TnE JOURNAL OF UROLOGY
95, May
Copyright © 1966 by The Williams & Wilkins Co.
TRAUl\1:ATIC RUPTURE OF THE TESTICLE
ROBERT WASKO AND
From the Department of Urology, Temple University Medical Center, Philadelphia, Pennsylvania
Traurn.atic rupture of the tunica albuginea
without associated laceration of the scrotal skin
is rare. Bronk and Derry reviewed the literature
in 1962 and found 23 cases. 1 To our knowledge, 10
additional cases have been described. Three pa-
tients with traumatic rupture of the testicle who
were treated at our institutions prompted our
report.
CASE REPORTS
Case 1. E. T., a 15-year-old boy, injured his
right testicle while sliding down a lamppost on
September 14, 1953. He experienced sudden se-
vere scrotal pain which persisted for 24 hours.
The next day his physician noted a moderately
tender scrotal niass the size of a baseball. The
lesion did not transmit light and there was no
discoloration of the scrotal skin. Conservative
treatment yielded symptomatic relief; however,
because of a persistent scrotal niass, surgery was
advised. Exploration on October 3 revealed a
large hematocele which was evacuated of blood
clots. The testicle appeared normal except for a
small laceration of the tunica albuginea which
was repaired. The scrotum was then drained.
Convalescence was uneventful and the patient
was discharged on October 11. Two weeks post-
operatively, the testicle was unremarkable. Un-
fortunately, the patient was lost to followup
evaluation.
Case 2. G. D. R., a 39-year-old white man, first
consulted a physician on September 21, 1964, 6
weeks after being hit in the right scrotum. by a
baseball. Immediately following the injury, he
experienced severe pain, nausea and rapid en-
largement of the right hemiscrotum. The patient
used ice packs and a scrotal support but be-
cause of a persistently large scrotal mass, he
finally sought medical advice. The tentative
diagnosis at the initial examination was that of a
large hydrocele. The mass faintly transillumi-
nated light and was non-tender. The scrotal con-
Accepted for publication June 30, 1965.
Read before the Philadelphia Urological Society,
Apnl 26, 1965.
1 Bronk, W. S. and Berry, J. L. · J. Urol., 87:
564, 1962.
Vol.
Printed ,:r,. U.S.A.
ARTHUR G. GOLDSTEIN
tents were indistinct. Exploration of the right
i,crotun1 on September 24 disclosed a hydrocele
containing dark yellow fluid. The testicle was
slightly enlarged and on its anterior surface there
was a I-inch vertical laceration of the tunica
albuginea. A small amount of testicular paren-
chyrn.a protruded through the laceration, the
edges of which exhibited early granulation. The
herniated tissue was excised and the edges of the
tunica were freshened and then reapproximated.
The patient had a srn.ooth convalescence and was
discharged on September 28. The right testicle
was normal to palpation on October 15.
Case 3. V. L., a 21-year-old Negro, sustained
blunt trauma to the left Ecroturn following a fall
against a machine on January 22, 1965. He int-
rn.ediately had nausea, oevere scrotal pain and
later scrotal swelling. Because of persistent symp-
toms the patient was hospitalized on .January 25.
Examination revealed a large left scrotal mass the
size of an orange. Definitive Ecrotal elements
could not be outlined but the point of maximum_
tenderness was posteriorly in the area of the
epididymis. There was a fluctuant region an-
teriorly ,vhich did not transrn.it light. The tenta-
tive diagnosis was hematocele and/or infectious
epididymo-orchitis. Because conservative treat-
ment was ineffective, exploration lrning the
inguinal approach was performed on January 29.
A large hernatocele was evacuated of 200 cc
of blood clots. The testicle exhibited a I-inch
transverse tear in the tunica albuginea. The
entire testicular parenchyrna had been replaced
by organized blood clots (fig. 1). An orchiectmny
was performed. The pathologist reported exten-
sive coagulation necrosis of the testicle with
hematoma of the cord. The convalescence was
uneventful and the patient was discharged on
February 6.
DISCUSSION
The true incidence of traumatic rupture of the
testicle is unknown. No doubt many cases occur
and are treated con.~ervatively. This entity must
be considered in any patient who has an enlarging
scrotal mass following blunt, non-penetrating
721
722 WASKO AND GOLDSTEIN
Fm. 1. Case 3. Entire parenchyma of ruptured
testicle has been replaced by organized blood
clots.
trauma to this region. However, this does remain
an unusual injury because the mobility of the
testicle in the scrotum precludes significant
trauma. Wesson reported that a force of 50 kg.
was necessary to rupture the testicle. 2 McCrea
suggested that impingement of the testicle against
the pubis or thigh was a contributing factor to
rupture. 3 As reported by Cassie, a trivial injury
may cause testicular rupture when associated
with an underlying testicular neoplasm. 4 Most
cases of traumatic rupture of the testicle occur in
1nen less that 50 years old, this being the period of
greatest physical activity.
At surgery, varying amounts of blood and
clots are usually found within the tunica
vaginalis. However, occasionally a traumatic
hydrocele will be present. 5 The gross appearance
of a ruptured testicle can vary from a small
laceration of the tunica albuginea with minimal
herniation of tubular tissue to a large laceration
with complete destruction of the testicular par-
enchyma.
The most consistent symptom of testicular
rupture is severe scrotal pain which may diminish
in intensity with time. Fainting, nausea and
vomiting are often present. Typically, there is
gradual enlarge1nent of the involved he1niscrotum
due to bleeding into the tunica vaginalis. Ecchy-
mosis and obliteration of the rugae of the scrotal
skin may be present. An enlarging scrotal mass is
an important aid to diagnosis. In all of our cases
the lesion was at least the size of a baseball.
Transillumination of the scrotal mass and delinea-
tion of the testicle are usually impossible.
2 Wesson, M. B.: Urol. & Cutan. Rev., 50: 16,
1956.
3 McCrea, L. E.: J. Urol., 66: 270, 1951.
4 Cassie G. F.: Brit. J. Urol., 28: 283, 1956.
5 Malap~rt, M.: Gaz. Med., Paris, 87: 15, 1916.
The differential diagnosis includes: simple
hematocele without testicular rupture (this
diagnosis is most often responsible for delay in
surgical intervention), torsion of the testicle or
one of its appendages, testicular neoplasm,
infectious epididymo-orchitis, ruptured varico-
cele6 and traumatic hydrocele.
Prompt exploration of the scrotum is indicated
when traumatic rupture of the testicle is
suspected. In view of the possibility of testicular
neoplasm (with or without testicular rupture) it is
suggested that an inguinal incision with isolation
and occlusion of the cord structures be utilized
prior to manipulation of the testicle. With a
small laceration of the tunica albuginea and
viable testicular parenchyma, primary closure of
the tunica should be performed. Any obviously
devitalized, protruding testicular tissue should
be excised prior to closure. vVith more extensive
injuries, all attempts should be made to salvage
any normal appearing testicular substance. If
there is insufficient tunica albuginea to cover the
testicular tissue, Schneiderman advises covering
the defect with the tunica vaginalis. 7 With
complete destruction, orchiectomy is indicated.
In 1895, Recluse stated that repair of an
injured testicle would eventually be followed by
atrophy of the organ. Contrary to this observa-
tion, there have been sufficient case reports of
apparently viable testicles following surgical
repair of the rupture. 2 • 3 • 5 • 7 - 13
CONCLUSIONS
We believe that early exploration of scrotal
masses secondary to trauma is indicated for
numerous reasons: 1) Study of all previously
reported cases of traumatic rupture of the testicle
seems to indicate that orchiectomy was performed
more frequently when surgical exploration was
delayed. In most of the cases where the testicle
was salvaged, early exploration had been per-
formed. 2) Without exploration, pressure atrophy
of the testicle may occur with subsequent loss of
6 Cotton, F. J.: Arner. J. Urol., 2: 587, 1905,
1906.
7 Schneiderman, C.: J. Urol., 78: 54, 1957.
8 Barbosa de Baros, J.: Rev. Paul. Med., 35:
429, 1949,
'Bernardi, R. and Agugliaro, J.P.: Rev. Ar-
gent. Urol., 28: 81, 1959.
1 0 Dundon, C.: Lancet, 1: 903, 1952.
11 Laird, R. M.: Lancet, 1: 601, 1954.
12 Ortiz, A. B. and Bonta, A. R.: Rev. Argent.
Urol., 17: 665, 1948.
13 Trabucco, A., Cornotto, C. and Amendolaro,
F.: Rev. Argent. Urol., 20: 46, 1951.
 TRAUJ\!IATIC RUPTURE OF TESTICLE
spermatogenesis and hormone production.
3) Early exploration will decrease the period of
discomfort for the patient as well as the hospital
stay. 4) Aspiration of hematoceles for relief of
discomfort may be complicated by secondary
infection. The finding of blood in the aspirate
neither proves nor disproves testicular rupture.
5) Traumatic rupture of a testicular neoplasm has
been reported by Cassie. 4 6) With salvage of a
ruptured testicle, the patient benefits from a
physiologic, cosmetic and psychologic standpoint.
SUMMARY
Three cases of traumatic rupture of the testicle
are reported. An enlarging, severely painful,
scrotal mass associated with blunt, non-pene-
trating trauma is suggestive of this entity.
Prompt surgical exploration should be performed
whenever the diagnosis of testicular rupture is
suspected.
723
Appreciation is expressed to Dr. Trudeau
Horrax for case 2 and to Dr. Julio d'Escrivan for
translation of many foreign articles.
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