the penile skin. Though reimplantation with

chromic and a penrose is placed. The drain can

nonmicrosurgical techniques has been reported,

be removed after 24 h, and antibiotics should be

there is increased likelihood of skin loss, ure-

administered for 7 days.

thral stricture, and poor sensation with this

approach. Therefore, every attempt should be

Imaging

made to transfer the patient to a tertiary care

center with expertise in microsurgery such that

the reimplant can occur within 16 h.

Imaging is an essential part of the evaluation of

trauma to the genitourinary tract,and a thorough

Scrotal and Testicular Trauma

understanding of each imaging modality, includ-

ing indications, techniques, and interpretation, is

critical to the effective management of the trauma

Traumatic injuries to the scrotum and its con-

patient. Here, we discuss the most commonly

tents are rarely life-threatening, but require

used imaging modalities in genitourinary trauma

prompt management in order to avoid long-

and techniques for performing them.

term morbidity related to fertility, pain, and cos-

mesis. The most common scrotal injury is

CT-IVP (CT with Delayed Images)

testicular rupture, a tear in the tunica albuginea

that most commonly results from blunt trauma

CT is more sensitive than IVP in the diagnosis of

during sporting events. Testicular rupture can

renal and ureteral injuries and has largely

also occur as a result of MVA, straddle injury, or

replaced IVP in the workup of the trauma patient.

penetrating trauma from a gunshot or stab

Delayed images are essential for proper evalua-

wound. It is well accepted that immediate inter-

tion of the collecting system and ureters, but are

vention reduces the incidence of testicular loss,

inadequate for diagnosis of bladder injuries.

chronic pain,infection,and infertility.Therefore,

when testicular rupture is suspected prompt

Technique

surgical intervention is mandatory.58,59

The history and physical are essential to the

The study should be performed in three phases:

diagnosis of testicular rupture. Typically, the

an initial, unenhanced phase; a nephrogenic

patient reports acute onset of pain or edema

phase performed 90–100 s after the administra-

associated with nausea and vomiting. The simi-

tion of nonionic contrast material (100–150 mL

larities in presentation between this and other

of 300 mg/mL Iodine at a rate of 2–4 mL/s); and

acute scrotal conditions call for a broad differ-

a delayed phase, typically obtained 10 min fol-

ential diagnosis, including testicular torsion,

lowing contrast administration. Because ure-

torsion of the appendix testis, hematocele or

teral injuries often manifest with absence of

hydrocele, and hematoma of the epididymis or

contrast in the ureter on delayed images, it is

spermatic cord.

essential to trace both ureters throughout their

Ultrasound is highly sensitive in detecting

entire course. If the original study did not ade-

testicular rupture60 and can be used when the

quately demonstrate the ureters, a KUB can be

diagnosis is not clear, but clinical judgment

performed to assess for delayed drainage.

in this case is paramount and exploration should

never be delayed in order to perform an

ultrasound. In the absence of testicular rupture,

Cystogram

small hematoceles, epididymal hematomas, and

contusions of the testis can generally be man-

Cystogram is the most accurate test for bladder

aged non-operatively, though large hematomas

rupture. It is critical to adequately distend the

should be explored and debrided. The testicle

bladder: contrast opacification of the bladder

can be approached through a transverse or mid-

following CT,even if the Foley catheter is clamped,

line longitudinal incision. The tunica albuginea

is inadequate40. Both conventional radiography

should be incised and necrotic tubules should

and CT are adequate, but CT is superior as it

be debrided. The tunica albuginea is then closed

allows for identification of the location of many

with 3-0 or 4-0 running absorbable suture.

bladder injuries and may allow for identification

Dartos and skin are closed with 3-0 and then 4-0

of bladder neck injury.