Pediatric emergency medicine trisk 833

SCROTUM
Goal of Treatment
The goals of the acute management of children with scrotal injuries are to
determine the extent of injury, evaluating for testicular injury and, in consultation
with urology, ensuring adequate workup to determine definitive care.

FIGURE 108.5 Posterior urethral disruption and pelvic fracture. Computed tomography of
pelvis shows extravasation of contrast material from posterior urethra into the surrounding
tissues.

CLINICAL PEARLS AND PITFALLS
Scrotal trauma may occur as a result of straddle injuries or bicycle
accidents, during sporting events or less commonly, from animal bites or
machine injuries. The patient may present with scrotal tenderness,
edema, and ecchymosis. Potential injuries include skin or dartos
ecchymosis and lacerations, intrascrotal hematomas, testicular
hematomas, testicular dislocation, and testicular rupture. In addition, a
testicle may torse after trauma.

Clinical Considerations
Clinical Recognition


When inspection of the scrotum and its contents is obscured by local swelling and
pain, ultrasonography is helpful to define the extent of the injury. An
intratesticular hematoma may show as an echogenic or hypoechoic testicular
mass. A hematocele produces a complex extratesticular fluid collection.
Sonographic findings of rupture include the presence of hematocele, parenchymal
heterogeneity, intraparenchymal hemorrhage, and disruption of the tunica
albuginea or parenchyma. If the ultrasound examination is inconclusive,
radionuclide scanning may provide additional information. Both ultrasonography

and nuclear scintigraphy help in the diagnosis of testicular torsion (see Chapter
119 Genitourinary Emergencies ).
Patients who sustain small intrascrotal hematomas, skin ecchymosis, or minor
skin and dartos injury without evidence of injury to the testes can be managed
conservatively. Treatment consists of ice packs and scrotal support. Minor
testicular injuries such as contusions or hematomas can also be treated
conservatively. Large testicular hematomas (>3 to 5 cm) or testicular disruption
may require surgical management. Delay in surgery may lead to ischemic
necrosis, pain, secondary infections, and disruption of testicular function.

Initial Assessment, Management, and Diagnostic Testing
Superficial lacerations of the scrotum can be repaired using absorbable sutures.
Local infiltration with lidocaine plus epinephrine provides adequate anesthesia.
Urologic consultation should be obtained if the laceration extends through the
dartos. Physical examination of the scrotal contents determines the need for
debridement and primary closure. All penetrating testicular injuries require
surgical exploration.
Degloving injuries of the scrotum can be seen after motor vehicle (particularly
motorcycle), industrial, or farm machinery accidents. Scrotal injuries are
associated with varying degrees of penile skin loss. The underlying penile and
scrotal structures are usually spared. Management involves debridement with
primarily closure or coverage of the defect by skin flaps or grafting if more than
50% to 70% of the scrotal skin is lost.
Testicular rupture is a surgical emergency. It is characterized by a tear of the
tunica albuginea and extravasation of testicular contents into the scrotal sac. Such
injuries require early surgical exploration and repair to avoid the potential
complications of atrophy and persistent pain. Ultrasonography has been
demonstrated to be sensitive in the diagnosis of testicular rupture by informing
the clinician of the integrity of the scrotal contents early. The high specificity of
the ultrasonography may also provide information to guide the clinician on the

necessity of surgical exploration. Testicular salvage is more likely when


exploration is performed within 24 hours of the injury. Ultrasonography has
shown poor accuracy, however, for the evaluation of isolated epididymal lesions.
Other injuries requiring surgical management include tense hematoceles and
torsion after trauma.
Testicular dislocation may occur either as a result of an upward blow to the
scrotum or, rarely, as a result of compressive displacement following severe blunt
abdominal trauma. Dislocation has been described in the context of mild scrotal
trauma as well. Diagnosis of testicular dislocation can be made by thorough
physical examination, including palpation of the testes. Examination will reveal a
well-developed, but empty, scrotal sac or palpation of an abnormally located
testis. Severe scrotal pain, obesity, ecchymosis, swelling, or associated pelvic
injuries may make examination and diagnosis difficult. In most cases, the
dislocated testis lies in the inguinal canal. Associated injuries, such as pelvic
fracture, are common. Operative repair is required if closed reduction fails.

PENIS
Clinical Recognition
The most common cause of penile trauma in infants is iatrogenic, especially at the
time of circumcision. Complications include transection of the glans,
urethrocutaneous fistula, deskinning of the penile shaft, and coagulation necrosis
of the entire penis from electrocautery. These injuries usually require extensive
surgical repair.
Penile gunshot wounds are uncommon because of the position and mobility of
the penis but have the potential to significantly affect quality of life. Signs that
may indicate corpora cavernosa injury include uncontrolled bleeding, expanding
hematoma, blood at the meatus, or a palpable corporeal defect. Urethral injury
should be ruled out by retrograde urethrography if these signs are present. These

injuries require urologic evaluation to determine the need and timing of surgical
management.
Blunt penile trauma from toilet seats falling on the glans or distal shaft can
occur in toddlers. Significant injury to the corporal bodies or the urethra is
fortunately rare and patients can generally be managed expectantly with warm
soaks. Although the child does not commonly experience urinary retention, he
may be more comfortable voiding in a tub of warm water.
Tourniquet injuries to the penis may result from bands, rings, or human hair. In
the infant, strangulation with a fine hair may be difficult to recognize because of
local edema. The initial diagnosis may be balanitis or paraphimosis. Local or


general anesthesia may be required to expose and remove the hair. A high degree
of suspicion should be maintained as complications include urethrocutaneous
fistula or loss of the penis.
Fracture of the penis is produced by traumatic rupture of the corpus
cavernosum. This injury usually occurs when the erect penis is forced against a
hard surface, most commonly during sexual activity. The patient may hear a
cracking sound and develop pain, edema, and deformity of the penis shaft with
abrupt loss of erection. An “eggplant deformity” of the penis is often present. The
urethra may be involved in 3% to 32% of injuries, especially in those with more
extensive or bilateral corporal injuries. Penile fractures require surgical treatment
with evacuation of the penile hematoma, repair of the torn tunica albuginea,
urethral repair if necessary and a pressure dressing.
Superficial lacerations of the penile shaft can be repaired with absorbable
sutures under local anesthesia or penile block. Lacerations extending to the
corporal bodies or the urethra require urologic consultation due to the depth of
injury and significant bleeding. Injuries to the corporal bodies should be repaired
primarily to prevent fibrosis and impotence. If concomitant urethral injury is
suspected, diagnostic evaluation includes a RUG to define the extent of the injury.

Injuries to the urethra may require primary repair and/or temporary urinary
diversion.
Zipper entrapment of the penis or foreskin is a common complaint that can be
managed in the ED. Methods of emergent release have been described in relation
to the zipper parts and depending on the type of zipper. The median bar of the
zipper may be cut with wire cutters and thus disassembling the zipper mechanism
( Fig. 108.6 ). This technique may sometimes prove difficult when the metal bar
is sturdy and there is edema of the entrapped penile tissue within the zipper
fastener, limiting access to the metal bar. Such may be the case with heavy metal
zippers such as those found on jeans and dungarees, and success may depend on
the strength of the operator and the availability of bone or wire cutters. Therefore,
this technique may work best with plastic or lightweight zippers. Cutting the
dentition of the zipper at any position, permitting unzipping of the zipper from the
rear may work best for heavy-duty metal zippers. Disengagement of the fastener
by inserting a flathead screwdriver between the inner and outer faceplates and
applying torque toward the median bar ( Fig. 108.7 ) may prove helpful when it is
difficult to grasp the tiny median bar with bulky cutting pliers. Elliptical incision
of the entrapped foreskin or emergency circumcision can be of value when less
invasive methods have failed. Regardless of technique, procedural sedation may
facilitate the procedure. Edema can be treated with warm soaks.