Traumatic testicular dislocation: a case report and literature review


CN Parnaby1, P Hendry2, RP Coggins1
1Department of Surgery, Raigmore Hospital, Inverness
2Department of Radiology, Raigmore Hospital, Inverness

Corresponding Author: Craig Parnaby
Raigmore Hospital, Inverness

Email: craigparnaby@aol.com

Background
Traumatic testicular dislocation is rare1. Therefore, initial diagnosis can easily be missed. This can result in testicular ischaemia, persistent patient discomfort, reduced fertility or increased risk of future malignancy2.
We report a recent case of traumatic testicular dislocation. The mechanism of injury, assessment and subsequent management are discussed.

Case Report
A 38 year old male motorcyclist was admitted to the emergency department following a 50mph head-on collision with a car. Primary survey revealed no respiratory, haemodynamic or neurological compromise. The patient complained of left inguinal discomfort. Abdominal examination revealed bruising and tenderness over the left inguinal region and left iliac fossa. There was a palpable lump in the left inguinal region which was not pulsatile. Scrotal examination revealed generalised tenderness. The right testis was palpable but it was not possible to palpate the left testis. Further questioning did not reveal previous history of ectopic, retractile or undescended testes. A diagnosis of possible traumatic testicular dislocation was made.


An abdominal and pelvic CT scan was performed. This did not reveal any intraabdominal or retroperitoneal pathology. A dislocated testis was identified in the left inguinal area (Figure 1).

Figure 1: CT image of left dislocated testis (arrow) in the superficial inguinal region

A scrotal and inguinal ultrasound was performed. This confirmed the presence of an intact testis with adequate blood flow, in the left superficial inguinal region. No left testis was identified in the scrotum.
He was observed overnight and remained haemodynamically stable. An attempt at reduction on the ward was not successful. He was taken to theatre. The viable, intact testis was identified in the superficial inguinal region. This was mobilised and an orchidopexy was performed. The patient was discharged after 48 hours.


Discussion
Traumatic testicular dislocation is rare with only approximately 100 cases reported in the literature. Due to the rarity of this condition, initial diagnosis can easily be overlooked or not suspected.
The diagnosis can be suspected from the mechanism of injury. Motorcycle straddle injuries provide the most common cause of testicular dislocation3. The mechanism appears to be a crushing injury to the scrotum due to the fuel tank of the motorcycle. The testis is then displaced superiorly and laterally travelling through the spermatic cord layers. The testis then bursts through these layers usually at the level of the external ring. The dislocated testis can then be found anywhere along a circle (radius being the spermatic cord and its centre the external ring)4. The most common site reported is the superficial inguinal region. In the majority of cases the testis remains intact5. Bilateral testicular dislocation has been reported but its incidence is extremely rare2.


After the primary survey, testicular dislocation should be suspected when an empty scrotum/hemiscrotum is found with or without an abnormally palpated testis. However, severe patient discomfort, scrotal swelling or distracting injuries can make the diagnosis difficult.


CT has become the imaging modality of choice for evaluating haemodynamically stable patients with blunt abdominal trauma6,7. The present case illustrates its use in the diagnosis of testicular dislocation. This is in agreement with Ko and colleagues1. In the present case, after confirming no intraabdominal, retroperitoneal pathology, the testis was identified in the superficial inguinal region with an empty left hemiscrotum. Doppler ultrasound can then be performed to confirm an intact, viable testis8. We acknowledge that testicular dislocation can also be caused by low velocity injuries such as a direct blow to the scrotum. In these cases, doppler ultrasound alone provides adequate images of the scrotum and dislocated testis.


Unless associated testicular injury has occurred, a trial of manual closed reduction can be attempted. This technique is only successful in 15% of cases due to the small defect in the spermatic cord layers and oedema after trauma9. For this reason, many authors advocate groin exploration, open reduction and orchidopexy as the preferred initial treatment10. This procedure is simple, successful and associated with low morbidity.
In summary, if suspected from the mechanism of injury, the diagnosis of testicular dislocation will rarely be missed. This will avoid the comorbidity associated with a missed diagnosis. Testicular dislocation is easily treated with surgical exploration and relocation.

References

  1. Ko SF, Ng SH, Wan YL et al. Testicular dislocation: an uncommon and easily overlooked complication of blunt abdominal trauma. Annals of Emergency Medicine 2004;43:371-5.
  2. Bromberg W, Wong C, Kurek S, Salim A. Traumatic bilateral testicular dislocation. J Trauma 2003;54:1009-1011.
  3. Nagarajan VP, Pranikoff K, Imahori SC et al. Traumatic dislocation of testis. Urology 1983;22:521-524.
  4. Alyea EP. Dislocation of testis. Surg Gynecol Obstet 1929;49:600-616.
  5. Schwartz SL, Faerber GJ. Dislocation of the testis as a delayed presentation of scrotal trauma. Urology 1994;43:743-745.
  6. Royal College of Radiologists. Making the best use of clinical radiology services: referral guidelines. London: RCR, 2007.
  7. Jansen JO, Yule SR, Loudon MA. Investigation of blunt abdominal trauma. BMJ 2008;336:938-942.
  8. Toranji S, Barbaric Z. Testicular dislocation. Abdom Imaging 1994;19:379-380.
  9. Singer AJ, Das S, Gavrell GJ. Traumatic dislocation of testes. Urology 1990;35:310-312.
  10. Shefi S, Mor Y, Dotan ZA, Romon J. Traumatic testicular dislocation: a case report and review of published reports. Urology 1999;54:744-745.