臺北市立萬芳醫院 泌尿科1 臺北醫學大學 醫學院 泌尿學科2
Pin-Wen Wang1, Liang-Ming Lee1, Yu-Ching Wen1,2, Ke-Hsun Lin1, Chi-Hao Hsiao1, Syuan-Hao Syu1, Benjamin Chung Howe Lai1, Yung-Wei Lin1, Cho Hsing Chung1
To our knowledge, testicular injury mostly happens from blunt scrotal trauma. Besides, early exploration and repair of testicular injury is associated with increased testicular salvage and reduced convalescence and disability, faster return to normal activities, and preservation of fertility and hormonal function. However, there is less data about the intratesticular hematoma without rupture of the tunica albuginea following blunt scrotal trauma and the management choices between conservative treatment or scrotal exploration is still controversial. We hereby present our experience of a patient with intratesticular hematoma without rupture of the tunica albuginea following a motorcycle traffic accident.
This is a 20 years old man without systemic disease. He suffered from a motorcycle traffic accident and his scrotum was hit by the tank of the motorcycle. 3 hours later, he came to our emergency room for help due to severe pain. Physical examination revealed no obvious swelling or scrotal ecchymosis and bilateral intact testicles but with severe tenderness upon palpation. Scrotal sonogram revealed intratesticular hematoma and the size was about 2 cm. We then arranged contrast CT and right scrotal hyperdensity was noted, indicating possible hematoma or active bleeding. Besides, persistent pain and gradually enlarging scrotum was noted. Therefore, due to the risk of failure conservative treatment and to maximally protect his fertility function, he was arranged for emergent scrotal exploration.
Massive blood clots with necrotizing tissue and bleeding were noted after the tunica albuginea incision. After debridement, we pushed the residual healthy seminiferous tubules back into tunica albuginea and then closed it. No specific events happened during post-operative care. During outpatient department follow-up, good circulation of repaired testis was noted via scrotal sonogram.
According to Cass and Luxenberg’s study in 1998, significant intratesticular hematomas should be explored and drained, even in the absence of testicular rupture to prevent progressive pressure necrosis and atrophy, delayed exploration, and orchiectomy. Chandra’s study in 2007 demonstrated the opposite opinion about conservative management. Diana’s study in 2014 suggested scrotal exploration in patients with significant pain or evidence of a large and/or expanding intratesticular hematoma. Redmond’s study in 2018 suggested that urgent exploration is not essential in the management of blunt scrotal injury based on a retrospective chart review with conservative management regardless of sonogram findings.
In conclusion, many factors need to be considered, including active bleeding, enlarging hematoma, and disease progression. Recent literature indicates that conservative treatment appears to be non-inferior to surgical treatment. Based on our experience, if a patient with evident intratesticular hematoma with progression, scrotal exploration needs to be done as soon as possible to avoid the risks of testis atrophy, intratesticular abscess or even orchiectomy.