AVULSION, EDEMA, HEMATOMA
Traumatic avulsion of the scrotum and penis is seen with animal attacks, motor vehicle accidents, assaults with sharp or high-velocity missiles, self-mutilation, and machinery-related (i.e., industrial, agricultural) accidents. It is most commonly observed in men aged 10 to 30 years. The entire scrotal tissue may be lost and complete sloughing of remaining skin may occur due to infection. Partial loss of the scrotum is managed by debridement, excision of islands of remnant full- thickness scrotal wall, and primary closure with absorb- able sutures. If the complete scrotal skin has been avulsed, it may be necessary to transplant the uninjured testes into the subcutaneous tissues of the upper thigh or within the inguinal region. The ability of small fragments of remaining skin to regenerate a full-sized scrotum is remarkable, and transplantation of the testes can be avoided if some skin remains. The vascularity, compliance, and elasticity of the dartos layer allow scrotal ﬂaps to cover substantial areas of loss. Clean granulation tissue usually coats the surface of the exposed testicles, followed by regeneration of the scrotum.
Complete scrotal loss requires skin grafting to expedite healing. Split-thickness grafting (0.008 to 0.014 in) that is meshed to allow ﬂuid to drain is ideal for scrotal coverage because it does not result in hair growth. With the penis, split-thickness skin grafts are needed for the denuded area, as the penile skin must be pliable to allow for erections. Healing by regeneration of skin from a nearby avulsed margin would result in a relatively inelastic covering. Testicles should be ﬁxed together in a dependent position to minimize motion and maximize graft “take.” The use of “thigh pouches” for the testes may be necessary with infected wounds until they are clean enough for grafting. Long-term success with skin grafting for scrotal injury is excellent. Only 20% of patients require signiﬁcant revisions and most of these can be managed in the ofﬁce. Acute trauma without infection can be managed simply with wet-to-dry dressings until deﬁnitive graft placement.
Edema of the scrotum results from either localized or generalized pathology. The loose and elastic structure of the scrotum facilitates edema from even the slightest inﬂammatory reaction or vascular or lymphatic disturbance. Epididymo-orchitis is frequently accompanied by scrotal edema, as are allergic states or obstruction of the lymphatic or vascular system. Marked edema or anasarca that involves the scrotum can result from chronic cardiac insufﬁciency, liver cirrhosis, ascites, and renal failure. Malignancy affecting retroperitoneal and inguinal lymph nodes may, by obstructing the lymphatics, result in a nonpitting edema of the scrotum. Simple edema may also be the ﬁrst sign of elephantiasis (lymphatic ﬁlariasis) and other tropical diseases. Trauma or surgery to the scrotum is usually followed by a considerable amount of edema. Notable edema may also result from spider bites or allergies (angioneurotic edema). When the edema is massive, the dependent portion of the scrotal skin may become moist, denude, and form ulcers. Patients with scrotal edema should elevate the scrotum to accelerate venous and lymphatic drainage.
Scrotal hematoma or diffusion of blood through the subcutaneous scrotal tissue is most commonly observed after scrotal surgery or blunt trauma. The scrotum is an uncommon location for idiopathic bleeding, as its contracting smooth muscle layers efﬁciently compress blood vessels. With an acute bleed, the scrotum becomes dark and assumes a purple color. Over time, the coloration changes to yellow and then to normal color. However, it may take several weeks for blood pigments to be resorbed and for normal skin color to be completely restored. Hematoma is usually accompanied by variable degrees of edema and should be treated with moderate compression, suspension, and the application of ice or cold packs as early as possible. If bleeding is brisk, it may extend upward into the inguinal area and frequently over the penis under the continuity of the dartos and Scarpa and Colles fasciae (see Plate 2-20).