Genital & Scrotal Trauma
Male genital injuries encompass trauma to the penis, anterior urethra, scrotum, and testicles. Blunt mechanisms account for up to 75% of testicular injuries, while penetrating injuries — especially gunshot wounds — constitute the most common etiology of severe penile trauma.[1] Female genital trauma ranges from superficial labial contusions to complex vaginal lacerations and internal pelvic organ injuries, with straddle injury from bicycle-related trauma being the most common unintentional mechanism.[2] Prompt evaluation, appropriate imaging, and early surgical intervention when indicated are critical to preserving function and preventing long-term complications. This page is based on the ACS Best Practices Guidelines for Management of Genitourinary Injuries (August 2025).[3]
Testicular Trauma
Mechanism and Classification
Blunt testicular trauma is the predominant mechanism; typically only one testis is involved. Blunt force may cause testicular rupture (parenchymal laceration with tunica albuginea disruption), testicular torsion, hematocele, dislocation, or intratesticular hematoma.[3] Penetrating scrotal trauma is associated with unilateral testicular injury in ~50% of cases and bilateral injury in ~30%, with spermatic cord vascular or vas deferens injury in up to 9%.[3]
AAST Testicular Injury Scale
| Grade | Description |
|---|---|
| I | Contusion or hematoma |
| II | Subclinical laceration of tunica albuginea |
| III | Laceration of tunica albuginea with <50% parenchymal loss |
| IV | Major laceration of tunica albuginea with ≥50% parenchymal loss |
| V | Total testicular destruction or avulsion |
Evaluation and Imaging
The degree of scrotal pain and swelling does not reliably correlate with the severity of testicular injury.[3]
Scrotal ultrasound with duplex Doppler is the primary imaging modality for blunt scrotal trauma and should be obtained in all patients presenting with a history of blunt scrotal trauma, pain, ecchymosis, and significant swelling.[3]
Ultrasound findings suggestive of testicular rupture:
- Parenchymal heterogeneity
- Loss of normal testicular contour
- Disruption or defect in the tunica albuginea
:::note Ultrasound Limitation Interruption of the tunica albuginea is the most specific sign of testicular rupture but is not always visualized on ultrasound. If ultrasound is inconclusive and rupture is strongly suspected clinically, do not delay surgical exploration for additional imaging. MRI can be used as a second-line modality for inconclusive cases when exploration is not immediately planned.[3] :::
Up to 10% of testicular tumors are discovered incidentally at the time of scrotal trauma evaluation — all scrotal ultrasounds should be reviewed for incidental lesions.[3]
Penetrating scrotal trauma does not require imaging before surgical exploration when a high clinical suspicion of injury exists.
Management: Blunt Testicular Trauma
| Injury | Management |
|---|---|
| Minor blunt trauma, contained hematoma or hematocele without rupture | Conservative: scrotal ice, elevation, analgesics |
| Isolated expanding scrotal hematoma without rupture | Surgical exploration and drainage to prevent pressure necrosis and impaired testicular perfusion |
| Testicular rupture | Urgent surgical exploration, debridement, and repair (see below) |
Testicular repair technique:[3]
- Inguinal or scrotal approach (scrotal approach commonly used for acute trauma)
- Debridement of nonviable, extruded seminiferous tubules
- Closure of tunica albuginea with absorbable sutures
- For a solitary testicle with complex injury: tunica vaginalis flap harvested from the ipsilateral scrotum can close larger tunica albuginea defects and avoid excessive debridement
- Orchiectomy for completely nonviable or destroyed testicles
:::note Timing of Repair Early testicular repair within 3 days of injury is associated with increased testicular salvage rates, faster recovery, and improved preservation of reproductive capability. Every effort should be made to achieve testicular salvage.[3] :::
Intratesticular hematoma contained within an intact capsule: follow with serial scrotal ultrasound with Doppler until resolution to evaluate for testicular ischemia or an underlying testicular tumor necessitating surgical intervention.[3]
Management: Penetrating Scrotal Trauma
All penetrating scrotal trauma requires urgent surgical exploration, debridement, and repair due to the high rate of testicular, spermatic cord, and vascular involvement.[3]
- Bilateral testicular exploration is warranted based on injury trajectory and symptoms
- When a testicle is injured: attempt repair and salvage to the maximum extent possible; technique mirrors blunt injury repair
- Augmented repair with tunica vaginalis flap when insufficient viable tunica albuginea remains for primary closure
- Injured vas deferens: ligate and debride acutely; delayed repair may be considered
- Orchiectomy for nonviable or destroyed testicles
Scrotal Degloving and Soft Tissue Injuries
Degloving injuries of the scrotum may result from industrial machinery, motor vehicle trauma, or assault. The dartos fascia and scrotal skin have significant mobility and regenerative capacity. Key management principles:
- Irrigate and debride devitalized tissue
- Testicles can be temporarily placed in thigh pouches if complete scrotal skin loss prevents primary closure
- Delayed scrotal reconstruction with split-thickness skin grafting or local flaps once wound is clean
- Avoid tension on testicular blood supply when using temporary thigh pouches
Female Genital Trauma
Epidemiology and Mechanism
Female genital trauma involves the vulva, labia majora and minora, clitoris, perineum, vagina, and potentially internal pelvic organs. The most common unintentional mechanism is straddle injury from bicycle-related trauma. Penetrating injuries occur from falls onto sharp objects, pelvic fracture bone fragments, or assault. Sexual assault is an important etiology requiring forensic evaluation and multidisciplinary response.[3]
Evaluation
- Ensure a chaperone is present for all female genital examinations
- Use a vaginal speculum for thorough examination
- When abuse or sexual assault is suspected: involve a Sexual Assault Nurse Examiner (SANE) or Sexual Assault Response Team (SART) early; strongly consider examination under anesthesia
- Consider cross-sectional CT imaging with pelvic injury, hemodynamic instability, or suspected internal organ injury
- Perform urethral and bladder evaluation (cystography or cystourethroscopy) when gross hematuria or lower urinary tract injury is suspected
Management by Injury Type
Labial and vaginal lacerations:
- Superficial without significant bleeding: local wound care
- Deep or actively bleeding lacerations: surgical debridement and repair with absorbable sutures under local or general anesthesia; thorough irrigation; multi-layer closure when contamination is absent; ligate active bleeding sources
Large labial or perineal hematomas (>5 cm): Require incision and drainage to prevent expansion, pressure necrosis, and infection.
Proximal vaginal canal and cervical injuries:
- Obtain subspecialty gynecologic care following resuscitation and vaginal packing for hemorrhage control
- Injuries extending beyond vagina and cervix: exploratory laparoscopy or laparotomy to exclude intraperitoneal organ or anorectal involvement
- Perform urologic evaluation when vaginal trauma is associated with gross hematuria or concern for urethral or bladder involvement
Sexual assault workup (when applicable):[3]
- Forensic specimen collection
- Testing for sexually transmitted infections
- Emergency contraception consideration
- HIV post-exposure prophylaxis consideration
Transfer Criteria
Patients with complex vaginal or cervical injuries presenting to lower-level trauma centers should be transferred to a facility with gynecologic and urologic expertise once hemodynamically stabilized.
Pediatric Genital Trauma
General Considerations
The most common cause of pediatric genital injury is unintentional trauma (straddle injury, zipper entrapment, toilet seat crush injuries). All pediatric genital trauma evaluations must include an assessment for child abuse.[3]
Examination under anesthesia is strongly recommended when abuse or intentional injury is suspected.
Specific Pediatric Injuries
Penile tourniquet/strangulation: Penile swelling and erythema with or without urinary complaints in a child requires evaluation for hair, thread, or rubber band tourniquet injuries. Expedited removal prevents ischemia and necrosis.
Penile zipper injuries:
- Administer local or general anesthesia based on severity and patient tolerance
- Options: mineral oil lubrication, incising cloth between zipper teeth, metal cutting tool to release the median bar, screwdriver to release the zipper shield
Penile toilet seat crush injuries: Usually minor; manage with supportive care. More severe injuries with testicular rupture or urethral injury concerns require standard adult evaluation and management principles.
Genital Bite Injuries
| Type | Management |
|---|---|
| Animal bite | Copious irrigation; tissue debridement; absorbable suture closure; prophylactic antibiotics (amoxicillin–clavulanic acid); tetanus and rabies prophylaxis; notify local health department as indicated |
| Human bite | Copious irrigation; tissue debridement; prophylactic antibiotics (amoxicillin–clavulanic acid or moxifloxacin); do not perform primary skin closure due to high contamination and infection risk |
Human bite wounds carry a high polymicrobial infection risk and must not be closed primarily. Animal bites, conversely, can be closed with absorbable suture after thorough irrigation and debridement.[3]
References
1. Partin AW, Dmochowski RR, Kavoussi LR, Peters CA, Wein AJ, eds. Campbell Walsh Wein Urology. 12th ed. Philadelphia, PA: Elsevier; 2020.
2. Lopez HN, Focseneanu MA, Merritt DF. Genital injuries acute evaluation and management. Best Pract Res Clin Obstet Gynaecol. 2018;48:28–39. doi:10.1016/j.bpobgyn.2017.09.009.
3. American College of Surgeons Trauma Quality Programs. ACS TQP Best Practices Guidelines: Management of Genitourinary Injuries. Chicago, IL; August 2025. facs.org/cot.