Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 32  |  Issue : 2  |  Page : 99-102

Traumatic testicular dislocation – A case report


1 Department of Urology, Nicosia General Hospital, Aglandjia, Cyprus
2 Department of Urology, Nicosia General Hospital, Strovolos, Cyprus

Date of Submission14-Nov-2019
Date of Decision18-Nov-2019
Date of Acceptance09-Jan-2020
Date of Web Publication28-Nov-2020

Correspondence Address:
Andreas P Christodoulides
Nicosia General Hospital, Aglandjia
Cyprus
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/HUAJ.HUAJ_7_20

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  Abstract 


We report a motorcyclist who presented with a case of empty scrotum and bilateral dislocated testes in the groin after a blunt scrotal injury. Ultrasound and computed tomography revealed viable testes. Manual reduction was performed with success under anesthesia following orchidopexy. The patient made an uneventful recovery.

Keywords: Blunt trauma, case report, dislocation, empty scrotum, testicles, urology


How to cite this article:
Christodoulides AP, Kiriazi Z, Ibrahim ZM. Traumatic testicular dislocation – A case report. Hellenic Urology 2020;32:99-102

How to cite this URL:
Christodoulides AP, Kiriazi Z, Ibrahim ZM. Traumatic testicular dislocation – A case report. Hellenic Urology [serial online] 2020 [cited 2022 Oct 4];32:99-102. Available from: http://www.hellenicurologyjournal.com/text.asp?2020/32/2/99/301824




  Introduction Top


Traumatic testicular dislocation is a rare clinical sequel complication of a blunt trauma of the scrotum or abdominopelvic injury and may be overlooked because of associated major injuries.[1] Its diagnosis depends on the awareness of the physician of its possible occurrence.[2]

It takes place after direct pressure on the scrotum rupturing the fascia of the spermatic cord[3] and dislocating one or both normally located testes out of their normal position[4] to the surrounding tissue, usually the inguinal region. Traumatic dislocation of the testis (TDT) occurs more often at the time of injury, but it has been recognized as a later event in a few cases.

The condition mainly occurs in younger men with a mean age of 25 years.[3]

Although diagnosis can be made by physical examination or with the use of examinations such as Doppler ultrasound (US) and computed tomography (CT), it is common for cases to go undetected and undiagnosed.

Motorcycle collisions are the most frequent mechanism cause today. Dislocation usually results from straddle injuries.[4] Cremasteric muscle spasm is a major contributing factor. It is important to prevent any delay in diagnosis as this can lead to loss of spermatogenic function of the testis, malignant transformation, and increased risk of orchiectomy.

Manual reduction of the dislocated testis is a quick, convenient treatment option for preservation, but it has a very high rate of failure because of the “buttonhole” defect in the coverings of the cord and the accompanying edema[5] and may overlook coexisting injuries.[6],[7]


  Case Report Top


A 47-year-old motorcyclist presented at the emergency department of our hospital after a road traffic accident, with multiple injuries and fractures (right ankle, left wrist, left femur, right shin, and left knee) and an empty scrotum upon physical examination.

He reported that during the accident, his motorcycle collided with a car and was knocked against the handlebar.

At presentation, he was fully conscious, oriented, hemodynamically stable, and neurologically intact.

On physical examination, tender soft masses were palpable in the groin. The perineum and penoscrotal region had minor abrasions, and the empty scrotum had no swelling or ecchymosis after sustaining the straddle injury [Figure 1].
Figure 1: Palpable masses in the groin, indicating the position of the dislocated testes

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He had no medical or surgical history and no genitourinary problems at the moment. He denied cryptorchidism, undescended/retractile testis, or inguinal hernia.

US and CT scan confirmed that the testicles were of normal size and had adequate blood supply. The left testicle was located in the inguinal canal and the right testicle at the external inguinal ring [Figure 2], [Figure 3], [Figure 4].
Figure 2: Computed tomography scan confirming an empty scrotum

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Figure 3: Axial computed tomography scan presenting the left testicle in the inguinal canal

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Figure 4: Axial computed tomography image presenting the right testicle at the external inguinal ring

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Both testicles were of normal size. The right testicle had heterogeneity upon US revealing intraparenchymal contusions. The left testicle had an area of low attenuation being 1,7 cm in diameter, indicative of an intraparenchymal hematoma. The tunica albuginea and vaginalis seemed to be intact bilaterally.

Overall, CT brain was normal, CT of the cervical spine and chest with no pathological findings. CT abdomen showed additional fractures to the ones mentioned above including a cross-sectional fracture of the right O1 vertebra and stable fractures upon the pelvic bones.

The patient was taken to theater for immediate assessment by the urology and orthopedic surgeons, with good vital signs and in a stable condition.

After anesthesia, a closed manual reduction of the testes to the scrotum bilaterally was performed easily. Both testicles were palpated and revealed no signs of edema or excessive injury. It was considered profitable for the patient to undergo exploratory scrotal surgery and orchidopexy. Surgery confirmed apparently healthy and viable testes, with normal spermatic chords, and so they were fixated to the dartos muscle.

As far as the genitals are concerned, the patient recovered well.

Follow-up physical examination and US at the 7th, 30th, and 60th postoperative days at the outpatient clinic were normal. The preoperative findings on US had adequately subsided, and the patient was asymptomatic. The wound healed well.


  Discussion Top


Blunt scrotal trauma is a common injury in young men and is usually caused by getting kicked or hit by a ball and motorcycle and bicycle accidents.[8]

It can be a cause of several testicular injuries such as minor contusions, hematoma, ruptured tunica, and even completely shattered testicles.[7] It causes about 85% of testicular injuries.

Traumatic testicular dislocation, also referred to as traumatic luxation of the testis, is an uncommon consequence of blunt testicular trauma.

It was first described by Claubry in 1809 when a victim had been run over by a wagon wheel.[1],[6]

It is difficult to determine the actual incidence because it is likely to be underreported.[1],[7] Bilateral dislocation is even less common (30% of patients) and constitutes about one-third of all cases. A recent review concluded that less than 200 cases had been notified in literature around the world.[1],[4]

Most cases result from straddle injuries during high-speed motorcycle collision accidents when the rider is propelled forward with traumatic impact of the perineum and scrotum over the fuel tank or handlebar. The shape of fuel tank wedges the groin area, forcibly displacing the testis into superolateral direction.[4] The testicle passes through the smooth loose coverings of the cord until it bursts through them, after rupture of the fasciae (external, cremasteric, and internal), and comes to lie in the superficial inguinal pouch anterior to the external oblique aponeurosis, at the level of the external ring.[1],[9] In its superficial location, the testicle is covered only by skin, subcutaneous tissue, and deep fascia.[10]

Nonetheless, possible locations of a dislocated testis include the superficial inguinal (50%), pubic (18%), canalicular (8%), penile (8%), intra-abdominal (6%), perineal (4%), and crural (2%) regions. Rarely, in association with pubic bone fracture, retrovesical dislocation can be found.[1],[7] Goulding has classified traumatic testicular dislocation in three categories as seen on [Table 1].[11],[12]
Table 1: Goulding's TDT classification

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Although TDT occurs more often at the time of injury, in a few cases, TDT has been recognized as a later event.[1]

There is not a specific method to differentiate between truly undescended, retractile testes, traumatic testicular torsion, high-lying testes,[4] and those that sustained traumatic dislocation. The clinical history and physical examination have a crucial part in the investigation.[4]

The ultimate location of testicular dislocation is related to the mechanism of injury, the direction and intensity of the impact, the presence of anatomic abnormalities, and a brisk contraction of the cremaster muscle at the moment of trauma, associated with a secondary cremaster muscle spasm contraction.[4]

The most common factor contributing to the dislocation of the testis is cremasteric muscle reflex, which can forcefully retract the testis out of the scrotal sac, wide external inguinal ring, indirect inguinal hernia, and atrophic testis.[1],[6],[7]

A thorough physical examination defines the diagnoses of an empty scrotum with possible palpable masses. Doppler US is traditionally the primary investigation used to evaluate the viability and blood flow to the testis[7] and diagnose hematoceles and hematomas, testicular rupture, ruptured tunica, torsion, epididymal avulsion, minor contusions, and completely shuttered testes.

Moreover, the presence of this type of injury can be very useful in the course of medicolegal investigations of a fatal motorcycle accident, helping to identify the motorcycle driver and to determine responsibilities in the accident.[4]

In difficult cases, CT may be needed to locate the gonads [Figure 5].
Figure 5: Coronal computed tomography image presenting both dislocated testicles

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Manual reduction is the initial treatment of choice for a normal testicle without coexisting injuries. Manual reduction is the initial treatment of choice for a normal testicle without coexisting injuries. However, it is successful in only 15% of patients. This can be attempted at the emergency department when detection is early and the testicle is palpable. Manual reduction may also be attempted in the first 3–4 days after dislocation when the edema has subsided and before adhesion formation.[1],[10]

Delayed reduction of a dislocated testicle in postpubertal men has been reported to impair spermatogenesis, which is usually detected 4 months after the dislocation takes place. The histological changes in these patients are hyalinization and atrophy of seminiferous tubules, absence of sperm or spermatid formation, presence of germ cells, and an increase in alternative germ cells. However, various reports have shown that once the condition is treated, the prognosis for recovery of the endocrine function and fertility can be excellent.[7],[12]

Further potential complications of delayed reduction include torsion, testicular ischemia, acute and chronic discomfort interfering with daily activities, and malignant transformation.[1],[4],[6]

Surgical exploration and orchidopexy should be performed early to evacuate hematoma, repair lacerated tissue, and fix the testicle after repositioning it.[4]

Goulding suggested that for traumatically dislocated testes located in the abdomen that are not relocated (e.g., with prolonged delay of diagnosis), the testicle should be surgically removed because of the theoretical increased potential for a neoplasm to develop. The hypothesis of a postdislocation neoplasm is unproven.[12]


  Conclusions Top


Testicular dislocation is a rare sequel of blunt scrotal injury, which carries with it many risks and is easily overlooked.[13],[14]

The empty scrotal sac leads the investigation!

With proper management, prognosis is excellent.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Zavras N, Siatelis A, Misiakos E, Bagias G, Papachristos V, Machairasa A. Testicular dislocation after scrotal trauma: A case report and brief literature review. The department of General Surgery ''Attikon'' University Hospital, National and Kapodistrian University of Athens, Athens, Greece. Urol Case Rep 2014;2:101-4.  Back to cited text no. 1
    
2.
Reynaldo G, Oscar S, Gabriel C, Pablo M, Miroslav D. Traumatic testicular dislocation. Int Urol Nephrol 2014;46. 10.1007/s11255-014-0736-8.  Back to cited text no. 2
    
3.
Knipe H, Smith H. Testicular dislocation. Radiopaedia. Available from: https://radiopaedia.org/articles/testicular-dislocation#references. [Last accessed on 2020 Jul 13].  Back to cited text no. 3
    
4.
Vasudeva P, Dalela D, Singh D, Goel A. Traumatic testicular dislocation: A reminder for the unwary. J Emerg Trauma Shock [serial online] 2010;3:418-9. Available from: http://www.onlinejets.org/text.asp?2010/3/4/418/70762. [Last cited on 2020 Jul 13].  Back to cited text no. 4
    
5.
Shefi S, Mor Y, Dotan ZA, Ramona J. Traumatic testicular dislocation: A case report and review of published reports. Gold J Urol 1999;54:744.  Back to cited text no. 5
    
6.
Taia YS, Chenb YS, Tsaia PK, Wonga WJ. Traumatic testicular dislocation: A rare occurrence of blunt scrotal injury. Urol Sci 2014;25:158-60.  Back to cited text no. 6
    
7.
Aslam M, Ward O, Aconbury E, Way CH, Worcester UK; Worcestershire Royal Hospital. Testicular dislocation: A rare consequence of blunt scrotal injury. Can Urol Assoc J 2009;3:E1-3.  Back to cited text no. 7
    
8.
WebMD Medical Reference Reviewed by Melinda Ratini, DO, MS. Testicular Injuries; January 24, 2018. Available from: https://www.webmd.com/men/guide/testicle-injuries#1. [Last accessed on 2020 Jul 13].  Back to cited text no. 8
    
9.
Pollen JJ, Funckes C. Traumatic dislocation of the testes. J Trauma 1982;22:247-9.  Back to cited text no. 9
    
10.
Chang KJ, Sheu JW, Chang SH, Chen SC. Traumatic dislocation of the testis. Am J Emerg Med 2003;21:247-8.  Back to cited text no. 10
    
11.
Vijayan P. Traumatic dislocation of testis. Indian J Urol [serial online] 2006;22:71-2. Available from: http://www.indianjurol.com/text.asp?2006/22/1/71/24663. [Last cited on 2020 Jul 13].  Back to cited text no. 11
    
12.
Madden JF. Closed reduction of a traumatically dislocated testicle. Acad Emerg Med 1994;1:272-5.  Back to cited text no. 12
    
13.
Shu-Hang Ng SF, Wan YL, Huang CC, Lee TY, Kung CT, Liu PP. Testicular dislocation. Ann Emerg Med Int J 2004;43:371-5.  Back to cited text no. 13
    
14.
Blake SM, Bowley DM. Traumatic dislocation of the testis: A rare sequel of perineal injury. Emerg Med J 2003;20:567.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1]



 

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