Rare case of traumatic bilateral testicular dislocation

Abstract

Bilateral traumatic testicular dislocation is an uncommon condition and usually occurs after a direct impact on the scrotum. Herein, we report this as a rare case of a 21-year-old man presenting with bilateral traumatic dislocation of testes into the inguinal canal following a motorcycle accident. Imaging studies ruled out any other associated injuries. The patient underwent bilateral orchidopexy without any further complications.

Background

Bilateral traumatic dislocation of the testes is an uncommon sequel of scrotal trauma, occurring after direct pressure on the scrotum following blunt abdominopelvic trauma.¹ Even it is an acute finding, some cases have been recognised and presented as a later event.² Clinical examination, ultrasound and Doppler study are the main diagnostic tools of this condition. Early diagnosis and treatment are recommended to preserve testicular function and avoid malignant transformation.³ We report on a case of bilateral traumatic dislocation of testes diagnosed promptly and managed successfully.

Case presentation

A 21-year-old man presented with pain in the inguinoscrotal region, following a road traffic accident he sustained an injury to the scrotum and thigh. No other injuries were noted. As per the history of the patient, he did not remember the exact speed of the vehicle. However, he said that he was not fast and fell down while taking a turn and sustained an injury to the scrotum and perineum from the fuel tank of the vehicle. There was no personal or family history of undescended testes. Extended focused assessment with sonography for trauma was negative. He was haemodynamically stable. On examination, the scrotum was well developed. The right hemiscrotum was empty; the left hemiscrotum had 3 cm×2 cm tender swelling. Two ovoid tender swellings, one at the base of the scrotum and one at the inguinal region, with minimal overlying skin ecchymosis were present (figure 1). Minimal abrasions were present over the thighs.

Figure 1.

Image showing dislocated right testis (black arrow) in the superficial inguinal pouch and left testis (yellow arrow) in the root of the scrotum.

Ultrasonography (USG) revealed the absence of both testicles in the scrotum. The right testis was present in the superficial inguinal pouch and the left one in the root of the scrotum. A 2.4 cm×1 cm septated hypoechoic area with internal echoes was noted in the left hemiscrotum, suggesting a haematoma. Colour Doppler ultrasound confirmed the diagnosis of dislocated testes with its adequate blood supply. CT scan was done to confirm the testes’ location and rule out any other injuries (figure 2). The scrotal exploration was done immediately and both the testes were manually reduced (figure 3). Intraoperatively, the size of both testes was normal without any testicular–epididymal dissociation. The scrotal haematoma was evacuated and both testes were viable, were reposed back to the scrotum, gubernaculum fixed to the lower pole of the testes and bilateral orchidopexy was done. The postoperative period was uneventful.

Figure 2.

CT scan showing: (A) right testis in the superficial inguinal pouch (arrow), (B) left testis in the root of the scrotum (arrow) and (C) left scrotal haematoma (arrow).

Figure 3.

Intraoperative image showing manually reduced right testis (black arrow) and left testis (yellow arrow).

Outcome and Follow-up

The patient was followed postoperatively for 3 months. The patient underwent USG and Doppler of the scrotum and there was no evidence of recurrence or testicular atrophy. We also did semen analysis (volume—3 mL, sperm concentration—20 millions/mL, total motility—60%), serum follicle-stimulating hormone analysis (3 mIU/mL) and testosterone levels analysis (550 ng/dL) to assess the testicular function, which were found to be within normal range.

Discussion

Claubry first reported traumatic dislocation of the testis.⁴ It is defined as an abnormal displacement of the testis outside the scrotum due to blunt trauma, also referred to as traumatic luxation. This remains a rare entity, with only a few cases reported to date in the literature. The exact incidence is not known, as the condition may be under-reported or misdiagnosed.

Motorcycle accidents are the most common causes of such condition. It is usually related to straddle injuries from motorcycle accidents with the scrotum and perineum striking the fuel tank. The shape of the fuel tank is such that it drives a smooth wedge into the groin area, forcibly displacing each testis in the superolateral direction.⁵ Dislocation may be unilateral or bilateral, superficial pouch or internal ring. The testis is forced through the external ring into the inguinal canal or even into the abdominal cavity. Unilateral or bilateral dislocations are equally common. The sites of dislocation in descending prevalence include superficial inguinal, pubic, penile, canalicular, truly abdominal, perineal, acetabular and crural.² In our patient, right and left testes were dislocated into the superficial pouch and root of the scrotum, respectively.

USG of the scrotum may confirm the diagnosis by ascertaining the location of the testes. CT scan of the abdomen and X-rays help to rule out other associated injuries. Doppler study should be performed to confirm intact viable testis and exclude coexisting sequelae of trauma-like testicular rupture, torsion or haematoma.⁶ Delayed presentation or correction might result in infertility due to elevated temperature exposure, reduced spermatids, spermatogonia and relatively increased Sertoli cells.⁷ In our patient, both testes were viable and there was no evidence of any other injuries.

The manual reduction can be attempted but is only successful in 15% of the cases. In addition to being more successful, the surgical treatment also allows torsion to be corrected if present.³ Surgical exploration is preferred because of the possibility of testicular torsion/rupture, a high failure rate of closed reduction and minimal surgical morbidity. Surgical exploration also permits the thorough evacuation of haematomas. It avoids any chance of iatrogenic torsion testis while closed reduction, a potential danger which necessitates a post-reduction Doppler to exclude it.⁸ Fertility may be affected and a heightened risk of testicular malignancy can occur if the testicle is not reduced for a prolonged period.⁹ Our patient was explored immediately and underwent bilateral orchidopexy as both testes were viable.

Patient perspective.

I had come to the emergency department with complaints of pain in the scrotum and inguinal region following trauma. After preliminary scans and blood investigations, I was advised to undergo immediate surgery. I was taken to the operation theatre at the earliest. Postoperatively I was shifted to the ward and discharged after 2 days. I thank all my doctors for such prompt help.

Learning points.

• Isolated bilateral testicular dislocation is very rare following abdominopelvic trauma, especially seen in patients having motorcycle’s fuel tank injury to the perineum and groin.

• Clinical evaluation and imaging studies are of utmost importance to rule out any other associated injuries. Doppler study of testes confirms the viability of testes.

• Such patients must be explored immediately to prevent any future complications associated with a bilateral testicular dislocation.

Ethics statements

Patient consent for publication

Obtained.