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Genital & Scrotal Trauma

Genital and scrotal trauma in men involves the penis, anterior urethra, scrotum and testicles. Blunt mechanisms cause up to 75% of testicular injuries,[1][3] and penetrating penile injuries are usually gunshot injuries.[3] 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] Management below follows 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, and rupture is found in about half of direct blunt scrotal injuries.[4] 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 approximately 50% of cases and bilateral injury in approximately 30%, with spermatic cord vascular or vas deferens injury in up to 9%.[3]

AAST Testicular Injury Scale​

GradeDescription
IContusion or hematoma
IISubclinical laceration of tunica albuginea
IIILaceration of tunica albuginea with <50% parenchymal loss
IVMajor laceration of tunica albuginea with >50% parenchymal loss[13]
VTotal testicular destruction or avulsion

For bilateral testicular injuries, advance one grade, up to grade V.[13]

Evaluation and Imaging​

The degree of scrotal pain and swelling does not reliably correlate with the severity of testicular injury.[3] Obtain urinalysis during genital-trauma evaluation; visible hematuria in a male patient warrants retrograde urethrography under the EAU 2026 guideline.[4]

ACS advises scrotal ultrasound for all patients presenting with blunt scrotal trauma.[3] Pain, ecchymosis and significant swelling can accompany testicular rupture.[3][4] AUA recommends ultrasound for most blunt injuries with findings suggestive of testicular rupture (Statement 30a; Recommendation, Grade C).[8] The EAU strongly recommends ultrasound for suspected testicular trauma; heterogeneous parenchyma with loss of contour is a highly sensitive and specific sign of rupture, but studies disagree on how much ultrasound adds to examination alone. CT and MRI have not been shown to detect rupture more often.[4]

Ultrasound findings suggestive of testicular rupture:

  • Parenchymal heterogeneity
  • Loss of normal testicular contour
  • Disruption or defect in the tunica albuginea

Ultrasound Limitation. ACS describes interruption of the tunica albuginea as the most specific sign of rupture, although it is not always visualized.[3] AUA identifies contour loss and heterogeneous parenchymal echotexture as the most specific findings; suspected rupture, equivocal imaging or a large hematoma warrants exploration.[8] 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 clinical suspicion of injury is high.

Management: Blunt Testicular Trauma​

InjuryManagement
Minor blunt scrotal trauma without rupture, including a contained, nonexpanding hematomaConservative: scrotal ice, elevation, analgesics[3]
Isolated expanding scrotal hematoma without ruptureSurgical exploration and drainage to prevent pressure necrosis and impaired testicular perfusion
Hematocele smaller than three times the size of the contralateral testisConservative management[4]
Hematocele larger than three times the contralateral testisEarly surgery, even without rupture; at minimum evacuate the clot from the tunica vaginalis sac[4]
Suspected traumatic testicular torsionObtain Doppler ultrasound if rapidly available; explore urgently when imaging is unavailable or equivocal.[4][15]
Testicular dislocationManual replacement with secondary orchidopexy; immediate orchidopexy if manual reduction fails[4]
Testicular rupture, or inconclusive ultrasoundUrgent surgical exploration, debridement, and repair (see below); the EAU gives a strong recommendation to explore the injured testis in every rupture and every inconclusive study[4]

AUA recommends exploration, debridement and tunical closure for suspected testicular rupture, with orchiectomy only when nonsalvageable (Statement 30c; Standard, Grade B).[8]

Testicular repair technique:[3]

  1. Inguinal or scrotal approach (scrotal approach commonly used for acute trauma)
  2. Debridement of nonviable, extruded seminiferous tubules
  3. Closure of tunica albuginea with absorbable sutures
  4. When the albuginea cannot close primarily, a tunica vaginalis flap or graft can cover the defect (AUA Statement 30c discussion).[8] This can preserve tissue, including in a solitary testicle with complex injury[3][8]
  5. Orchiectomy for completely nonviable or destroyed testicles

Timing of Repair. Explore suspected rupture urgently. Every effort should be made to achieve testicular salvage.[3] The EAU states that hematoceles larger than three times the contralateral testis should be treated surgically, even without rupture.[4] In Cass and Luxenberg’s retrospective series of 86 patients, 72 had blunt trauma; among those patients, complete testicular loss occurred in 21% after initial conservative management versus 6% after prompt exploration.[14]

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]

Bilateral testicular loss. Complete testicular loss from bilateral orchiectomy for nonviable or destroyed testes leaves the patient hypogonadal. Arrange endocrine follow-up with serum testosterone and counsel on testosterone replacement.

Management: Penetrating Scrotal Trauma​

ACS advises urgent exploration, debridement and repair for all penetrating scrotal trauma.[3] AUA recommends prompt exploration for most penetrating scrotal injuries, with repair or orchiectomy when nonsalvageable (Statement 30b; Recommendation, Grade C), citing frequent testicular injury and limited ultrasound sensitivity.[8]

  • 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
  • Complete spermatic cord disruption: the EAU notes that realignment without vasovasostomy may be considered when feasible, with staged microsurgical vasovasostomy later (few cases reported)[4]
  • Most scrotal skin defects close primarily because of scrotal elasticity, even when the skin is only minimally attached; extensive tissue loss (for example, blast injury) needs staged reconstruction[4]
  • Orchiectomy for nonviable or destroyed testicles

Venous Thromboembolism Prophylaxis. Neither the ACS nor the EAU guideline gives a recommendation specific to scrotal exploration; scrotal exploration for hematocele evacuation or testicular repair is a short operation without prolonged immobility in most patients. The EAU trauma guideline's general chapter notes trauma patients overall are at elevated DVT risk and favors compression stockings and LMWH where bleeding risk allows, with early mobilization once able.[4] Apply the individual risk-based approach on the VTE Prophylaxis hub.

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. Management principles:

  • Irrigate and debride nonviable tissue while preserving potentially viable genital skin . Repeated procedures may precede definitive reconstruction.[8] The EAU notes that scrotal elasticity allows primary closure of most defects, even when the skin is only minimally attached; extensive tissue loss (for example, blast injury) usually needs complex staged reconstruction.[4] As a practical estimate, up to approximately 50% scrotal skin loss can still be closed primarily.[7] Residual skin viability, perfusion, geometry and closure tension still govern the choice.[7]
  • Testes exposed by extensive scrotal skin loss can be placed temporarily in thigh pouches before staged reconstruction; a 12-patient retrospective series included nine traumatic avulsions.[16]
  • 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
  • Tailor examination to age, symptoms and suspected depth of injury; a speculum is not routine in prepubertal children
  • When abuse or sexual assault is suspected: involve a Sexual Assault Nurse Examiner (SANE) or Sexual Assault Response Team (SART) early. Obtain consent and minimize repeat examinations; use anesthesia when necessary to assess or repair suspected internal injury[5]
  • Consider cross-sectional CT imaging when stable enough for scanning and pelvic or internal-organ injury is suspected; do not delay hemorrhage control
  • After blunt vulvar or perineal trauma, assess voiding and usually place a bladder catheter; a vulvar hematoma also warrants evaluation for associated vaginal or pelvic injury.[4]
  • Perform urethral and bladder evaluation (cystography or cystourethroscopy) when gross hematuria or lower urinary tract injury is suspected; the EAU recommends flexible or rigid cystoscopy to exclude urethral and bladder injury, and gynecologic assessment when blood is present at the introitus[4]

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.[3] Evacuate clots to reduce pressure necrosis and infection risk.[17]

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.

Penetrating Penile Trauma​

Inspect the wound trajectory and assess for urethral injury when there is blood at the meatus, gross hematuria or inability to void; use retrograde urethrography or cystoscopy when indicated.[3] For small superficial penetrating wounds with intact Buck’s fascia, the EAU permits nonoperative management; ACS recommends exploration for penetrating penile wounds.[3][4] For significant penetrating injuries, the ICSM recommends exploration, conservative debridement of nonviable tissue, hemostasis, foreign-body removal and repair of injured corpora or urethra, with urinary diversion in selected cases (Strong; moderate-quality evidence).[12] See Penile Fracture for blunt tunical injury.

Penile Suspensory-Ligament Rupture​

Penile suspensory-ligament injury after intercourse may cause penile-base instability, altered erection angle or a palpable gap below the pubic symphysis. The ligament is also divided in some penile augmentation procedures.[6] A described repair uses a transverse infrapubic incision and nonabsorbable sutures between the tunica albuginea and pubic symphysis; protect the dorsal neurovascular bundle.[9][10][11] In a retrospective series of 118 repairs for mixed indications, 66 followed sexual trauma; 85% had a composite good result (stability, straightening and return to normal sexual function) at mean follow-up of 8 months, and four patients had long-term erectile dysfunction.[9]

Penile / Glans Amputation​

Traumatic penile or glans amputation is rare but represents a true surgical emergency. AUA advises prompt penile replantation , without a numerical ischemia cutoff.[8] The EAU advises considering replantation in every patient, within 24 hours of amputation, and prefers a microsurgical repair (dorsal arteries, dorsal vein and nerves, corpora and urethra; the cavernosal arteries are usually too small to repair) with both urethral and suprapubic catheters.[4] Tissue viability and functional recovery vary; skin necrosis, urethral complications and impaired sensation or erections remain possible.[4]

Field / transfer essentials:

  • Transport the amputated segment in a two-bag system: saline-soaked gauze in the inner bag, placed in a second bag on ice (AUA Statement 32 discussion)[3][8]
  • Minimize warm and cold ischemia; contact the replant team immediately. Treat the 24-hour window as a target rather than a reason to discard a potentially salvageable segment. The EAU describes washing the part with saline, wrapping it in saline-soaked gauze, placing it in a sterile bag and immersing that bag in iced water, without direct contact with ice[4]
  • Hemostasis of the stump with a pressure dressing (the EAU also allows a tourniquet around the stump); do not clamp[4]
  • Transfer urgently to a microsurgical-capable center if local expertise is unavailable (ACS 2025 Best Practices)[3]
  • AUA advises psychological, interpersonal or reproductive counseling when loss of sexual, urinary or reproductive function is anticipated .[8] Provide psychological support; obtain urgent psychiatric assessment and protection from further harm when injury was self-inflicted.[3][4]

For the complete operative protocol (preoperative preparation, dorsal-artery / dorsal-nerve / deep-dorsal-vein anastomosis steps, optional IEPA repair to prevent shaft-skin necrosis, glans-specific protocol, postoperative leech / HBO / antithrombotic adjuncts, allotransplantation alternative, and pediatric considerations), see the dedicated atlas page: Microsurgical Penile / Glans Replantation.

When the amputated segment is non-viable or lost, alternatives include the Total Anterior Scrotal Flap (Zhao) for partial-loss reconstruction with length deficit, or phalloplasty options under GAS Masculinizing Surgery / penile allotransplantation for total loss.

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]

The ACS 2025 best-practices document strongly encourages examination under anesthesia in children, particularly when abuse or intentional injury is suspected, and strongly considers it for female genital trauma when abuse is suspected.[3] The AAP report says most suspected-abuse examinations need no instruments; prepubertal office speculum examination is contraindicated, and suspected intravaginal trauma calls for vaginoscopy under anesthesia.[5] Involve pediatric forensic and multidisciplinary abuse-assessment expertise early to plan the examination.

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​

TypeManagement
Animal biteCopious irrigation; tissue debridement; absorbable suture closure; prophylactic antibiotics (amoxicillin–clavulanic acid); assess tetanus vaccination and exposure-specific rabies prophylaxis; notify local health department as indicated
Human biteCopious 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] The EAU adds that antibiotics follow local resistance patterns, rabies risk depends on region, animal and whether the attack was provoked, and human bites call for offering hepatitis B vaccine/immunoglobulin and/or HIV post-exposure prophylaxis.[4]

Follow-up​

Tailor follow-up to the structures injured: assess testicular atrophy, chronic pain, fertility, erectile function and urethral stricture symptoms; consider early psychological counseling.[4]

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. ACS guideline PDF.

4. European Association of Urology. EAU Guidelines on Urological Trauma, sections 3.3.5 (thromboprophylaxis and bed rest) and 4.5 (genital trauma; limited update March 2026). Guideline.

5. Jenny C, Crawford-Jakubiak JE; Committee on Child Abuse and Neglect. The evaluation of children in the primary care setting when sexual abuse is suspected. Pediatrics. 2013;132(2):e558–e567; reaffirmed 2018. doi:10.1542/peds.2013-1741.

6. Garaffa G, Sansalone S, Ralph DJ. Augmentation Procedures for the Penis. In: Muneer A, Arya M, Jordan GH, eds. Atlas of Male Genitourethral Surgery: The Illustrated Guide. Wiley-Blackwell; 2014:92–102. doi:10.1002/9781118651292.ch8

7. Broghammer JA, Wessells H. Repair of Genital Injuries. In: Smith JA Jr, Dmochowski RR, Thomas JC, Preminger GM, eds. Hinman's Atlas of Urologic Surgery. 5th ed. Elsevier; 2025:988–997.

8. Morey AF, Broghammer JA, Hollowell CMP, et al. Urotrauma Guideline 2020: AUA Guideline. J Urol. 2021;205(1):30–35. doi:10.1097/JU.0000000000001408. Full guideline, published 2014; amended April 2017 and August 2020.

9. Ralph O, Shroff N, Anfosso M, Blecher G, Ralph D. "Repair of the penile suspensory ligament for congenital and acquired pathology." BJU Int. 2019;124(4):687–692. doi:10.1111/bju.14750

10. Liu W, Calopedos R, Blecher G, Love C. "Penile suspensory ligament: anatomy, function, and clinical perspectives of its repair." J Sex Med. 2025;22(1):175–183. doi:10.1093/jsxmed/qdae166

11. Filipoiu FM, Ion RT, Filipoiu ZF, Tulin AD, Enciu O, Enyedi M. "Suspension of the penis – dissection, anatomical description and highlighting of anatomical risks in sectioning the suspensory ligaments." Basic Clin Androl. 2023;33:26. doi:10.1186/s12610-023-00202-1

12. Chung E, Morey A, Seyam R, et al. "Male genitalia trauma. Recommendations from 5th International Consultation on Sexual Medicine (ICSM 2024)." Sex Med Rev. 2026;14(1):qeaf058. doi:10.1093/sxmrev/qeaf058

13. Moore EE, Malangoni MA, Cogbill TH, et al. "Organ injury scaling VII: cervical vascular, peripheral vascular, adrenal, penis, testis, and scrotum." J Trauma. 1996;41(3):523–524. doi:10.1097/00005373-199609000-00023

14. Cass AS, Luxenberg M. "Testicular injuries." Urology. 1991;37(6):528–530. doi:10.1016/0090-4295(91)80317-z.

15. Munter DW, Faleski EJ. "Blunt scrotal trauma: emergency department evaluation and management." Am J Emerg Med. 1989;7(2):227–234. doi:10.1016/0735-6757(89)90143-5.

16. Kochakarn W, Hotrapawanond P. "Scrotal reconstruction using thigh pedicle flaps: long-term follow-up of 12 cases." J Med Assoc Thai. 2001;84(12):1738–1742. PMID: 11999821.

17. Lapresa Alcalde MV, Hernández Hernández E, Bustillo Alfonso S, Doyague Sánchez MJ. "Non-obstetric traumatic vulvar hematoma: Conservative or surgical approach? A case report." Case Rep Womens Health. 2019;22:e00109. doi:10.1016/j.crwh.2019.e00109.