Penile traumatic testicular dislocation: a case report

Abstract

Traumatic testicular dislocation is rare and usually occurs in patients after a traumatic motor accident. Manual reduction or surgical exploration is the main treatment for this condition. We report a rare case of unilateral traumatic testicular dislocation in a man with an ectopic testis in the middle of the penis after a motorcycle crash injury. On the sixth day of hospitalization, the patient found a lump in the middle of his penis. Doppler ultrasound showed an ectopic testicle in the middle of the penis with good blood flow. After consultation, a manual reduction was successfully performed. A careful physical examination should be performed in patients with multiple injuries from the first medical exam. Early detection and timely reduction are critical to protect testicular function.

Introduction

Traumatic testicular dislocation (TTD) is an unusual condition, and often occurs after direct pressure on the scrotum and causes the testis to be outside of its normal position to the surrounding regions, mostly in the groin area. TTD is mainly caused by impact accidents and straddle injuries, and motorcycle accidents are the leading cause for this condition. ¹ A delayed or missed diagnosis of TTD may be due to associated injuries or a lack of awareness of its possible occurrence. TTD should be suspected in all high impact injuries, including gunshot injury involving the groin and perineum, after excluding a history of cryptorchidism and retractile testis. Delayed correction of TTD may result in infertility. There have been few reports on TTD.^1,2 Recent reports have found that traumatic dislocation of the testis in the penile shaft is treated using surgical reduction and testicular fixation. ² Early detection and timely reduction, including manual reduction and surgical reduction, are crucial to protect function of the testis. We report a case of TTD in a patient who was admitted to our hospital in April 2018. The reporting of this study conforms to the CARE guidelines. ³

Case presentation

A 20-year-old man was hospitalized 2 days after being injured in a motorcycle crash. He had multiple aches and pains throughout his body and limited mobility. He had no previous history of cryptorchidism or a penile mass. A physical examination showed the following: stable vital signs, swelling of the left lower limb, skin and soft tissue contusion in the middle of the left thigh, limited movement, swelling of the right foot, swelling of the left ring finger, and good blood flow of the extremities. On the sixth day of the hospitalization, the patient found a lump in the middle of his penis, without any pain or other discomfort. A physical examination showed a lump of 2.5 × 3 × 4 cm on the right side of the middle of the penis. There was no redness or swelling on the surface of the skin, and the lump was movable and had no tenderness. Palpation of the left testis showed no obvious abnormality (Figure 1).

Figure 1.

Photograph showing that the right testis is located in the penis and the right scrotum is empty.

A color Doppler ultrasound was performed, which showed the absence of the testicle in the right scrotum. The testicle on the right side was found in the middle of the penis, and a blood flow signal was visible. No abnormalities were observed in the left testicle. After consultation, the patient was diagnosed with TTD. Manual reduction was performed after consultation with the patient and his family because the patient had no local pain or discomfort, and color ultrasound indicated good blood flow in the right testicle. This procedure was successfully performed. The right testicle was returned into the right scrotum, and the patient had minimal discomfort (Figure 2). After the manual reduction, Doppler ultrasound showed that the testicles were present in the scrotum and the blood flow signal was good (Figure 3). After discharge, the patient was followed up by telephone for 6 months, and bilateral testicles and sexual function were normal.

Figure 2.

Photograph showing that the right testis is located in the right scrotum after manual reduction.

Figure 3.

Color Doppler ultrasound shows normal blood flow of the right testis after manual reduction.

Discussion and conclusions

TTD is a rare traumatic disease of the genitourinary system in which the testicles are pushed out of the scrotum by external force. TTD usually appears immediately after trauma, or appears several days later or even a few weeks later. TTD usually occurs in patients with trauma of a car or motorcycle accident. Sudden collision in a motorcycle accident causes the scrotum to strike against the fuel tank exerting a blunt force, which dislocates the testis. Contraction of cremasteric muscles may further increase the exerted force. Other influencing factors of TTD are a wide external ring, an indirect inguinal hernia, and atrophic testes. Individuals with retractile testes are also at a higher risk of developing TTD owing to the absence of gubernacular attachment, thus requiring a considerably lower magnitude of force to dislocate the testes.^4,5

Unilateral testicular ectopia is usually the most common dislocation in TTD, while bilateral testicular dislocation is relatively rare, accounting for approximately 30% of cases.^6,7 The sites occupied by the displaced testis under superficial dislocations are superficial inguinal, penile, pubic, perineal, and crural locations. In the rarer internal dislocations, the testis reverses its anatomical path of embryological descent into the inguinal canal, and even into the abdominal cavity. The locations of displaced testes in approximate order of frequency are the superficial inguinal pouch (40%–50%), pubis (18%), penis (8%), canalicular area (8%), intra-abdominal area (6%), perineum (4%), and crural region (2%). ⁶ Our patient’s right testicle was found in the middle of the penis. Although no acute fatal injury occurred, a delay in the diagnosis and treatment may have resulted in irreversible damage to the testicle, leading to infertility, testicular torsion, and malignant transformation.

The clinical history and a physical examination are critical for the assessment of TTD. Emptiness of the scrotum or even a palpable lump can be detected by a careful physical examination. Therefore, a careful physical examination plays a vital role in the diagnosis of TTD. An ectopic testis is easily overlooked if there are multiple severe injuries. Physicians should pay attention to whether the patient has previously had cryptorchidism. Therefore, in cases of multiple trauma, especially in the pelvis, groin, perineal area, and scrotal trauma, patients should be alert to the possibility of TTD. Conducting a physical examination of the scrotum and adjacent areas in a timely manner and performing a color Doppler ultrasound examination when necessary are required for the diagnosis and treatment of TTD. Color Doppler ultrasound can be helpful for making a clear diagnosis, and it can also be used to observe testicular blood flow. A computed tomography scan can be used to identify the location of ectopic testis, especially in patients with ectopic testis in the abdominal cavity, and can also be used to diagnose related pelvic and scrotal injuries. ⁸

The reduction methods of TTD are divided into manual reduction and surgical exploration. A manual reduction can be carried out first when an ectopic testicle is found in the early stage without other injuries. However, the direction and degree of testicular torsion should be accurately determined during the manual reduction. Manual reduction may increase the risk of testicular torsion because of possible local edema of the scrotum after ectopic testis, with a low success rate of approximately 15%. ⁸ In case of unsuccessful manual reduction and other testicular injuries, surgical exploration must be carried out in a timely manner. During the operation, blood circulation and spermatic cord position of the testis can be observed. If the patient has testicular torsion and testicular blood flow is good after the reduction, testicular fixation should be performed. If the testicle is ischemic and necrotic, an orchiectomy should be performed if necessary. Surgical relocation is required in the majority of cases because manual reduction has a low success rate owing to the fact that the path traversed is difficult to retrace owing to edema or hematoma. Many physicians advocate early surgical relocation owing to various reasons, including early pain relief, detection and relief of complications such as torsion and rupture, a poor success rate of manual reduction, and minimal morbidity.^9,10 Regardless of the reduction method used, early detection and timely reduction are critical to relieve pain and avoid further testicular damage. In this case, manual reduction was performed after consultation with the patient and his family, although the patient did not have local pain or discomfort. A color ultrasound examination showed good blood flow in the right testicle. The procedure was successfully performed. After successful reduction, color Doppler ultrasound showed good blood flow in the right testicle.

TTD is rare and usually occurs in patients with car or motorcycle accidents. Physicians should be aware of the possibility of testicular ectopia if the scrotum is found to be empty on a physical examination. Color Doppler ultrasound is recommended to investigate the position and blood flow of the ectopic testicle. The most common ectopic testicle is located in the groin area. Early detection and timely reduction play major roles in protecting testicular function.