Working Diagnosis:
Ruptured testicle

Treatment:
Based on the elapsed time and repeat ultrasound results, the likelihood of salvageable testicular tissue was low. The patient was offered conservative treatment or surgical exploration with possible repair or orchiectomy. He opted for surgery, which revealed a hematocele, rupture of the tunica albuginea, and absent arterial flow in the left testicle or spermatic cord. Due to absence of blood flow, the urologist decided to perform an orchiectomy rather than debride and attempt closure. Surgical pathology demonstrated a left fractured testicle, infarction of the seminiferous tubules, intertubular hemorrhage, and defects in the tunica vaginalis and albuginea.

Outcome:
The athlete resumed skating and non-contact activities on post-operative day 5 and full contact activities on post-operative day 10. He was counseled on the importance of wearing genital protection now that he has a solitary testis.

Author's Comments:
Scrotal trauma, although rare, is often associated with severe injuries, with testicular rupture amongst them. A missed testicular rupture has an increased risk of secondary infection and atrophy. It also could contribute to impaired spermatogenesis and a hypogonadal state. A timely diagnosis is important since early surgical intervention maximizes the potential for testicular salvage. Unfortunately, one cannot rely solely on a thorough history and exam as they can be misleading and limited. Ultrasound is the imaging modality of choice used to guide management as it has been found to be highly specific and sensitive for testicular rupture. Those with normal ultrasounds may be managed conservatively. One should have a low threshold for surgical exploration in light of the high rate of salvageability with early intervention. If an athlete presents with a history of blunt testicular trauma along with concerning symptoms and examination, these mandate surgical exploration, regardless of ultrasound findings.

Editor's Comments:
This case highlights the importance of early, often urgent, referral for further evaluation and management of testicular injuries in athletes.

References:
Chandra RV, Dowling RJ, Ulubasoglu M, et al. Rational Approach to Diagnosis and Management of Blunt Scrotal Trauma. Urology. 2007 Aug;70(2):230-234.

Mulhall JP, Gabram SG, Jacobs LM. Emergency Management of blunt testicular trauma. Acad Emerg Med. 1995 Jul;2(7):639-643.

Buckley JC and McAninch JW. Diagnosis and Management of Testicular Ruptures. Urol Clin North Am. 2006 Feb;33(1):111-116.

Hunter SR, Lishnak T, Powers AM, Lisle DK. Male Genital Trauma in Sports. Clin Sports Med. 2013 Apr;32(2):247-254.

Koester MC. Initial Evaluation and Management of Acute Scrotal Pain. J Athl Train. 2000 Jan;35(1):76-79.

Bhatt S and Dogra VS. Role of US in Testicular and Scrotal Trauma. Radiographics. 2008 Oct;28(6):1617-1629.

Guichard G, El Ammari J, Del Coro C, et al. Accuracy of Ultrasonography in Diagnosis of Testicular Rupture After Blunt Scrotal Trauma. Urology. 2008 Jan;71(1):52-56.

Papoutsoglou N and Thiruchelvam N. Diagnosis and Management of Testicular Injuries. Med Surg Urol. 2013 June 13;2(2):108.

Herrera F and Coimbra R. Blunt Pelvic Trauma Resulting in Unilateral Ruptured Testicle: A Case Report and Review of the Literature. The Internet Journal of Urology. 2008;6(1).

Freehill MT, Gorbachinsky I, Lavender JD, et al. Presumed Testicular Rupture During a College Baseball Game: A Case Report and Review of the Literature for On-Field Recognition and Management. Sports Health. 2015 Mar;7(2):177-180.

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