Int Urol Nephrol DOI 10.1007/s11255-014-0736-8
UROLOGY - ORIGINAL PAPER
Traumatic testicular dislocation Reynaldo G. Go´mez • Oscar Storme Gabriel Catala´n • Pablo Marchetti • Miroslav Djordjevic
•
Received: 31 December 2013 / Accepted: 2 May 2014 Ó Springer Science+Business Media Dordrecht 2014
Abstract Introduction Traumatic testicular dislocation is a rare entity. It occurs after a direct blunt scrotal trauma causing the testicle to migrate outside the scrotum, most frequently to the superficial inguinal region. Materials and methods A review of the diagnostic database of our two institutions was performed searching for complex genital trauma between 1990 and 2012. Results Seven cases of traumatic testicular dislocation were identified (four on the left side; one on the right side and two bilateral) for a total of nine testicles. Six were motorcycle accidents, and the other case suffered a pelvic crush injury. All victims had significant associated injuries, one case had an open dislocation and two were killed by the accident. The testicle was located at the inguinal region in four cases at the suprapubic area in four, and the other was an open dislocation. Diagnosis was suspected with the physical examination and confirmed by Doppler ultrasound; however, in one case, the diagnosis was missed during several weeks. In one case, the testicle was reduced into the scrotum immediately at the emergency department. Two cases were operated shortly after admission, performing testicular reduction into the scrotum and standard orchidopexy. Two other cases underwent delayed intervention, and both needed release of peri-testicular adhesions. Two cases (both bilateral) died at the accident site and were diagnosed by autopsy. In all surviving cases, it R. G. Go´mez (&) O. Storme G. Catala´n P. Marchetti Urology Service, Hospital del Trabajador, Ramon Carnicer 185, Providencia, Santiago, Chile e-mail: [email protected] M. Djordjevic Department of Urology, School of Medicine, University Children’s Hospital, University of Belgrade, Belgrade, Serbia
was possible to obtain a satisfactory orchidopexy with gonadal preservation. Conclusions Traumatic testicular dislocation is rare and diagnosis can be elusive. It should be suspected in motorcycle and high-energy accidents around the groin area and depends on a careful physical examination. With proper management, prognosis is excellent. Keywords Blunt scrotal trauma Testicular injuries Testicular dislocation Motorcycle injuries
Introduction Traumatic testicular dislocation corresponds to the extra scrotal migration of one or both testicles as a consequence of a direct scrotal trauma. Claubry first described this entity in 1818 [1, 2]. Since then, the literature reports only small series or case reports, coming mainly from the Asian literature [3– 13]. In a recent review, it is estimated that less than 200 cases have been reported in the indexed world literature [4]. Its most common location is in the superficial inguinal area [2, 15, 16]. Its occurrence 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 [2, 14, 15]. Because of its low incidence, it is an entity little known to the trauma teams, implying low suspicion and probable under diagnosis. This is very important because proper management is related directly to testicular and fertility preservation [5, 6]. Moreover, the presence of this type of injury can be very useful in the course of the medico legal investigation of a fatal motorcycle accident, to assist in identifying the driver of the motorcycle and determine responsibilities in the accident [17].
123
Int Urol Nephrol
Patients and methods We reviewed retrospectively the medical records of all patients diagnosed with complicated traumatic genital injury treated at our two institutions in the period between
January 1990 and January 2012. Patients who suffered a testicular dislocation were selected and their charts reviewed for age, type and cause of the accident, laterality, associated injuries, time of diagnosis, clinical presentation, imaging, outcome and follow-up.
Table 1 Characteristics of seven cases of traumatic testicular dislocation Case
Age
Accident
Driver
Side
Associated injuries
Diagnosis
Clinical findings
Imaging
Surgery
Followup (days)
1
39
Motorcycle
Yes
Left
Left femur fracture, laceration of adductor muscles of the left thigh
On admission
Palpable nonreducible left inguinal mass, empty left hemiscrotum
Doppler ultrasound
Orchidopexy
15
2
26
Motorcycle
Yes
Left
Multiple fractures of the left femur
After 35 days
Palpable nonreducible left inguinal mass, empty left hemiscrotum
On admission
Orchidopexy at 2 months for delayed diagnosis
60
3
48
Pelvic crush injury
–
Right
Fracture of the right femur and both feet, extensive injury of soft tissues of the perineum and both legs
On admission
Testicle at the right inguinal canal, empty left hemiscrotum
No
Orchidopexy at 47 days for associated injuries
90
4
25
Motorcycle
Yes
Left
Pelvic fracture and rupture of the membranous urethra
On admission
Inguinal laceration with dislocation and exposure of the left testicle
On admission
Surgical debridement and orchidopexy
21
5
27
Motorcycle
Yes
Left
Blunt penile wound
On admission
Palpable left inguinal mass, scrotal erosions, empty left hemi-scrotum
On admission
Manual reduction at the emergency department
90
6
24
Motorcycle
Yes
Bilateral
Severe closed head injury, open right leg fracture, extensive injury of soft tissues in both thighs
Autopsy
Scrotal and perineal erosions, empty scrotum, both testicles in suprapubic region
–
–
–
7
21
Motorcycle
Yes
Bilateral
Laceration of the heart, lungs, liver, mesenterium, thoracic aorta, ribs and spine fractures, laceration of both thighs
Autopsy
Extensive inguinal and genital injury, empty scrotum, both testicles in suprapubic area
–
–
–
123
Int Urol Nephrol
Results In the study period, a total of 1,883 patients were admitted with a diagnosis of Genital Trauma, 83 of which were complex injuries and seven of them had a traumatic testicular dislocation (0.37 % of the total and 8.4 % of the complex; Table 1). In four patients, the dislocation affected the left testicle, in one case affected the right testicle and it was bilateral in the other two, totaling nine testicles. One of the patients had an open dislocation (Fig. 1). The average age was 30 years (range 21–48). Six patients suffered a motorcycle accident, and in all of these, the victim was the driver of the vehicle. All patients had significant associated injuries: femur and or pelvis fracture in five and severe adductor muscle injury in two. One case presented an open dislocation of the left testis secondary to a motorcycle accident, which also caused a fractured pelvis and a section of the membranous urethra (Case 4). The location of the testis was inguinal in five cases and suprapubic in four. The diagnosis was suspected on physical examination and confirmed by testicular ultrasound in four cases (one diagnosis went unnoticed for several weeks); the patient with open dislocation was diagnosed by physical examination and the other two patients died at the moment of the motorcycle accident, being diagnosed at autopsy; and these two patients had bilateral lesions (four testis). The treatment of the five surviving patients included manual reduction into the scrotum on admission to the emergency room in one case, immediate surgical orchidopexy in two and the other two patients were operated on late: in one of them, genital surgery had to be postponed due to severe associated injuries and in the other, the diagnosis went unnoticed for 35 days. In these two patients operated late, important adhesions requiring significant peri-testicular orchidolysis were found. In all surviving
Fig. 1 Open testicular dislocation (Case 4): traumatic inguinal laceration is noted through which the testicle is exteriorized
patients, a satisfactory orchidopexy was achieved without immediate complications. The average follow-up was 55.2 days (range 15–90) and in all patients, adequate gonadal preservation was verified.
Discussion Traumatic testicular dislocation is a rare injury and therefore is little known to the trauma team. As described in the literature, and as noted in our review, it is the result of high-energy accidents, particularly in motorcycles [2–4, 7– 9, 15]. It typically affects the motorcycle driver, who slips the perineum to collide abruptly with the fuel tank, which squeezes the testicle outside its normal scrotal location. Ko reported nine cases, seven of which were motorcycle accidents, mostly young men with an average age of 29 years [9], almost identical to that observed in our study. This mechanism also explains why most of the reports come from the Asian literature, due to the widespread use of these vehicles on that continent (Table 2). In fact, the largest published series with 36 cases comes from Thailand. Although motorcycle accidents are the most frequent etiology, this injury can result after any sudden blunt compression mechanism in the groin area. The presence of a testicular dislocation in the investigation of a fatal motorcycling accident can be crucial in the forensic field, since its presence strongly suggests that the carrier was the driver of vehicle [17]. This occurred in two of our patients who were victims of a motorcycling accident which killed both occupants of the motorcycle. The presence of a testicular dislocation helps to identify the vehicle driver. This lesion has also been described in different accidents involving perineal violence, such as falls astride, abuse, kicks or blows with rotating elements [2, 15]. It has been reported that the dislocation and the final location of the testis depend on the direction and intensity of the impact, associated with a secondary cremaster muscle spasm contraction and the presence of some type of anatomic abnormality such as an inguinal hernia [2] or laxity of the inguinal ring [15]. It also may be a rupture of the spermatic fascia, and it has been postulated that these would create a sort of grommet preventing the testicle to go back to its normal position once the momentum that led to their ectopic situation is over. Clinically, Brockman’s sign, which is the presence of a well developed but empty loose scrotum, helps with the differential diagnosis with a preexisting cryptorchidism. Palpation of the testis in a subcutaneous ectopic situation raises suspicion, which may be confirmed by ultrasonography. Although often presented as unilateral, there are several reports of bilateral dislocation, as in two cases of this series [5, 7, 9, 10]. It is interesting to
123
Int Urol Nephrol Table 2 Published series on testicular dislocation References Claubry [1] Lo´pez Alcina [2]
Patients (number) 1 2
Trauma mechanism 1 Wagon wheel trauma 1 Motorcycle accident 1 Genital kick
Ihama [3]
1
1 Motorcycle accident
Phuwapraisirisan [4]
1
1 Motorcycle accident
Sakamoto [5]
1
1 Motorcycle accident
Yoshimura [7]
1
1 Motorcycle accident
Lee [8]
2
1 Motorcycle accident 1 Automobile accident
Ko [9]
9
7 Motorcycle accident 1 Explosive injury 1 Seat belt injury
Kochakarn [10]
36
36 Motorcycle accident
Nagarajan [11]
3
3 Motorcycle accident
Ezra [12]
1
Motorcycle accident
Tsurukiri [13]
1
Motorcycle accident
Morgan [14]
4
2 Road accident 1 Motorcycle accident 1 Bicycle accident
Luja´n [15]
1
Motorcycle accident
Schwartz [16]
1
Pedestrian-motor vehicle accident
Jecmenica [17]
2
2 Motorcycle accident
Vasudeva [18]
1
Motorcycle accident
Present series
7
6 Motorcycle accident
serves to evaluate associated injuries and eventual testicular vascular compromise, which fortunately rarely occurs [8, 9]. CT scan can also be used in borderline cases of inguinal deep location [9, 12, 13]. Regarding treatment, once the diagnosis is done—particularly if it is early—it is possible to attempt a close reduction under anesthesia with Doppler ultrasound guidance to verify testicular indemnity and to discard torsion. When in doubt, surgical approach is preferable. Even in early-operated patients, a fast developing adherence phenomenon has been reported. Careful dissection and release of these adhesions with relocation and fixation of the testicle into the scrotal sac are advised [4, 15]. Surgical result is uniformly satisfactory as shown in our survivor patients [4, 7–9, 15]. Recovery of spermatogenesis has been reported in cases of bilateral dislocation undergoing orchidopexy many years after the injury, which further supports surgery in cases of late diagnosis [5].
Conclusion Traumatic testicular dislocation is a rare entity. Urologist and trauma surgeons providing emergency care should be aware of its occurrence in front of any violent pelvic trauma, particularly suffered by the occupants of a motorcycle. Diagnosis depends directly on suspicion and a careful admission physical examination; early surgery is the preferred treatment, having excellent prognosis in the vast majority of cases.
1 Pelvic crush injury Conflict of interest
note that our two fatal cases were precisely those who had bilateral dislocation, testifying the severity of the impact. In our series, five cases had a superficial dislocation to the inguinal or peri-inguinal area, which is typical of this entity, [15, 16] but dislocation to the deep inguinal area, pubis, contralateral inguinal region and even to the penis [2, 9, 11, 15] have also been reported. Although it may look simple, the diagnosis is not always obvious. In some cases, the injury remained unnoticed and was recognized by the patient himself after discharge [4, 9]. It should be remembered that these patients usually have severe associated injuries, which divert the attention of the genital area and sometimes can also mask the diagnosis because of the coexistence of hematomas and inflammatory involvement or soft tissues of the scrotum [18]. Late diagnosis can be observed days or weeks after the accident [2, 4, 9, 16], but there are reports of more than 10 years of delay [5, 7]. We recommend the use of Doppler ultrasonography for evaluation; apart from documenting the ectopic location, it
123
None.
References 1. Claubry EG (1818) Observacions sur une retrocession subite des deux testicles dans l0 abdomen, a la suite d’une violente compression de la parte infe´rieure de la paroid abdominale par une roue´ de la charrette. J Ge´n Me´d Chir Prham 64:325–328 2. Lo´pez Alcina E, Martı´n JC, Fuster A, Pe´rez J, Puertas M, Moreno J (2001) Dislocacio´n testicular, aportacio´n de 2 nuevos casos y revisio´n de la literatura. Acta Urol Esp 25:299–302 3. Ihama Y, Fuke C, Miyazaki T (2007) A two-rider motorcycle accident involving injuries around groin area in both the driver and the passenger. Leg Med (Tokyo) 9:274–277 4. Phuwapraisirisan S, Lim M, Suwanthanma W (2010) Surgical reduction in a delayed case of traumatic testicular dislocation. J Med Assoc Thail 93:1317–1320 5. Sakamoto H, Iwasaki S, Hushima M, Shichijo T, Ogawa Y (2008) Traumatic bilateral testicular dislocation: a recovery of spermatogenesis by orchiopexy 15 years after the onset. Fertil Steril 90:9–11 6. Choi SE, Kiik MC, Kim CJ, Lee SC, Park KW, Jung SE, Kim WK (2009) Effects of compression/stretching of the spermatic cord and blunt dissection on testicular growth and fertility. J. Pediatri Surg 44:2163–2167
Int Urol Nephrol 7. Yoshimura K, Okubo K, Ihioka K, Terada N, Matsuta Y, Arai Y (2002) Restoration of spermatogenesis by orchiopexy 13 years after bilateral traumatic testicular dislocation. J Urol 167:649–650 8. Lee JY, Cass AS, Streitz KM (1992) Traumatic dislocation of testes and bladder rupture. Urology 40:506 9. Ko SF, Ng SH, Wan YL, Huang CC, Lee TY, Kung CT, Liu PP (2004) Testicular dislocation: an uncommon and easily overlooked complication of blunt abdominal trauma. Ann Emerg Med 43:371–375 10. Kochakarn W, Choonhaklai V, Hotrapawanond P, Muangman V (2000) Traumatic testicular dislocation a review of 36 cases. J Med Assoc Thail 30:409–411 11. Nagarajan VP, Pranikoff K, Imahori SC et al (1983) Traumatic dislocation of testis. Urology 22:521 12. Ezra N, Afari A, Wong J (2009) Pelvic and scrotal trauma: CT and triage of patients. Abdom Imaging 34:541–544
13. Tsurukiri J, Nauyuki K, Shiro M (2011) Bilateral traumatic testicular dislocation. Urology 76:1306 14. Morgan A (1965) Traumatic luxation of the testis. Br J Surg 52:669 15. Luja´n S, Budı´a A, Bango V, Ramı´rez M, Delgado FJ, Jime´nez JF (2006) Dislocacio´n testicular postrauma´tica. Acta Urol Esp 30:409–411 16. Schwartz SL, Faerber GJ (1994) Dislocation of the testis as a delayed presentation of scrotal trauma. Urology 43:743 17. Jecmenica D, Alempijevic D, Pavlekic S, Aleksandrik B (2011) Traumatic testicular displacement in motorcycle driver. J of Forensic Sci 56:541–543 18. Vasudeva H, Dalela D, Singh D, Goel A (2010) Traumatic testicular dislocation: a reminder for the unwary. J Emerg Trauma Shock 3:418–419
123
UROLOGY - ORIGINAL PAPER
Traumatic testicular dislocation Reynaldo G. Go´mez • Oscar Storme Gabriel Catala´n • Pablo Marchetti • Miroslav Djordjevic
•
Received: 31 December 2013 / Accepted: 2 May 2014 Ó Springer Science+Business Media Dordrecht 2014
Abstract Introduction Traumatic testicular dislocation is a rare entity. It occurs after a direct blunt scrotal trauma causing the testicle to migrate outside the scrotum, most frequently to the superficial inguinal region. Materials and methods A review of the diagnostic database of our two institutions was performed searching for complex genital trauma between 1990 and 2012. Results Seven cases of traumatic testicular dislocation were identified (four on the left side; one on the right side and two bilateral) for a total of nine testicles. Six were motorcycle accidents, and the other case suffered a pelvic crush injury. All victims had significant associated injuries, one case had an open dislocation and two were killed by the accident. The testicle was located at the inguinal region in four cases at the suprapubic area in four, and the other was an open dislocation. Diagnosis was suspected with the physical examination and confirmed by Doppler ultrasound; however, in one case, the diagnosis was missed during several weeks. In one case, the testicle was reduced into the scrotum immediately at the emergency department. Two cases were operated shortly after admission, performing testicular reduction into the scrotum and standard orchidopexy. Two other cases underwent delayed intervention, and both needed release of peri-testicular adhesions. Two cases (both bilateral) died at the accident site and were diagnosed by autopsy. In all surviving cases, it R. G. Go´mez (&) O. Storme G. Catala´n P. Marchetti Urology Service, Hospital del Trabajador, Ramon Carnicer 185, Providencia, Santiago, Chile e-mail: [email protected] M. Djordjevic Department of Urology, School of Medicine, University Children’s Hospital, University of Belgrade, Belgrade, Serbia
was possible to obtain a satisfactory orchidopexy with gonadal preservation. Conclusions Traumatic testicular dislocation is rare and diagnosis can be elusive. It should be suspected in motorcycle and high-energy accidents around the groin area and depends on a careful physical examination. With proper management, prognosis is excellent. Keywords Blunt scrotal trauma Testicular injuries Testicular dislocation Motorcycle injuries
Introduction Traumatic testicular dislocation corresponds to the extra scrotal migration of one or both testicles as a consequence of a direct scrotal trauma. Claubry first described this entity in 1818 [1, 2]. Since then, the literature reports only small series or case reports, coming mainly from the Asian literature [3– 13]. In a recent review, it is estimated that less than 200 cases have been reported in the indexed world literature [4]. Its most common location is in the superficial inguinal area [2, 15, 16]. Its occurrence 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 [2, 14, 15]. Because of its low incidence, it is an entity little known to the trauma teams, implying low suspicion and probable under diagnosis. This is very important because proper management is related directly to testicular and fertility preservation [5, 6]. Moreover, the presence of this type of injury can be very useful in the course of the medico legal investigation of a fatal motorcycle accident, to assist in identifying the driver of the motorcycle and determine responsibilities in the accident [17].
123
Int Urol Nephrol
Patients and methods We reviewed retrospectively the medical records of all patients diagnosed with complicated traumatic genital injury treated at our two institutions in the period between
January 1990 and January 2012. Patients who suffered a testicular dislocation were selected and their charts reviewed for age, type and cause of the accident, laterality, associated injuries, time of diagnosis, clinical presentation, imaging, outcome and follow-up.
Table 1 Characteristics of seven cases of traumatic testicular dislocation Case
Age
Accident
Driver
Side
Associated injuries
Diagnosis
Clinical findings
Imaging
Surgery
Followup (days)
1
39
Motorcycle
Yes
Left
Left femur fracture, laceration of adductor muscles of the left thigh
On admission
Palpable nonreducible left inguinal mass, empty left hemiscrotum
Doppler ultrasound
Orchidopexy
15
2
26
Motorcycle
Yes
Left
Multiple fractures of the left femur
After 35 days
Palpable nonreducible left inguinal mass, empty left hemiscrotum
On admission
Orchidopexy at 2 months for delayed diagnosis
60
3
48
Pelvic crush injury
–
Right
Fracture of the right femur and both feet, extensive injury of soft tissues of the perineum and both legs
On admission
Testicle at the right inguinal canal, empty left hemiscrotum
No
Orchidopexy at 47 days for associated injuries
90
4
25
Motorcycle
Yes
Left
Pelvic fracture and rupture of the membranous urethra
On admission
Inguinal laceration with dislocation and exposure of the left testicle
On admission
Surgical debridement and orchidopexy
21
5
27
Motorcycle
Yes
Left
Blunt penile wound
On admission
Palpable left inguinal mass, scrotal erosions, empty left hemi-scrotum
On admission
Manual reduction at the emergency department
90
6
24
Motorcycle
Yes
Bilateral
Severe closed head injury, open right leg fracture, extensive injury of soft tissues in both thighs
Autopsy
Scrotal and perineal erosions, empty scrotum, both testicles in suprapubic region
–
–
–
7
21
Motorcycle
Yes
Bilateral
Laceration of the heart, lungs, liver, mesenterium, thoracic aorta, ribs and spine fractures, laceration of both thighs
Autopsy
Extensive inguinal and genital injury, empty scrotum, both testicles in suprapubic area
–
–
–
123
Int Urol Nephrol
Results In the study period, a total of 1,883 patients were admitted with a diagnosis of Genital Trauma, 83 of which were complex injuries and seven of them had a traumatic testicular dislocation (0.37 % of the total and 8.4 % of the complex; Table 1). In four patients, the dislocation affected the left testicle, in one case affected the right testicle and it was bilateral in the other two, totaling nine testicles. One of the patients had an open dislocation (Fig. 1). The average age was 30 years (range 21–48). Six patients suffered a motorcycle accident, and in all of these, the victim was the driver of the vehicle. All patients had significant associated injuries: femur and or pelvis fracture in five and severe adductor muscle injury in two. One case presented an open dislocation of the left testis secondary to a motorcycle accident, which also caused a fractured pelvis and a section of the membranous urethra (Case 4). The location of the testis was inguinal in five cases and suprapubic in four. The diagnosis was suspected on physical examination and confirmed by testicular ultrasound in four cases (one diagnosis went unnoticed for several weeks); the patient with open dislocation was diagnosed by physical examination and the other two patients died at the moment of the motorcycle accident, being diagnosed at autopsy; and these two patients had bilateral lesions (four testis). The treatment of the five surviving patients included manual reduction into the scrotum on admission to the emergency room in one case, immediate surgical orchidopexy in two and the other two patients were operated on late: in one of them, genital surgery had to be postponed due to severe associated injuries and in the other, the diagnosis went unnoticed for 35 days. In these two patients operated late, important adhesions requiring significant peri-testicular orchidolysis were found. In all surviving
Fig. 1 Open testicular dislocation (Case 4): traumatic inguinal laceration is noted through which the testicle is exteriorized
patients, a satisfactory orchidopexy was achieved without immediate complications. The average follow-up was 55.2 days (range 15–90) and in all patients, adequate gonadal preservation was verified.
Discussion Traumatic testicular dislocation is a rare injury and therefore is little known to the trauma team. As described in the literature, and as noted in our review, it is the result of high-energy accidents, particularly in motorcycles [2–4, 7– 9, 15]. It typically affects the motorcycle driver, who slips the perineum to collide abruptly with the fuel tank, which squeezes the testicle outside its normal scrotal location. Ko reported nine cases, seven of which were motorcycle accidents, mostly young men with an average age of 29 years [9], almost identical to that observed in our study. This mechanism also explains why most of the reports come from the Asian literature, due to the widespread use of these vehicles on that continent (Table 2). In fact, the largest published series with 36 cases comes from Thailand. Although motorcycle accidents are the most frequent etiology, this injury can result after any sudden blunt compression mechanism in the groin area. The presence of a testicular dislocation in the investigation of a fatal motorcycling accident can be crucial in the forensic field, since its presence strongly suggests that the carrier was the driver of vehicle [17]. This occurred in two of our patients who were victims of a motorcycling accident which killed both occupants of the motorcycle. The presence of a testicular dislocation helps to identify the vehicle driver. This lesion has also been described in different accidents involving perineal violence, such as falls astride, abuse, kicks or blows with rotating elements [2, 15]. It has been reported that the dislocation and the final location of the testis depend on the direction and intensity of the impact, associated with a secondary cremaster muscle spasm contraction and the presence of some type of anatomic abnormality such as an inguinal hernia [2] or laxity of the inguinal ring [15]. It also may be a rupture of the spermatic fascia, and it has been postulated that these would create a sort of grommet preventing the testicle to go back to its normal position once the momentum that led to their ectopic situation is over. Clinically, Brockman’s sign, which is the presence of a well developed but empty loose scrotum, helps with the differential diagnosis with a preexisting cryptorchidism. Palpation of the testis in a subcutaneous ectopic situation raises suspicion, which may be confirmed by ultrasonography. Although often presented as unilateral, there are several reports of bilateral dislocation, as in two cases of this series [5, 7, 9, 10]. It is interesting to
123
Int Urol Nephrol Table 2 Published series on testicular dislocation References Claubry [1] Lo´pez Alcina [2]
Patients (number) 1 2
Trauma mechanism 1 Wagon wheel trauma 1 Motorcycle accident 1 Genital kick
Ihama [3]
1
1 Motorcycle accident
Phuwapraisirisan [4]
1
1 Motorcycle accident
Sakamoto [5]
1
1 Motorcycle accident
Yoshimura [7]
1
1 Motorcycle accident
Lee [8]
2
1 Motorcycle accident 1 Automobile accident
Ko [9]
9
7 Motorcycle accident 1 Explosive injury 1 Seat belt injury
Kochakarn [10]
36
36 Motorcycle accident
Nagarajan [11]
3
3 Motorcycle accident
Ezra [12]
1
Motorcycle accident
Tsurukiri [13]
1
Motorcycle accident
Morgan [14]
4
2 Road accident 1 Motorcycle accident 1 Bicycle accident
Luja´n [15]
1
Motorcycle accident
Schwartz [16]
1
Pedestrian-motor vehicle accident
Jecmenica [17]
2
2 Motorcycle accident
Vasudeva [18]
1
Motorcycle accident
Present series
7
6 Motorcycle accident
serves to evaluate associated injuries and eventual testicular vascular compromise, which fortunately rarely occurs [8, 9]. CT scan can also be used in borderline cases of inguinal deep location [9, 12, 13]. Regarding treatment, once the diagnosis is done—particularly if it is early—it is possible to attempt a close reduction under anesthesia with Doppler ultrasound guidance to verify testicular indemnity and to discard torsion. When in doubt, surgical approach is preferable. Even in early-operated patients, a fast developing adherence phenomenon has been reported. Careful dissection and release of these adhesions with relocation and fixation of the testicle into the scrotal sac are advised [4, 15]. Surgical result is uniformly satisfactory as shown in our survivor patients [4, 7–9, 15]. Recovery of spermatogenesis has been reported in cases of bilateral dislocation undergoing orchidopexy many years after the injury, which further supports surgery in cases of late diagnosis [5].
Conclusion Traumatic testicular dislocation is a rare entity. Urologist and trauma surgeons providing emergency care should be aware of its occurrence in front of any violent pelvic trauma, particularly suffered by the occupants of a motorcycle. Diagnosis depends directly on suspicion and a careful admission physical examination; early surgery is the preferred treatment, having excellent prognosis in the vast majority of cases.
1 Pelvic crush injury Conflict of interest
note that our two fatal cases were precisely those who had bilateral dislocation, testifying the severity of the impact. In our series, five cases had a superficial dislocation to the inguinal or peri-inguinal area, which is typical of this entity, [15, 16] but dislocation to the deep inguinal area, pubis, contralateral inguinal region and even to the penis [2, 9, 11, 15] have also been reported. Although it may look simple, the diagnosis is not always obvious. In some cases, the injury remained unnoticed and was recognized by the patient himself after discharge [4, 9]. It should be remembered that these patients usually have severe associated injuries, which divert the attention of the genital area and sometimes can also mask the diagnosis because of the coexistence of hematomas and inflammatory involvement or soft tissues of the scrotum [18]. Late diagnosis can be observed days or weeks after the accident [2, 4, 9, 16], but there are reports of more than 10 years of delay [5, 7]. We recommend the use of Doppler ultrasonography for evaluation; apart from documenting the ectopic location, it
123
None.
References 1. Claubry EG (1818) Observacions sur une retrocession subite des deux testicles dans l0 abdomen, a la suite d’une violente compression de la parte infe´rieure de la paroid abdominale par une roue´ de la charrette. J Ge´n Me´d Chir Prham 64:325–328 2. Lo´pez Alcina E, Martı´n JC, Fuster A, Pe´rez J, Puertas M, Moreno J (2001) Dislocacio´n testicular, aportacio´n de 2 nuevos casos y revisio´n de la literatura. Acta Urol Esp 25:299–302 3. Ihama Y, Fuke C, Miyazaki T (2007) A two-rider motorcycle accident involving injuries around groin area in both the driver and the passenger. Leg Med (Tokyo) 9:274–277 4. Phuwapraisirisan S, Lim M, Suwanthanma W (2010) Surgical reduction in a delayed case of traumatic testicular dislocation. J Med Assoc Thail 93:1317–1320 5. Sakamoto H, Iwasaki S, Hushima M, Shichijo T, Ogawa Y (2008) Traumatic bilateral testicular dislocation: a recovery of spermatogenesis by orchiopexy 15 years after the onset. Fertil Steril 90:9–11 6. Choi SE, Kiik MC, Kim CJ, Lee SC, Park KW, Jung SE, Kim WK (2009) Effects of compression/stretching of the spermatic cord and blunt dissection on testicular growth and fertility. J. Pediatri Surg 44:2163–2167
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