TRAUMATICDISLOCATIONOFTESTESAND BLADDERRUPTURE

J. Y. LEE, M.D. A. S. CASS, M..B.B.S. J. M. STREITZ, M.D.

From the Divisions of Urology, Hennepin County Medical Center, Minneapolis, and St. Luke’s Hospita1 of Duluth, Duluth, Minnesota

ABSTRACT-Traumatic dislocation of the testes with bladder rupture oc- curred in 2 multiply injured patients with pelvic fracture. One had a history of retractile testes and the other of previous testicular dislocation. Surgical correc- tion was performed after closed reduction faìled. These ìnjurìes must be recog- nined and treated promptly to maximixe the likelihood of testicular salvage. If early intervention is not possible, duplex ultrasonography and pulsed Doppler analysis are the optional valuative studies.

Traumatic dislocation of the testes is rare, with only 50 cases reported in the literature, and has occurred primarily in patients multiply injured in motor vehicle accidents. Prompt recognition and repair is essential to maximize the likeli- hood of testicular salvage. Two cases are re- viewed and the management is outlined. The association of dislocation with bladder rupture, the traumatic dislocation of the testis on two separate occasions in the same patient, and dis- location with a history of retractile testes have not been reported previously.

Case 1 Case Reports

A twenty-three-year-old man was admitted with multiple injuries secondary to a motorcy- cie accident, including pelvic fractures, an in- traperitoneal rupture of the bladder, and frac- tures of the right radius and left femur. The left testis was moderately tender but otherwise nor- mal. The right hemiscrotum was empty, and the right testis was located near the internal in- guinal ring. The testis was tender but not enlarged or swollen. With his limited English, the patient described the right testis as being congenitally undescended.

A computerized tomography (CT) scan of the pelvis obtained to evaluate the stability of the

bony pelvis demonstrated an intact right in- guinal testis. There were no signs of rupture or hematocele. The orthopedie injuries and the in- traperitoneal rupture of the bladder were re- paired surgically. The patient was further stabi- lized in the intensive care unit and given transfusions to maintain a hemoglobin concen- tration of 10 g/dL. On further questioning, the patient revealed that both testes were normally located in the scrotum and retracted only on oc- casion to the external inguinal ring. The testicu- lar pain from the accident resolved within twenty-four hours.

On the thirteenth day after injury the patient suffered a gradual onset of pain and tenderness in the right inguinal testis. Ultrasound scanning revealed a homogenous parenchymal echo pat- tern with a slightly enlarged epididymis and without any signs of masses or hematocele. Scanning on the left demonstrated an intact tes- tis, but the parenchyma had a coarse heteroge- nous echo pattern consistent with contusion. Pulsed Doppler analysis showed good blood flow in the right testis. The patient was treated with antibiotics, and the epididymitis resolved. Attempts at closed reduction were unsuccessful.

Three months after his injury he elected to undergo a right orchiopexy. The grossly nor- mal-appearing right testis was found in the

506 UROLOGY / DECEMBER1992 / VOLUME40,NUMBER6

subcutaneous tissues superficial to the external oblique fascia with the spermatic cord exiting from the external inguinal ring and coursing cephalad to the testis at the leve1 of the internal inguinal ring. The adhesions were .iysed, a biopsy was obtained, and the testis was re- placed in the right hemiscrotum. Pathologie ex- amination revealed hypospermatogenesis with increased Sertoli cells, diffusely decreased sper- matogonia, and no spermatids. The later post- operative course was complicated by right epi- didymitis confirmed with a nuclear scan. The diameter of the left testis had shrunk from 3.5 to 2.0 cm. The epididymitis resolved with anti- biotics. A semen analysis one month later showed a volume of 1.5 mL and a sperm con- centration 113,000 per mL with 5 percent motility and 47 percent normal forms.

Case 2 A nineteen-year-old man was admitted after

an automotive accident in which he had sus- tained a pelvic fracture and an extraperitoneal rupture of the bladder that was managed by in- dwelling urethra1 catheter drainage for four- teen days. The right hemiscrotum was empty, and the right testis was palpated near the ex- ternal inguinal ring. The patient had suffered a similar testicular dislocation several years pre- viously after a bicycle accident but was able to reduce the testis after forty-five minutes of ma- nipulation. On this admission closed reduction of the right testis was unsuccessful.

After four weeks surgical exploration re- vealed a normahappearing testis located in the subcutaneous tissues anterior to the pubic bone near the external ring. It was freed of adhesions and replaced in the right hemiscrotum. Postop- erative examination of the testis was grossly normal. NO biopsy or semen analysis data were available.

Comment

From 1961 through 1989, 80 males with tes- ticular injuries caused by external trauma were admitted to Hennepin County Medical Center and St. Paul Ramsey Medical Center, but only one of these had traumatic dislocation of the testes (our other patient was admitted at an af- filiated hospital) . Indeed, since Claubry’s origi- na1 description in 1818,’ only 50 cases have been reported, of which 13 were bilateral and 37 unilateral. Our 2 cases represent the first re- port of traumatic dislocation associated with in- juries to the bladder. However, serious asso-

ciated injuries are common2-4 as traumatic dislocations of the testes have resulted mainly from motorcycle accidents.2J The need for stabi- lization of these multiply injured patients may cause a delay in definitive surgery for the testicu- lar injury even if it is recognized promptly.

In our first patient, the delay in obtaining an accurate history and the patient’s delay in de- ciding to have surgery prolonged the time be- tween the injury and its repair. Occasionally a patient delays presentation until he suffers a second onset of pain in the dislocated testis weeks after the initial injury. Herbst and Polkey5 reported on a patient who presented with acute gonorrheal epididymitis of the dislo- cated testis and Nagarajan3 reported on a pa- tient who presented three weeks after initial in- jury with sudden pain without a clear etiology.

Most reports have recommended early inter- vention to protect the testicle from degenera- tion.2J,s,7 Closed reduction should be attempted with sedation. It has been suggested that the optimal time for this attempt is four days after injury after the initial edema has subsided and before fibrosis occurs.8 Immediate surgical re- duction also bas been recommended for the fol- lowing reasons: (1) the possibility of testicular torsion or rupture; (2) the high incidence of failure of closed reduction; and (3) the minima1 morbidity associated with surgery. 3

Delays in correction can result in irreversible testicular changes from the deleterious effects of an ectopic position. In the rat, correction of ar- tificial cryptorchidism within six days is neces- sary to assure postoperative recovery of sperma- togenesis,g but it is difficult to translate this timing to the clinical situation. Moreover, the testis displaced in an accident may have sus- tained additional trauma. The three reported biopsies of dislocated testes, one obtained five weeks after the injury, and that of our first pa- tient consistently revealed absent spermatids, a decreased number of spermatogonia, and rela- tively increased number of Sertoli cells.2-4 Re- covery of spermatogenesis was seen in a patient who had bilateral dislocation of the testes with orchiopexy at eight weeks when a biopsy speci- men had shown no spermatids2 However, semen analysis three months after the orchiopexy showed a volume of 1.5 mL and a sperm concen- tration 40,800,OOO per mL with 80 percent motil- ity and 40 percent normal forms. In Case 1, where three months elapsed before orchiopexy, the semen analysis revealed considerable testicu- lar impairment, but further semen analysis and

UROLOCY / DECEMBER 1992 / VOLUME 40, NUMBER 6 507

serum hormone assays wil1 be required to deter- mine the extent of testicular recovery.

If early intervention is not possible, the status of the testis can be ascertained by duplex ultra- sonography and pulsed Doppler analysis. Un- like ultrasonography for the nonpalpable cryp- torchid testes, ultrasonography of the palpable traumatic dislocated testes reliably provides high-resolution images to help differentiate an intact testes from a ruptured testes. Pulsed Dop- pler analysis can demonstrate blood flow in both smal1 and large vessels to help identify tes- ticular torsion. Radionuclide imaging is not helpful in evaluating torsion in these cases be- cause when the testis is in the inguinal region, the background activity from the underlying pelvic vessels obscures the characteristic “cold” spot seen in intrascrotal testicular torsion. Al- though CT scanning may not be the primary imaging study, it often is obtained to evaluate the associated injuries, an examination of the area of the dislocated testis can help identify a rupture.

Radiographic imaging can also be used to de- termine the etiology of a new onset of pain in the dislocated testis after the initial injury. When our first patient had recurrent episodes of testicular pain beginning thirteen days after the injury, duplex ultrasonography and pulsed Doppler analysis revealed epididymitis in the dislocated testis and radionuclide imaging later revealed recurrent epididymitis three weeks af- ter orchiopexy. It is imperative to consider a full differential diagnosis when pain occurs in the dislocated testis.

A patient may be predisposed to traumatic dislocation of the testes. Several authors3,5J0 maintain that with an existing anomaly such as a widely open external inguinal ring, an in- direct inguinal hernia, or an atrophic testis, a properly directed trauma might force the gonad into the inguinal canal or the abdominal cavity. Also, although this view has been questioned by Edson and Meek,’ Herbst and Polkey5 felt that spasm of the cremaster was a predisposing fac- tor. Our first patient, who had a history of testi-

cles retractile to the external inguinal ring, would support the latter authors. Our second patient had traumatic dislocation of his right testis on two different occasions, which likewise suggests a predisposing factor for traumatic dis- locations, although we have not identified any definite factors.

During the past fifteen years traumatic dislo- cation of the testes has been the result of motor vehicle accidents, almost always involving mo- torcycles. Although associated injuries may pre- clude early reduction of dislocated testes in the multiply injured patient, repair should be un- dertaken at the earliest opportunity in view of the possible deleterious effects of the ectopic po- sition. Radiographic imaging, particularly ul- trasonography, is a valuable adjunct in assessing the dislocated testis. These patients may wel1 have some predisposing factor for traumatic dislocation of the testes.

Division of Urology Department of Surgery

Hennepin County Medical Center 701 Park Avenue South

Minneapolis, Minnesota 55415 (DR. ~23~)

References

1. Claubry EG: Observations sur une retrocession subite des deux testicules dans l’abdomen, a la suite d’une violente compres- sion de la partie inferieure de la paroi abdominale par une roue de charrette, J Gen Med Chir Pharm 64: 325 (1818).

2. Pollen JJ, and Funckes D: l+aumatic dislocation of the testes, J Trauma 22: 247 (1982).

3. Nagarajan VP, Praninkoff K, Imahori SC, and Rabinowitz R: ‘Baumatic dislocation of testis, Urology 22: 521 (1983).

4. Goulding FJ: Traumatic dislocation of the testis, J Trauma 16: 100 (1976).

5. Herbst RH, and Polkey HJ: Laxatio testes traumatica and experimental study of the mechanisms, Am J Surg 34: 18 (1936).

6. Singer AJ, Das S, and Gavrell GJ: ‘Baumatic dislocation of testes, Urology 35: 310 (1990).

7. Edson J, and Meek J: Bilateral testicular dislocation unllat- era1 rupture, J Urol 122: 419 (1979).

8. Morgan A: Traumatic luxation of the testis, Br J Surg 52: 102 (1965).

9. Sadi A, Hayashi H, and Cedenho AP: Histology of artificial cryptorchid testis followed by orchiopexy in pubertal rats, Arch Androl 7: 75 (1981).

10. Alyea EP: Dislocation of the testis, Surg Gynecol Obstet 49: 600 (1929).

508 UROLOGY / DECEMBER 1992 / VOLUME 40, NUMBER 6