A rare and potentially overlooked case of bilateral testicular dislocation

Sangavi MC¹, Ashok Nandagopal²

¹Emergency Medicine Resident, Department of Emergency Medicine, Kauvery Hospital Alwarpet

²Clinical Lead and Consultant, Department of Emergency Medicine, Kauvery Hospital Alwarpet

Abstract

Patient presented to Emergency department following an RTA with injury to Perineum. On evaluation he had bilateral groin tenderness and empty scrotum. He ascertained a previous normal scrotal position of both testes. The doppler ultrasound confirmed the diagnosis of B/L dislocated testes in inguinal canal. There were no associated injuries and all layers were intact. Manual closed reduction was done and testes relocated in normal scrotal position. Patient was admitted for further observation

Case Presentation

A 18yrs aged gentleman presented to ER with a history of RTA (2 wheeler vs 4 wheeler). The patient was the bike rider. He had trauma to genitals (petrol tank hit against genitals) and patient hit the 4 wheeler’s windshield. On arrival to ER patient had complained of pain over B/L groin region above scrotum. Not voided urine since injury.

Past medical history: No significant medical history. No H/o undescended testes.

On Examination

Airway: Patent

Breathing: B/L air entry, NVBS,

Circulation: S1S2+, no murmur

P/A- Soft, BS+ Non tender, no external injuries seen

B/L Groin: Tenderness+, firm tender ovoid structures palpable in region of superficial ring.

Penis: No blood at meatus

Scrotum: Empty

As the testicles got dislocated within the cremasteric fascia and into the inguinal canal via the superficial ring, manual closed reduction was done.

Procedure

After obtaining consent, and making the patient lie flat and fixing the upper skin of the scrotum with one hand, the testicles were grabbed in the inguinal canal, and closed reduction was done by gently pulling down the testes to the scrotum via superficial ring. Patient was catheterized and post reduction USG doppler showed mild inflammatory changes, catheter removed and voided without difficulty. Patient discharged in stable condition.

Discussion

Testicles are well protected due to: fixation by the gubernaculum to a strong capsule; the low friction sliding ability given by the lubrication that occurs between the two layers of the tunica vaginalis; the cremasteric reflex and the fibrous and tensile resistant tunica albuginea.

During a motor vehicle collision, the sudden deceleration causes the scrotum to collide with the fuel tank, generating blunt impact that displaces the testes, while the simultaneous contraction of cremasteric muscles amplifies the applied force. Pressure exerted on the scrotum during trauma can push the testes back in the inguinal canal. Bilateral dislocation accounts for approximately one third of all cases.

Diagnostic tools include ultrasound and abdominal CT. Ultrasound can be used to perform the preliminary diagnosis of ectopic testes and confirm the testes integrity and current blood flow.

Abdominal CT is the most precise modality, it can provide details of the location of the testes, associated injuries and relationship with adjacent anatomy.

The treatment of choice for testicular dislocation is manual reduction, but it has been successful in only 15% of cases followed by surgical reduction

Conclusion

A scrotal physical examination is strongly recommended for pelvic trauma patients in order to exclude testicular injury. It is essential to keep this diagnosis in mind when faced with such presentation. A delay in diagnosis can lead to infertility, testicular atrophy and testicular neoplasia.

Reference

Goulding FJ. Traumatic dislocation of testis: addition of two cases with a changing etiology. J Trauma. 1976; 16:1000–2.
Carvalho, N.M.N.D.; Marques, A.C.X.; Souza, I.T.D.; Soares, V.G.; Nascimento, F.G.D.; Pinto, L.M.; Dias, L.V.R.; Teixeira, G.C. Bilateral traumatic testicular dislocation. Case Rep. Urol.2018, 7162351.
Ko, S.F.; Ng, S.H.; Wan, Y.L.; Huang, C.C.; Lee, T.Y.; Kung, C.T.; Liu, P.P. Testicular dislocation: An uncommon and easily overlooked complication of blunt abdominal trauma. Emerg. Med.2004, 43, 371–375.
Zavras, N.; Siatelis, A.; Misiakos, E.; Bagias, G.; Papachristos, V.; Machairas, A. Testicular Dislocation After Scrotal Trauma: A Case Report and Brief Literature Review. Urol. Case Rep. 2014, 2, 101–104.

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A rare and potentially overlooked case of bilateral testicular dislocation