatic cord torsions are believed to be precipitated by trauma'''; torsion should be considered in all cases of significant scrotal pain without signs or symptoms of major scrotal trauma
* Physical exam
** Clinical examination of the scrotum following trauma can be limited due to significant scrotal swelling and patient discomfort
** Swelling and ecchymosis are variable, and the degree of hematoma may not correlate with the severity of testicular injury; absence does not entirely rule out testicular rupture, and contusion without fracture can manifest as significant bleeding.
** Scrotal hemorrhage and hematocele along with tenderness to palpation often limit a complete physical examination.
** '''A nonpalpable testis in a trauma patient should raise the possibility of dislocation outside the scrotum'''. Manual or surgical reduction of the displaced testis is indicated.

===== <span style="color:#ff0000">Imaging</span> =====
* '''<span style="color:#ff0000">Modality: ultrasound</span>'''
** Can reliably diagnose testicular rupture with a high level of accuracy in the setting of blunt scrotal trauma.
*** The utility of scrotal ultrasound for the evaluation of testicular rupture in the setting of penetrating scrotal trauma is limited.
** '''<span style="color:#ff0000">Ultrasound findings suggestive of testicular fracture include (2):</span>'''
**# '''<span style="color:#ff0000">Heterogeneous pattern of the testicular parenchyma</span>'''
**# '''<span style="color:#ff0000">Disruption of the testicular contour/tunica albuginea</span>'''
** '''<span style="color:#ff0000">A normal or equivocal ultrasound study should not delay surgical exploration when physical examination findings suggest testicular damage; definitive diagnosis is often made in the operating room.</span>'''

==== <span style="color:#ff0000">Management</span> ====
* Minor scrotal injuries without testicular damage may be managed with ice, elevation, analgesics, and irrigation and closure.
* '''<span style="color:#ff0000">Indications for scrotal exploration (6):</span>'''
*# '''<span style="color:#ff0000">Imaging findings of testicular rupture</span>'''
*# '''<span style="color:#ff0000">Equivocal imaging but suspected testicular rupture</span>'''
*# '''<span style="color:#ff0000">Large hematoma</span>'''
*#* '''Should be explored and drained even in the absence of testicular rupture''' to prevent progressive pressure necrosis and atrophy, delayed exploration, and orchiectomy.
*# '''<span style="color:#ff0000">Clear physical findings of testicular rupture</span>'''
*# '''<span style="color:#ff0000">Penetrating scrotal injuries</span>'''
*#* Inspect for testicular, vascular and vasal injury; >50% will have testicular rupture
*#** The injured vas should be ligated with nonabsorbable suture, and delayed reconstruction should be performed if necessary
*#* '''<span style="color:#ff0000">≈30% of gunshot wounds injure both testes, and exploration of the contralateral testis should be considered, depending on the findings of physical examination and the path of the projectile</span>'''
*# '''<span style="color:#ff0000">Significant hematoceles</span>''' (not in 2020 AUA guidelines)
*#* Up to 80% are caused by testicular rupture
* '''<span style="color:#ff0000">Early exploration and repair of testicular injury is associated with (6):</span>'''
*# '''<span style="color:#ff0000">Increased testicular salvage rates</span>'''
*#* '''<span style="color:#ff0000">Salvage rates with exploration and repair within 72 hours of injury: >90%</span>'''
*#** '''Orchiectomy rates 3-8x higher with conservative management and delayed surgery'''
*#** '''Recall'''
*#*** '''Penile fracture: repair within 7 days does not adversely affect outcomes'''
*#*** '''Ischemic priapism: shunting procedure is considered within 72 hours of onset'''
*# '''<span style="color:#ff0000">Reduced ischemic atrophy</span>'''
*# '''<span style="color:#ff0000">Reduced risk of infection</span>'''
*# '''<span style="color:#ff0000">Preservation of fertility and hormonal function</span>'''
*# '''<span style="color:#ff0000">Reduced convalescence and disability</span>'''
*# '''<span style="color:#ff0000">Faster return to normal activities</span>'''
* '''Technique'''
** '''Incision:''' transverse scrotal incision is preferable in most cases.
** The tunica albuginea should be closed with small absorbable sutures after removal of necrotic and extruded seminiferous tubules.
** '''Every attempt to salvage the testis should be performed;''' loss of capsule tissue may require removal of additional parenchyma to allow closure of the remaining tunica albuginea.
*** '''A flap or graft of tunica vaginalis may be used to cover a large defect in the tunica albuginea in an otherwise salvageable testis'''
*** '''<span style="color:#ff0000">Orchiectomy is performed when the testicle non-salvagable</span>'''
* Males with a solitary testis
** Testicular injuries are exceedingly rare in boys involved in individual or team contact sports and recreational activities.
** Parents of boys with a solitary testis should be appropriately counseled, and a protective cup device should be recommended.