| Abstract|| |
Traumatic dislocation of testis (TDT) is an uncommon event. During trauma, the cremasteric reflex can forcefully retract the testis out of the scrotal sac saving the testis from the injury. However, associated injuries in the form of skin degloving, penile avulsion, and amputation can be present. Early surgical intervention to locate and deposit the displaced testis to the scrotal sac is essential. We present a case of a 33-year-old man with bilateral congenital cryptorchidism who suffered blunt trauma to his genitalia following a road traffic injury. On presentation, based on a well-developed scrotum, it looked like a case of TDT. However, good history along with detailed physical and radiological evaluation helped us reach the correct diagnosis. TDT must be suspected in a case of blunt trauma to the genitalia when the scrotal sac (well-developed) is empty. This case report highlights the importance of detailed clinical and radiological evaluation in such cases.
Keywords: Blunt injuries, cryptorchidism, degloving injuries
|How to cite this article:|
Agrawal M, Gite VA, Sankapal P. Congenital cryptorchidism masquerading as traumatic dislocation of testis. J Emerg Trauma Shock 2021;14:243-5
| Introduction|| |
Traumatic dislocation of testis (TDT) is an uncommon event. It is defined as the displacement of one or both testes out of the scrotum. A cremaster muscle spasm is a major contributing factor., The associated soft tissue injuries can be skin degloving, penile avulsion, or amputation but are not life-threatening., We present a case of an adult male with bilateral congenital cryptorchidism who suffered blunt trauma to his genitalia following a road traffic injury. As the patient did not confirm the presence of prior cryptorchidism, absent bilateral testes in a well-developed scrotum made it looked like a case of TDT. However, detailed history by the mother (telephonically) revealed the history of bilateral congenital cryptorchidism. This study highlights the importance of proper history, examination, and evaluation in such cases to reach a correct diagnosis.
| Case Report|| |
A 33-year-old man presented to the emergency department with a history of a road traffic accident. He sustained injuries to his genitalia and left lower limb. At presentation, the patient was conscious, oriented, and hemodynamically stable. On examination, there was a degloving injury of the penis extending to the right hemiscrotum. The degloved penile skin was rolled up at the distal penile end [Figure 1]a and [Figure 1]b. There was no blood at the meatus. On palpation, the abdomen was soft with no tenderness. The bladder was not palpable. The pelvic compression test was negative. Digital rectal examination was not suggestive of any abnormality. Bilateral testes were not palpable on scrotal, inguinal, and abdominal examination. The scrotum was well formed with rugosities. Initially, the patient did not confirm bilateral congenital cryptorchidism and gave contradictory statements. Still, the patient's mother revealed (telephonically) that the patient had an absence of bilateral testes since birth. There was no history of any prior inguinal or scrotal surgery.
|Figure 1: (a) Degloved penile skin rolled up at the distal penile end with glans and external meatus buried in it. (b) Degloving injury extending to the right hemiscrotum. The scrotum is well developed. Degloved penile skin was attached ventrally to the base of the penile shaft by a small bridge of skin. (c and d) Axial cut of the arterial phase of contrast-enhanced computed tomography at the level of the pelvis with right and left intra-abdominal testes seen adjacent to external iliac arteries (white arrows)|
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The patient was resuscitated in the emergency department. After catheterization with 14 French Foley, 200 ml of clear urine was drained. Blood investigations were within normal limits. Focused assessment with sonography for trauma was negative. Considering the history of congenital cryptorchidism and well-developed scrotum on examination, he underwent contrast-enhanced computed tomography (CECT) of the abdomen and pelvic region. It revealed bilateral intra-abdominal testes anterior to the psoas muscle and adjacent to external iliac arteries [Figure 1]c and [Figure 1]d.
The patient underwent emergency primary repair under general anesthesia. On abdominal examination under anesthesia, testes were not palpable. The open wound was washed with povidone-iodine, hydrogen peroxide, and warm saline. There was no evidence of fracture of the corporeal bodies or any urethral injury. The degloved penile skin did not show any signs of devascularization. The penile and scrotal skin margins were freshened, and primary suturing was done with interrupted 3-0 polyglactin sutures in a tension-free manner [Figure 2]a and [Figure 2]b.
|Figure 2: (a) Primary repair of the penile skin and scrotal wall injuries was done using interrupted 3-0 polygalyctin sutures. Subcutaneous corrugated rubber drain was placed (white arrow). (b) There was no loss of skin and degloved penile skin was sufficient for the primary repair. (c and d) Image taken 1 month after the surgical repair showing well-healed penile and anterior scrotal wall wounds|
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On a postoperative day (POD) 2, there was edema of the penile and scrotal region with no blackish discoloration of overlying skin. It was managed with anti-inflammatory, antibiotics, and light compression dressing. A Foley catheter was left in place to prevent the occlusion of the external meatus. Edema and swelling gradually subsided. Foley catheter was removed on POD 7. There were no urinary symptoms at 1 month, and the surgical site had healed with acceptable cosmetic results [Figure 2]c and [Figure 2]d. The patient is awaiting definitive management for cryptorchidism.
| Discussion|| |
TDT was described for the first time in 1809 by Claubry and is an uncommon complication of blunt testicular trauma.,, A review concluded that less than 200 cases had been notified in indexed literature around the world. Testicular injury, however, is rare, presumably owing to the cremasteric reflex, which can forcefully retract the testis out of the scrotal sac, saving the testis., To differentiate between true TDT and undescended/retractile testes, one must rely on history, physical, and radiological examination.
In our case, despite a history of bilateral congenital cryptorchidism, the patient had well-developed scrotal sac on the examination, which is a contradictory finding. Testes were not palpable on the inguinal and abdominal examination. Given the history of genital trauma with an empty well-developed scrotal sac, TDT seemed likely. This diagnostic dilemma was resolved over the telephone after talking to the patient's mother.
Although testicular dislocation is more common unilaterally, it occurs bilaterally in one-third of the cases. The anatomic dislocation sites have been described and primarily classified as superficial (superficial inguinal, pubic, penile, crural, or perineal), internal (abdominal, canalicular, acetabular, or femoral), or complex (prolapse associated with scrotum laceration). In such scenarios, to locate the testis and confirm the diagnosis, radiological investigations in the form of color Doppler ultrasound or CECT abdomen and pelvis are useful., In our case, the CECT abdomen confirmed the intra-abdominal presence of bilateral testes, which correlated with the history of congenital cryptorchidism. Associated injuries in the form of skin degloving, penile avulsion, and amputation can be present.,
Early surgical intervention to locate and deposit the traumatically displaced testis to the scrotal sac is essential. It helps relieve the pain and avoid irreversible testicular injury., However, in our case, as testes were undescended since birth and not as a result of traumatic dislocation, we decided to manage cryptorchidism later on as an elective procedure. Further, the lacerated scrotal wall and risk of wound infection were the reasons not to perform orchidopexy concurrently. It highlights the importance of reaching a correct diagnosis in managing such cases.
In conclusion, diagnosing TDT in a case of blunt trauma to the genitalia when the scrotal sac (well-developed) is empty is likely. However, when a scrotal sac is empty in a patient of trauma, one must keep diagnosis of congenital cryptorchidism as a differential diagnosis (even if scrotum is well-developed). One must ask for detailed history to rule out this possibility. Otherwise, in rare scenarios, congenital cryptorchidism can masquerade as TDT. It emphasizes the role of good history, examination, and radiological evaluation to reach the correct diagnosis.
Research quality and ethics statement
The authors followed applicable EQUATOR Network (http:// www.equator-network.org/) guidelines, notably the CARE guideline, during the conduct of this report.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Dr. Venkat Arjun Gite
Swastik Building No 4, House No 6 . Ist Floor, Grant Medical College and Sir JJ Hospital, Mumbai - 400 008, Maharashtra
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2]