Managing traumatic testicular dislocations: what we know after two centuries

Abstract

Traumatic testicular dislocation (TTD) is a rare consequence of blunt scrotal trauma. A 21-year old gentleman presented with inguinal pain following a motorcycle accident and physical examination revealed absence of both testes within a well-formed scrotal sac with bilateral inguinal swellings. Ultrasonography confirmed viability and location of the testes at the superficial inguinal pouch. He underwent emergent surgical reduction with orchidopexy and was discharged the next day. No evidence of testicular dysfunction or atrophy was noted at follow-up. We reviewed reports of TTDs reported in English over the last two centuries and discuss its occurrence, evolution and management.

Background

Traumatic testicular dislocation (TTD) is a rare consequence of blunt scrotal trauma. This condition was previously referred to as traumatic luxation of the testis and was first reported by Claubry in 1818 in a person who was run over by a wagon wheel.¹ TTD is the dislocation of a normally located testis out of the scrotal sac which occurs following blunt injury to the groin. It may be unilateral or bilateral depending on the mechanism of injury and presence of underlying predisposing anomalies such as a wide external ring, an indirect inguinal hernia and atrophic testes.² TTDs have been classified into two groups, namely (1) internal dislocation (abdominal, canalicular, acetabular and femoral) where the testis is forced through the external ring into the inguinal canal or the abdominal cavity and (2) superficial dislocation (superficial inguinal, pubic, penile, crural and perineal) where the testis is forced subcutaneously within a circular area having the radius as the spermatic cord length from the external inguinal ring.³

Case presentation

A 21-year-old motorcyclist presented with problems of pain and swelling at both inguinal regions following a motorcycle accident. He was wearing a helmet and riding a motorcycle with a large fuel tank placed in front of the seat. He was travelling at 60 km/hour before colliding into the back of a stationary vehicle. On collision, his inertia of motion caused a high impact blunt trauma to his groin from hitting the fuel tank. However, he did not dismount from the motorcycle and thus, he did not sustain any other injuries. He was brought to the hospital within an hour following the event. Physical examination revealed absence of bilateral testes within a well-formed scrotal sac and bilateral non-tender, non-pulsatile, firm inguinal swellings with well-defined margins (figure 1A, B). Both femoral pulses were present and the cough impulse was negative. On further questioning, he confirmed that both testes were felt within the scrotum and denied any history of undescended or retractile testis prior to the incident.

Figure 1.

(A, B) Empty but well-formed scrotal sac with dislocated testes visible as swellings at bilateral inguinal region. Minor abrasions with contusions are noted over the left inguinal crease and anteromedial aspect of the left thigh.

Investigations

An urgent ultrasound confirmed that the testes were located subcutaneously at the inguinal region bilaterally with intact vascularity.

Differential diagnosis

Retractile testis is an important differential diagnosis to rule out in history as patients with this condition have fully descended testis that may slide into the inguinal canal intermittently mimicking TTD (internal dislocation) by presenting clinically with a well-formed but empty scrotal sac and no other swellings palpable superficially. Retractile testis may be unilateral or bilateral. In this case, patient denied history of retractile testis and the presence of superficial swellings at bilateral inguinal region aided us in ruling out this condition.

Cryptorchidism or undescended testis also needs to be excluded in such cases as these patients also present with an empty scrotal sac. Thus, it is important to confirm with the patient regarding the presence of testis within the scrotal sac bilaterally prior to the incident. Another important clinical feature that differentiates TTD from cryptorchidism is a well-formed scrotal sac. Patients with cryptorchidism usually have poorly formed and small scrotal sacs with minimal rugosity due to the absence of a spontaneously descended testis. Other abnormalities of the male genitalia that may present with cryptorchidism are hernia, hydrocoele and hypospadiasis.

Treatment

He underwent emergent surgical reduction and orchidopexy of bilateral testis within 3 hours from the event. Incisions were made over the swelling at the level of the external ring bilaterally to expose the testes. Intraoperatively, both testes were intact, normal sized and located at the subcutaneous space anterior to the external ring (superficial inguinal pouch) bilaterally. Both testes were detached from its gubernaculum as evidenced by the raw area seen at the inferior pole. Both external rings were normal with no demonstrable hernia sac. There was a right spermatic cord haematoma and left epididymal haematoma but no haematocoele bilaterally (figure 2A, B). The hemiscrotum was inverted towards the ipsilateral inguinal incision and a 2-point orchidopexy was performed via a single incision. A 2-point orchidopexy was chosen over the standard 3-point fixation due to technical difficulty to perform the latter via a single inguinal incision as well as to reduce the possibility of breaching the blood-testis barrier. The inferior and medial surfaces of the testes were anchored to the dartos muscle and scrotal septum, respectively, to prevent recurrence and torsion of the testis along the x, y and z axes.

Figure 2.

(A, B) Bilaterally intact testes located at the superficial inguinal pouch with right spermatic cord haematoma and left epididymal haematoma. Detachment of the testis from its gubernaculum is evidenced by the raw area over the inferior pole of left testis (*).

In this case, the extent of external injuries was mild and thus surgery was fairly straightforward. In cases with inguinal haematoma and soft-tissue injury overlying the dislocated testis, access to the testis becomes more challenging and tissues need to be carefully dissected and haemostasis secured while evacuating any haematoma if present. Scrotal haematomas, however, can be managed conservatively if not expanding in size.

Outcome and follow-up

He progressed well postoperatively and was discharged home the next day. A follow-up at 6 months showed no evidence of testicular dysfunction or atrophy.

Discussion

A literature search in PubMed, Elsevier ClinicalKey, Google Scholar and Science Direct for articles in English containing keywords ‘testicular dislocation’ and ‘testicular luxation’ revealed a total of 64 articles from 1936 to 2017 reporting 180 cases (243 testes) over the last two centuries (table 1). Only four articles were retrospective studies and the remaining were case series or case reports. The largest of these retrospective studies was published by Herbst and Polkey in 1936 reporting all cases from 1818.² Although they reported 93 cases in total, 27 were cases of compound dislocation or herniation of the testis through an open wound in the scrotum and 9 more were classified as trauma to a congenitally ectopic testis.

Table 1.

Review of reported traumatic testicular dislocation^2–65

Year	Author	N	Age (mean)	MOI	Uni/bilateral	Location	Treatment
1936	Herbst RH.2	57	11–65 (29.8)	12 ROA 13 Muscular Effort 7 Falls 14 SI 8 Self Mutilation 3 Truss Injury	9 Bil 46 Uni 2 NM	23 IC & Abdomen 12 Pubic 4 Penile 10 SIP 8 Perineum 1 Thigh 6 NM	13 SR 1 Failed SR followed by orchidectomy 5 Orchidectomy 3 CR 2 Failed CR 1 Failed CR followed by SR 2 Spontaneous 1 Autopsy 9 Not treated 27 NM
1938	McCrea ED.16	1	20	SI	Uni	SIP	Spontaneous
1943	Shammon PJ.17	1	42	Muscular Effort	Uni	SIP	Orchidectomy
1946	Ockuly EA.18	1	24	SI	Bil	1 IC 1 Abdomen	1 SR 1 Not treated
1951	Charnock DA.19	1	40	ROA	Uni	SIP	SR
1965	Morgan A.20	4	9–20 (15.5)	1 SI 1 MA 2 RTA	4 Uni	4 SIP	1 CR 1 SR 2 Failed CR followed by SR
1967	Neistadt A.14	1	15	MA	Bil	2 Pubic	2 CR
1967	Sethi RS.21	2	34 to 40	1 ROA 1 SI	2 Uni	1 Penile 1 Abdomen	1 SR 1 Not treated
1972	Aquilina JN.22	1	47	SI	Uni	SIP	CR
1975	Boardman KP.23	1	17	RTA	Bil	2 SIP	2 SR
1976	Goulding FJ.3	2	22 to 20	2 MA	2 Uni	2 SIP	2 SR
1979	Edson M.24	1	21	SI	Bil	1 SIP 1 Pubic	1 SR 1 Orchidectomy
1980	Kauder DH.25	1	23	MA	Bil	1 SIP 1 IC	1 Failed CR followed by SR 1 CR
1981	Foster RS.26	1	28	MA	Uni	SIP	SR
1982	Pollen JJ.10	1	22	MA	Bil	2 SIP	2 SR
1983	Nagarajan VP.27	3	20–25 (22.3)	3 MA	1 Bil 2 Uni	3 SIP 1 IC	1 Failed CR followed by SR 2 SR 1 Spontaneous
1990	Ishikawa J.28	1	17	MA	Uni	SIP	Failed CR followed by SR
1990	Koga S.29	1	17	MA	Bil	1 Abd Wall 1 SIP	2 Failed CR followed by SR
1990	Singer AJ.30	1	19	MA	Uni	1 SIP	CR
1991	Feder M.15	1	20	SI	Uni	Abdomen	SR
1992	Lee JY.31	2	23 to 19	1 MA 1 RTA	2 Uni	2 SIP	2 Failed CR followed by SR
1993	Wright KU.32	1	35	MA	Uni	SIP	SR
1994	Madden JF.33	1	35	MA	Uni	SIP	CR
1994	Schwartz SL.34	1	38	RTA	Uni	SIP	SR
1994	Toranji S.35	1	19	MA	Uni	Abd Wall	SR
1996	Hayami S.8	1	17	RTA	Uni	SIP	SR
1998	O’Donnell C.36	1	18	MA	Bil	1 SIP 1 IC	2 SR
1998	Tan PK.37	3	18–20	3 MA	2 Uni 1 Bil	4 SIP	3 SR 1CR
1999	Yagi H.38	1	25	Boat accident	Uni	Thigh	Failed CR followed by SR
1999	Shefi S.39	1	22	MA	Uni	IC	SR
2000	Kochakarn W.40	36	18–38 (25)	35 MA 1 ROA	30 Bil 6 Uni	64 SIP 1 Perineum 1 Acetabular	14 CR 10 Failed CR followed by SR 11 SR 1 Orchidectomy 30 NM
2002	Yoshimura K.41	1	30	MA	Bil	2 SIP	2 SR
2003	Bromberg W.42	1	33	MA	Bil	2 SIP	1 CR 1 SR
2003	Blake SM.43	1	21	MA	Uni	Abd Wall	SR
2003	Chang KJ.44	1	18	MA	Uni	SIP	CR
2004	O’Brien MF.45	1	37	MA	Bil	1 SIP 1 Retrovesical	2 SR
2004	Ko SF.46	9	6–53 (23)	7 MA 1 explosion 1 seat belt injury	2 Bil 7 Uni	7 Pubic 3 IC 1 Penile	4 CR 6 SR 1 Orchidectomy
2004	Wu CJ.13	1	40	MA	Bil	2 SIP	2 SR
2004	Ng SH.47	1	35	MA	Uni	Pubic	CR followed by herniorraphy
2005	Bedir S.48	1	23	MA	Uni	Perineum	SR
2006	Vijayan P.49	1	18	RTA	Uni	SIP	CR
2007	Ihama Y.50	1	17	MA	Bil	2 SIP	Autopsy
2008	Sakamoto H.9	1	33	MA	Bil	2 SIP	2 SR
2009	Ezra N.4	1	26	MA	Bil	2 SIP	2 SR
2009	Kilian CA.12	1	22	SI	Bil	2 SIP	2 SR
2009	Aslam MZ.51	1	22	MA	Uni	IC	SR
2010	Vasudeva P.52	1	17	MA	Uni	SIP	SR
2010	Phuwapraisirisan S.7	1	27	MA	Uni	SIP	SR
2011	Perera E.53	1	30	MA	Uni	SIP	SR
2011	Tsurukiri J.54	1	32	MA	Bil	2 Perineum	2 SR
2011	Jecmenica DS.55	2	24 to 25	2 MA	1 Uni 1 Bil	3 Pubic	3 Autopsy
2012	Naseer A.56	1	53	MA	Uni	SIP	SR
2012	Smith CS.57	1	23	MA	Bil	2 SIP	2 SR
2012	Sinasi M.58	1	26	MA	Uni	SIP	CR
2013	Boudissa M.59	1	62	MA	Bil	1 Intrapelvic 1 IC	2 SR
2013	Matzek BA.60	1	10	SI	Uni	SIP	SR
2013	Dange A.5	1	22	MA	Uni	SIP	SR
2014	Pesch MH.61	1	15	SI	Uni	IC	SR
2014	Gomez RG.11	7	21–48	6 MA 1 Pelvic Crush Injury	5 Uni 2 Bil	4 SIP 1 SIP (open) 4 Pubic	4 SR 1 CR 4 Autopsy
2014	Zavras N.6	1	27	SI	Uni	IC	SR
2014	Meena S.62	1	35	MA	Uni	IC	CR
2014	Tai YS.63	1	27	MA	Uni	IC	Failed CR followed by SR
2016	Wiznia DH.64	1	44	MA	Uni	IC	SR
2016	Kim WY.65	1	57	Industrial Injury	Uni	SIP	Orchidectomy

Bil, bilateral; CR, closed reduction; IC, inguinal canal; MA, motorcycle accident; MOI, mechanism of injury; N, number of patients; NM, not mentioned; ROA, run over accident; RTA, road traffic accident; SI, straddle injury; SIP, superficial inguinal pouch; SR, surgical reduction; Uni, unilateral; Abd Wall, abdominal wall.

Mean age was 27 years and only 5 cases reported (2.8%) were of the paediatric age group (≤12 years). The ratio of unilateral:bilateral TTD is 1.74:1 (63.5% and 36.5%, respectively) with superficial dislocations being more common than internal dislocations. The most common site was superficial inguinal (57.6%) followed by canalicular and abdominal (16.9%), pubic (12.3%) and perineal (4.9%). Up to 1950s, TTDs were mainly caused by run over accidents and straddle injuries. However, with the evolution of technology and popularisation of motorcycles as a mode of transport, motorcycle accidents became the leading cause for this condition and remains so until today. Sudden deceleration causes the scrotum to strike against the fuel tank exerting a blunt force which dislocates the testis. Simultaneous contraction of cremasteric muscles further increases the exerted force. Other predisposing anomalies are a wide external ring, an indirect inguinal hernia and atrophic testes.² Those with retractile testes are also at a higher risk of developing TTD due to the absence of gubernacular attachment, thus requiring a significantly lower magnitude of force to dislocate the testes.

Similar to our case, many authors report no significant external injuries to the scrotum despite a high impact injury to the groin.^4–6 This is likely to be explained using the derivatives of Newton’s second law which states force is the change in momentum with time and momentum is the product of mass and velocity. In this scenario, the velocity is constant for both the scrotum and testes with mass and collision time being the only variables. Force is therefore directly proportional to mass and inversely proportional to collision time. Scrotum being lighter and a mobile structure allows a longer collision time as compared with the testes which is heavier and fixed to the scrotum by its gubernaculum and only becomes mobile on detachment. This results in a greater force acting on the testes as compared with the scrotum following the collision. Other possible factors that contribute to external injuries are the shape of the surface or the object that exerts force and position of the groin during impact.

Exploring the mechanism of injury and a careful groin examination ensures this condition is not missed. TTD should be suspected in all high impact injuries involving the groin and perineum after excluding history of cryptorchidism and retractile testis. Physical examination will reveal an empty but well-formed scrotum with a swelling corresponding to the site of a superficial dislocation. This swelling may or may not be palpable in internal dislocations. If ultrasonography with colour doppler is available without causing much delay, it should be performed to ascertain the location of the dislocated testis, its viability as well as exclude coexisting conditions like haematocoeles, haematomas, testicular rupture, torsion or epididymal avulsion. CT scans are helpful in cases of intra-abdominal dislocations or in the presence of associated pelvic trauma.⁶

Many articles advocate closed manual reduction (CMR) with sedation and muscle relaxant as the first treatment option for uncomplicated TTDs. A total of 60 testes were treated with this modality, resulting in a success rate of 60% (36 out of 60 testes) but was associated with a high risk of iatrogenic testicular torsion and recurrence. CMR failed in the other 40% (24 testes) of cases, of which 22 were successfully corrected with surgery and 2 were left untreated. Some authors even suggest a delayed manual reduction 3 to 4 days post trauma following a failed initial attempt. This carries a risk of missing a testicular torsion and is associated with an orchidectomy rate of 45%.⁷

Surgical reduction was performed primarily in 91 testes and following failed CMR in 22 testes of which all but 1 was successful, exhibiting a success rate of 99%. One case of failed surgical reduction has been reported by Partridge, in which the patient was subjected to an orchidectomy due to recurrence following surgery to replace a unilateral perineal TTD.² Such recurrences can however be prevented by performing an orchidopexy after surgically replacing the dislocated testis.

Performing a suture orchidopexy as explained above, however, is associated with a small risk of breaching the blood-testis barrier and resulting in infertility due to an autoimmune response. Another technique that can be considered is subdartos pouch orchidopexy, in which the testis is placed within a subdartos pouch and the neck of the pouch is narrowed. Adhesions that form between the testis and the pouch prevent movement or torsion of the testis. This technique eliminates the associated risk of breaching the blood-testis barrier.

In the context of an unstable trauma patient with TTD, the principle of management is damage control resuscitation and damage control surgery. If a patient is subjected to emergent life-saving surgery and is stable intraoperatively, surgical reduction can be considered in the same setting. However, if the patient is not stable, priority is given to life-saving measures with surgical reduction of the dislocated testis performed at a later date once the patient is stabilised. Delayed surgical reduction carries a risk of missing spermatic cord, epididymal or testicular injuries and concurrent torsion which may lead to non-viability of the testis and possible infertility due to breach in the blood-testis barrier. In the absence of such injuries or vascular compromise and early surgical intervention is not possible, delayed surgical reduction can be performed as soon as deemed feasible.

Hayami et al detected impaired spermatogenesis during surgical restoration of a missed TTD 4 months after the initial insult.⁸ Dislocation of the testes in postpubertal men impairs spermatogenesis and is evidenced histologically by hyalinisation and atrophy of the seminiferous tubules, the absence of sperm or spermatid formation, the presence of spermatogonia or germ cells and an increase in alternative Sertoli cells during the initial 4 months after the onset of a dislocation.⁹ Recovery of the impaired spermatogenetic function has been described by many authors via postprocedure semen analysis and hormonal assays following surgical reduction and fixation of the dislocated testis.^{8 10}

Early surgical reduction and orchidopexy should be the gold standard of treatment for TTD because it has a close to 100% success rate with low surgical morbidity, allows assessment of the integrity and viability of the testis and fixation to prevent recurrence. Other coexisting conditions, as mentioned above, may also be managed in the same setting.

In conclusion, a prompt diagnosis of TTD with early surgical restoration and orchidopexy is the key to ensure good outcomes with preservation of endocrine and reproductive functions of the testis.

Patient’s perspective.

An emotionally daunting experience because it was sudden and involved trauma to the genitalia. I was initially worried in terms of reproductive ability but I’m glad prompt surgery was able to correct the problem without any residual consequences.

Learning points.

• To consider a diagnosis of traumatic testicular dislocation (TTD) in high impact injuries involving the groin and perineum in males especially motorcycle fuel tank injuries.

• Pathognomonic features of TTD: an empty but well-formed scrotum with a swelling corresponding to the site of a superficial dislocation. This swelling may or may not be palpable in internal dislocations.

• Gold standard of management: early surgical reduction and orchidopexy.

• Low success rate of 60% associated with closed manual reduction.

• Missed TTD is associated with impaired spermatogenesis which is reversible by surgical reduction and orchidopexy.