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28. Skandhan KP, Soni A, Joshi A, Avni KPS, Gupta BD. Human epididymis: structural pattern, total length and inner surface area. Urol J. 2017;84(4):215–7. https://doi.org/10.5301/

uj.5000229.

29. Firoozabadi R, Stafford P, Routt M.Risk of spermatic cord injury during anterior pelvic ring and acetabular surgery: an anatomical study. Arch Bone Jt Surg. 2015;3(4):269–73. PMID: 26550592; PMCID: PMC4628634.

30. Abdelmohsen SM, Osman MA, Takrouney MH, etal. A spectrum of epididymis and vas deferens anomalies among children with cryptorchidism: a retrospective multi-center study. Ann Pediatr Surg. 2021;17:55. https://doi.org/10.1186/s43159- 021- 00111- w.

31. Virtanen HE, Toppari J.Epidemiology and pathogenesis of cryptorchidism. Human Reprod Update. 2008;14(1):49–58. https://doi.org/10.1093/humupd/dmm027.

32. Renfree MB. Review: Marsupials: placental mammals with a difference. Placenta. 2010;31(Suppl):S21–6. https://doi.org/10.1016/j.placenta.2009.12.023. Epub 2010 Jan 15. PMID: 20079531.

33. Abbas TO, Ali M. Bilateral neonatal testicular torsion; hidden surgical nightmare. Front Pediatr. 2018;6:318. https://doi.org/10.3389/fped.2018.00318. PMID: 30525011; PMCID: PMC6256121.

34. Riaz-Ul-Haq M, Mahdi DE, Elhassan EU.Neonatal testicular torsion; a review article. Iran J Pediatr. 2012;22(3):281–9. PMID: 23400637; PMCID: PMC3564080

35. Mercer S.Agenesis or atrophy of the testis and vas deferens. Can J Surg. 1979;22(3):245–6. PMID: 35276.

36. Pirgon Ö, Dündar BN.Vanishing testes: a literature review. J Clin Res Pediatr Endocrinol. 2012;4(3):116–20. https://doi.org/10.4274/Jcrpe.728. PMID: 22985611; PMCID: PMC3459158.

37. Bergholz R, Wenke K.Polyorchidism: a meta-analysis. J Urol. 2009;182(5):2422–7. https://

doi.org/10.1016/j.juro.2009.07.063. Epub 2009 Sep 17. PMID: 19765760.

38. Zahirian Moghadam T, Mohseni Rad H, Zandian H, etal. Five testicles in the genital area of a thirteen-month-old baby: a case report. BMC Urol. 2020;20:128. https://doi.org/10.1186/

s12894- 020- 00681- 8.

39. de Souza DAS, Faucz FR, Pereira-Ferrari L, Sotomaior VS, Raskin S.Congenital bilateral absence of the vas deferens as an atypical form of cystic brosis: reproductive implications and genetic counseling. Andrology. 2018;6(1):127–35. https://doi.org/10.1111/andr.12450. Epub 2017 Dec 7. PMID: 29216686; PMCID: PMC5745269.

40. Somoza I, Palacios MG, Mendez R, Vela D. Complete penoscrotal transposition: a threestage procedure. Indian J Urol. 2012;28(4):450–2. https://doi.org/10.4103/0970- 1591.105775. PMID: 23450271; PMCID: PMC3579132.

41. Fahmy MAB.Bid scrotum. In: Fahmy MAB, editor. Normal and abnormal scrotum. Cham: Springer; 2022. https://doi.org/10.1007/978- 3- 030- 83305- 3_14.

42. Kumar T, Vaughan R, Dangle PP.Hemangioma of the scrotal septum: a rare entity in infants with review of the literature. W V Med J. 2012;108(4):26–7. PMID: 22872962.

43. Chen G, Wang X, Zhao Y, etal. Splenogonadal fusion: a case report and review of the literature. BMC Urol. 2021;21:16. https://doi.org/10.1186/s12894- 021- 00781- z.

44. Psarris A, Dimopoulou A, Iakomidis E, Zavras N, Vaos G. Hemiscrotal agenesis: a rare congenital anomaly. J Clin Diagn Res. 2017;11(8):PD19–20. https://doi.org/10.7860/

JCDR/2017/28605.10507. Epub 2017 Aug 1. PMID: 28969205; PMCID: PMC5620846.

45. Mansy M, Kotb M, Abdelmeguid Y, etal. Hemiscrotal agenesis: a novel phenotype of a rare malformation. BMC Pediatr. 2020;20:536. https://doi.org/10.1186/s12887- 020- 02424- y.

46. Spagnoli A, Borsellino A, Crucianelli S, Bizzarri C, Mucciolo M, Trucchi A, Ferro F.Complete scrotal agenesis: new surgical approach using self-inating tissue expander. Urology. 2018;112:169–71. https://doi.org/10.1016/j.urology.2017.10.015. Epub 2017 Dec 6. PMID:

29080783.

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47. Janoff DM, Skoog SJ. Congenital scrotal agenesis: description of a rare anomaly and management strategies. J Urol. 2005;173(2):589–91. https://doi.org/10.1097/01.

ju.0000151136.56430.53. PMID: 15643265.

48. Shukla RM, Mandal KC, Roy D, Patra MP, Mukhopadhyay B. Scrotoschisis: an extremely rare congenital anomaly. J Indian Assoc Pediatr Surg. 2012;17(4):176–7. https://doi.

org/10.4103/0971- 9261.102342. PMID: 23243373; PMCID: PMC3518999.

49. Mahfouz M. Scrotoschisis: a rare congenital urologic anomaly. J Pediatr Surg Case Rep. 2018;32:90–2. https://doi.org/10.1016/j.epsc.2018.02.013. ISSN 2213-5766.

50. Fahmy MAB. Testis. In: Rare congenital genitourinary anomalies. Berlin: Springer; 2015.

https://doi.org/10.1007/978- 3- 662- 43680- 6_5.

42 Anatomy oftheScrotum andTesticles

Epidemiology ofScrotal andTesticular

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Trauma

Located in a pendulous and extensible scrotal sac with ample space to move in all directions, the testes are relatively well protected from scrotal blunt trauma. However, a violent direct impact results in their rupture in 50% of cases.

Over 8000 adult male patients with scrotal/testicular injury were recorded in the American National Trauma Data Bank (NTDB) in the period 2007–2015 representing only 0.23% of all trauma patients. The median age of the patients was 31years, blunt and penetrating mechanisms accounted for 44.6% and 50.5% of cases, respectively, and rearms represented 75.8% of all penetrating injuries [1]. However, these results are conictual as other studies mention a higher rate of blunt scrotal injury accounting for up to 85% of cases of scrotal or testicular injury [2–4].

French studies showed that the most common genito-urinary organ injured in the RTA is the kidney followed by the testis representing 41–43% and 23–24% of the total, respectively. Scrotal wall injuries accounted for about 8% of the total [5, 6]. However, when rening the data for two-wheeled motorized vehicles (motorcyclists) only, the proportion of testicular injuries was predominant accounting for 41% followed by renal injury with 28% contribution, while scrotal wall injury accounted for 10% [6].

Scrotal injuries mainly occur in young people aged 15–40years. Other data from the American NTDB suggest that patients older than 65years are less likely to develop injuries to the penis, testes, or scrotum while being more prone to sustain bladder and urethral injury and having equal odds for renal trauma compared with younger patients [4, 7–9].

Testicular and scrotal injuries account for less than 1% of all trauma cases. However, genito-urinary tract injuries are observed in 2.2–10.3% of trauma patients admitted to emergency units, and external genitalia injuries are observed in

27.8–68.1% (roughly one-third to two-thirds) of patients with genitourinary (GU) tract injuries [10, 11].

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43 Epidemiology ofScrotal andTesticular Trauma

Notably, 60% of all penetrating genitourinary trauma involve the external genitalia [12], and it is estimated that as many as 35% of all gunshot wounds (GSW) include external genitalia injuries of various degrees [11].

A large 30-year monocentric review recorded 110 patients with penetrating external genital trauma. Gunshot wounds (GSW) accounted for 49% of all the causes, followed by stab wounds/lacerations and bites accounting for 44% and 7%, respectively. Half of the cases were self-emasculation injuries, and testicular involvement was observed in all the above three mechanisms. Half of the patients having scrotal GSW had testicular injuries, and 35% had bilateral testicular involvement [13].

A study showed that the occurrence of blunt scrotal trauma is higher in militaries than in the general population. It involved 0.175% of nearly 400,000 soldiers, representing 1 out of 571 individuals [14]. Twenty-seven cases of scrotal injury were reported among British soldiers in Iraq and Afghanistan between 2003 and 2009, and the majority (21 cases) were caused by improvised explosive devices. Others were caused by mines, rocket-propelled grenades, and mortar rounds [15]. In wartime, civilians are sometimes more exposed than soldiers to either explosive devices or bullets [16].

References

1. Grigorian A, Livingston JK, Schubl SD, Hasjim BJ, Mayers D, Kuncir E, Barrios C, Joe V, Nahmias J. National analysis of testicular and scrotal trauma in the USA. Res Rep Urol. 2018;10:51–6. https://doi.org/10.2147/RRU.S172848. PMID: 30128306; PMCID: PMC6089605.

2. McAninch JW, Kahn RI, Jeffrey RB, Laing FC, Krieger MJ.Major traumatic and septic genital injuries. J Trauma. 1984;24(4):291–8. https://doi.org/10.1097/00005373- 198404000- 00002. PMID: 6368854.

3. Morey AF, Metro MJ, Carney KJ, Miller KS, McAninch JW. Consensus on genitourinary trauma: external genitalia. BJU Int. 2004;94(4):507–15. https://doi.org/10.1111/

j.1464- 410X.2004.04993.x. PMID: 15329102.

4. Wang Z, Yang JR, Huang YM, Wang L, Liu LF, Wei YB, Huang L, Zhu Q, Zeng MQ, Tang ZY. Diagnosis and management of testicular rupture after blunt scrotal trauma: a literature review. Int Urol Nephrol. 2016;48(12):1967–76. https://doi.org/10.1007/s11255- 016- 1402- 0. Epub 2016 Aug 27. PMID: 27567912.

5. Terrier JE, Paparel P, Gadegbeku B, Rufon A, Jenkins LC, N’Diaye A.Genitourinary injuries after trafc accidents: analysis of a registry of 162,690 victims. J Trauma Acute Care Surg. 2017;82(6):1087–93. https://doi.org/10.1097/TA.0000000000001448. PMID: 28328677.

6. Paparel P, N’Diaye A, Laumon B, Caillot JL, Perrin P, Rufon A.The epidemiology of trauma of the genitourinary system after trafc accidents: analysis of a register of over 43,000 victims. BJU Int. 2006;97(2):338–41. https://doi.org/10.1111/j.1464- 410X.2006.05900.x. PMID:

16430642.

7. Bjurlin MA, Goble SM, Fantus RJ, Hollowell CM.Outcomes in geriatric genitourinary trauma. J Am Coll Surg. 2011;213(3):415–21. https://doi.org/10.1016/j.jamcollsurg.2011.06.001. Epub 2011 Jul 1. PMID: 21723152.

8. Buckley JC, McAninch JW.Diagnosis and management of testicular ruptures. Urol Clin North Am. 2006;33(1):111–6, vii. https://doi.org/10.1016/j.ucl.2005.11.002. PMID: 16488285.

References

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9. Lee SH, Bak CW, Choi MH, Lee HS, Lee MS, Yoon SJ. Trauma to male genital organs: a 10-year review of 156 patients, including 118 treated by surgery. BJU Int. 2008;101(2):211–5.

https://doi.org/10.1111/j.1464- 410X.2007.07265.x. Epub 2007 Oct 8. PMID: 17922859.

10. McGeady JB, Breyer BN. Current epidemiology of genitourinary trauma. Urol Clin North Am. 2013;40(3):323–34. https://doi.org/10.1016/j.ucl.2013.04.001. Epub 2013 Jun 12. PMID: 23905930; PMCID: PMC4016766

11. Plas E, Berger I.Genital trauma. In: Hohenfellner M, Santucci RA, editors. Emergencies in urology. Berlin: Springer; 2007. https://doi.org/10.1007/978- 3- 540- 48605- 3_21.

12. Goldman C, Shaw N, du Plessis D, Myers JB, van der Merwe A, Venkatesan K. Gunshot wounds to the penis and scrotum: a narrative review of management in civilian and military settings. Transl Androl Urol. 2021;10(6):2596–608. https://doi.org/10.21037/tau- 20- 1175. PMID: 34295746; PMCID: PMC8261456.

13. Phonsombat S, Master VA, McAninch JW.Penetrating external genital trauma: a 30-year single institution experience. J Urol. 2008;180(1):192–5; discussion 195–6. https://doi.org/10.1016/j.

juro.2008.03.041. Epub 2008 May 21. PMID: 18499189.

14. Misgav Rottenstreich MC, Gofrit ON.Blunt scrotal trauma in soldiers—epidemiology and outcome. Mil Med. 2017;182(9–10):e1929–31. https://doi.org/10.7205/MILMED- D- 16- 00375.

15. Williams RJ, Fries CA, Midwinter M, Lambert AW.Battleeld scrotal trauma: how should it be managed in a deployed military hospital? Injury. 2013;44(9):1246–9. https://doi.org/10.1016/j.

injury.2013.02.023. Epub 2013 Apr 12. PMID: 23587211.

16. Abid AF, Naoum N. Penetrating scrotal injuries: a war time experience in a civilian setup. Open Access Maced J Med Sci. 2021;9(B):1198–202. https://oamjms.eu/index.php/mjms/

article/view/6888.

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Etiology, Mechanism,

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andAnatomopathology ofScrotal

andTesticular Trauma

44.1 Etiology andMechanism

As mentioned in Chap. 43, the American National Trauma Data Bank (NTDB) registry showed that blunt and penetrating (gunshot wounds and stabbing) mecha- nisms account for 44.6% and 50.5% of cases, respectively, and rearms represent

75.8% of all penetrating injuries [1]. A mention was also made of conicting results

with other studies that showed a predominance of blunt over penetrating mechanisms in scrotal/testicular injury [2–4]. An attempt to explain this discrepancy is the fact that NTDB data are provided by heterogeneous participating trauma centers, including large urban trauma centers accounting for a high volume of penetrating trauma [1].

Despite its relative protective environment, the testis can rupture when subjected to sudden pressure (blow, kick, etc.) against the bony pelvis or inner thigh. Wesson reportedly found in 1956 that a 50-kg force was necessary to rupture the tunica albuginea [5]. However, this research failed to clarify Wesson’s methodology. Nonetheless, this nding has been endorsed by many authors, although no further studies were performed using modern measurement technologies [4–9].

Direct impact in sports or in motor vehicle accidents accounts, respectively, for 50% and 14% of all causes of blunt testicular rupture, and because of its

bigger volume and more cranial position which increase the odds of being trapped against the inner thigh, the inferior pubic ramus, or the symphysis, the right testis is slightly more prone to injury than the left [4, 7, 9].

Other causes of blunt testicular injuries are straddle impacts, kicking during ghts, tractions, and birth injuries in breech presentation [9–11]. In a prospective study of 134 male breech infants delivered vaginally, 10 infants (7.5%) had testicular damage, and the injury appeared to be more likely to occur in infants with a birth weight of greater than or equal to 2500g and born to primipara [11].

For penetrating injuries, besides stabbing and gunshots, less frequent causes are degloving/avulsion resulting from rapid deceleration mechanisms and human or

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44 Etiology, Mechanism, andAnatomopathology ofScrotal andTesticular Trauma

animal bites [12]. Very rarely, penetrating injuries may arise from falling astride onto perforating objects such as a metallic rod (impalement injury) (Fig.44.1).

Patients riding motorcycles have a higher risk for scrotal/testicular trauma during a collision than bicycle riders because of the high-impact collision. Indeed, 62% of

injuries in motorcyclist victims of road trafc accidents involve external genitalia, and the testes alone are injured in 38% [1, 13, 14]. However, even low-

velocity impact sustained by cyclers hitting the handlebar or top tube can be harmful, and the most unfortunate of them can suffer severe trauma to the scrotum, testes, perineum, penis, and groin from impalement [15].

In contact sports (e.g., football, rugby, hockey, lacrosse, and wrestling cricket) and other sports involving jumping and balancing over hard objects (e.g., skateboard and pommel horse) in general and in the adolescent and pediatric population in particular, accidental scrotal kicking either by the ball or by the opponent or by falling astride on the hard supporting object is a common cause of blunt testicular trauma [16, 17].

A survey conducted in Pennsylvania in 2014 including 731 respondents of a mean age of 17.7years revealed that 18% of all athletes sustained a testicular injury during sports and 36.4% observed the same in team members. The prevalence of

Fig. 44.1 Penetrating injury of the scrotum with left testicular evisceration in a 13-year-old boy who fell astride from height on a metallic rod in a construction area. The rod path through the scrotum was lateral to the left testis and spermatic cord, and there were no associated injuries. (Courtesy Khurram Siddiqui, Urology, Sultan Qaboos University Hospital, Muscat, Oman)

44.2 Anatomopathology

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testicular injuries was the highest for lacrosse with a value of 48.5%, followed by wrestling, baseball, and American football with values of 32.8%, 21%, and 17.8%, respectively [18].

Thermal scrotal injuries (burns) have also been reported but are rarely isolated [12]. Another extremely rare mechanism is the degloving injury or avulsion caused by modern industrial machines [19]. Scrotal blast injuries are extremely rare and almost always extend to other anatomic regions [20].

377

44.2 Anatomopathology

Depending on the severity of the impact, blunt scrotal injuries may result in a simple hematoma of various sizes, a hematocele, testicular fracture or rupture, a torsion, a dislocation, and the spermatic cord might be injured and even avulsed when subjected to extreme traction forces. The so-called traumatic dislocation of the testis (TDT) is a rare event resulting from a forcible testicular push outside its normal position during blunt trauma. The most common TDT site is the supercial inguinal pouch accounting for 50% of all the cases [21]. Other possible sites are the pubic, penile, canalicular, abdominal, perineal, acetabular, and crural areas [21, 22] (Fig.44.2).

Penetrating agents produce supercial or deep incisions, partial or total scrotal excision, injury to the cord (partial injury or transection), and injury to the

testis of various degrees.

When there is isolated scrotal wall rupture (generally in penetrating injury), the intact testis may lie outside, i.e., eviscerate [23] (Figs.44.1 and 44.3). The true rupture of the testis is dened by breaking or giving way of its tunica albuginea followed by a protrusion of the seminiferous tubules.

The incidence of testicular rupture associated with blunt trauma was reported to be 48% (almost half of the cases) [24]. It is important, however, to

mention that this gure has been calculated from the number of patients presenting to the hospital for what they considered to be worrisome aftermath of the trauma: severe pain, swelling, and so on. In reality, the majority of testicular blunt traumas are mild, the pain disappears within minutes, and the individuals nd no reason to report to a hospital. Almost every boy in the world can attest to the truth of this statement.

Based on the American NTDB registry, the majority of the patients have isolated scrotal or testicular trauma (74.5%), and 48.3% require operation [1].

Scrotal blast injuries are very rarely isolated [20], and the most common associated genitourinary (GU) injuries with scrotal and testicular trauma are corpora cavernosa and urethra injuries. Soft tissue injury to the extremities is the most common non-GU-associated injury seen in more than half of the patients [25].

Industrial injuries might have devastating consequences in the genital organs consisting of complete penoscrotal skin degloving or complete avulsion in extreme cases [19] (Fig.44.4).

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Fig. 44.2 A 45-year-old man with a history of bike accident, sustaining undisplaced pubic fracture and testicular dislocation in the penis. There is a visible swelling on the ventral aspect of penis with an empty right hemiscrotum. (From Raykar etal. [22], with permission from Springer Nature)

44 Etiology, Mechanism, andAnatomopathology ofScrotal andTesticular Trauma

Fig. 44.3 Scrotal rupture with evisceration of the testicle and hematoma. (From Olivas etal. [23]. Creative Commons Attribution License CC-BY 4.0)

References

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Fig. 44.4 Total degloving injury of penis and scrotum. (From Li etal. [19], with permission from Wolters Kluwer Health)

379

References

1. Grigorian A, Livingston JK, Schubl SD, Hasjim BJ, Mayers D, Kuncir E, Barrios C, Joe V, Nahmias J. National analysis of testicular and scrotal trauma in the USA. Res Rep Urol. 2018;10:51–6. https://doi.org/10.2147/RRU.S172848. PMID: 30128306; PMCID: PMC6089605.

2. McAninch JW, Kahn RI, Jeffrey RB, Laing FC, Krieger MJ.Major traumatic and septic genital injuries. J Trauma. 1984;24(4):291–8. https://doi.org/10.1097/00005373- 198404000- 00002. PMID: 6368854.

3. Morey AF, Metro MJ, Carney KJ, Miller KS, McAninch JW. Consensus on genitourinary trauma: external genitalia. BJU Int. 2004;94(4):507–15. https://doi.org/10.1111/

j.1464- 410X.2004.04993.x. PMID: 15329102.

4. Wang Z, Yang JR, Huang YM, Wang L, Liu LF, Wei YB, Huang L, Zhu Q, Zeng MQ, Tang ZY. Diagnosis and management of testicular rupture after blunt scrotal trauma: a literature review. Int Urol Nephrol. 2016;48(12):1967–76. https://doi.org/10.1007/s11255- 016- 1402- 0. Epub 2016 Aug 27. PMID: 27567912.

5. Wasko R, Goldstein AG.Traumatic rupture of the testicle. J Urol. 1966;95(5):721–3. https://

doi.org/10.1016/s0022- 5347(17)63527- 4. PMID: 5935538.

6. Blok D, Flannigan M, Jones J.Testicular rupture following blunt scrotal trauma. Case Rep Emerg Med. 2019;2019:7058728. https://doi.org/10.1155/2019/7058728. PMID: 31934468; PMCID: PMC6942712.

7. Essien F, Eagle Z, Tate J, Barber A. Testicular rupture: the other nutcracker syndrome. Clin Med Insights Case Rep. 2022;15:11795476211052416. https://doi.

org/10.1177/11795476211052416.

8. Holliday TL, Robinson KS, Dorinzi N, etal. Testicular rupture: a tough nut to crack. Clin Pract Cases Emerg Med. 2017;1:221–4.

9. Dalton DM, Davis NF, O’Neill DC, Brady CM, Kiely EA, O’Brien MF.Aetiology, epidemiology and management strategies for blunt scrotal trauma. Surgeon. 2016;14(1):18–21. https://

doi.org/10.1016/j.surge.2014.06.006. Epub 2014 Aug 21. PMID: 25151340.

10. Negrine R, Easter W, Fraser I, Ellis S. Neonatal testicular trauma: scrotal rupture. Arch Dis Child Fetal Neonatal Ed. 2010;95(3):F193. https://doi.org/10.1136/adc.2009.181594. PMID:

20444811.

11. Tiwary CM. Testicular injury in breech delivery: possible implications. Urology. 1989;34(4):210–2. https://doi.org/10.1016/0090- 4295(89)90374- 9. PMID: 2800086.

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