Scrotal trauma in children and adolescents

INTRODUCTION — The evaluation and management of scrotal trauma in children will be discussed here.

Blunt genitourinary trauma, straddle injuries, and the medical causes of scrotal pain and its evaluation in children and adolescents are discussed separately.

●(See "Blunt genitourinary trauma: Initial evaluation and management".)

●(See "Straddle injuries in children: Evaluation and management".)

●(See "Causes of scrotal pain in children and adolescents" and "Evaluation of nontraumatic scrotal pain or swelling in children and adolescents".)

EPIDEMIOLOGY — Serious scrotal trauma is rare in children and adolescents. Blunt scrotal trauma occurs most commonly among 6 to 12 year old boys with typical mechanisms, including falls or kicks during sports and injuries from bicycle or motor vehicle collisions [1,2]. In toddlers and young children (less than six years of age), injuries from falls or toilet seats predominate. In adolescent males, injuries related to sports and falls also occur, but multiple trauma with associated scrotal injury from motor vehicle accidents and assaults is also an important etiology. Blunt scrotal trauma is typically unilateral and involves compression of the scrotal contents against the pubic bone [3].

Penetrating scrotal injuries are uncommon in children but can occur from bicycle handlebars, falls with impalement, and animal bites [4,5]. In adolescents and young adults, gunshot wounds account for most penetrating injuries [6]. Stab wounds, including self-emasculation injuries and human or animal bites, have also been described.

ANATOMY

Scrotal anatomy — The anatomy of the scrotum should be considered in a layered fashion. The scrotum is a sac that contains the testicles and portions of the spermatic cords. It provides two discrete cavities for the testicles. These cavities connect at the median raphe, a scrotal projection that extends from the dorsum of the penis to the anus. The layers of the scrotum include the skin and the dartos, a muscular layer that provides the septum for the two scrotal cavities and forms the outermost fascial layer of the scrotum (figure 1).

The testicle and its appendages, epididymis, spermatic cord and associated nerve, artery and venous vessels are contained within the tunica vaginalis (figure 2). The testicle itself has an additional covering called the tunica albuginea that maintains its oval contour. Additional testicular coverings include the infundibuliform fascia, cremaster muscle, and intercrural fascia.

Because the left spermatic cord is longer than the right, the left scrotum and testicle typically hang lower than the right. The higher relative position of the right testicle puts it at greater risk of blunt injury with compression against the pubic bone.

Injury patterns — Types of scrotal injury may include:

●Scrotal skin lacerations and contusions

●Scrotal hematomas external to the testicle, including lacerations of the tunica vaginalis

●Traumatic epididymitis

●Hematocele, ie, blood outside the tunica albuginea, but contained within the tunica vaginalis indicating disruption of the tunica albuginea and potential testicular rupture

●Testicular hematoma

●Testicular fracture

●Testicular avulsion

●Testicular dislocation into the inguinal canal or abdominal wall with unilateral or bilateral empty scrotum

●Traumatic testicular torsion

Adjacent structures — The proximity of the scrotum to the lower abdomen, pelvis, penis, rectum, and upper thighs with associated femoral vessels, warrants recognition of injuries to these adjacent structures. In gunshot related injuries, injuries other than genitourinary, particularly lower extremity injuries, are commonly associated with scrotal wounds [7,8].

In children with blunt abdominal trauma, scrotal trauma may accompany pelvic fractures, urethral injuries, and bladder injuries. Careful evaluation of the scrotum should assure that the testes are in the scrotum as testicular dislocation after abdominal trauma may be initially missed [9]. Due to the potential for the processus vaginalis to remain patent, there may be communication with the abdominal cavity. In children with scrotal swelling and significant abdominal trauma, hernias with blood tracking down from more remote intraabdominal injuries are another anatomical consideration.

CLINICAL FEATURES

History — Penetrating scrotal trauma and multiple trauma with blunt scrotal injury usually present soon after injury. Patients with isolated blunt scrotal trauma may delay medical evaluation. The mechanism of injury and its temporal relation to the onset of any scrotal swelling or pain, prior history of scrotal pain or swelling, and any associated symptoms should be obtained. Pain, swelling, bruising, and skin defects are common complaints. Nausea or vomiting may also be present. Significant pain with marked swelling localized to the testicle or scrotum suggests testicular injury and warrants prompt evaluation and surgical consultation. Serious blunt scrotal trauma typically arises from high force mechanisms (eg, motor vehicle collision) while the majority of children have trivial injury from minor falls or kicks during sports.

Physical examination — In the patient with a history of scrotal trauma or blunt abdominal trauma, the physical examination should begin with a primary survey and treatment of life-threatening injuries, especially in patients with multiple or penetrating trauma (table 1). Scrotal injury should be identified and treated as part of the secondary survey. Moderate to severe pain or scrotal swelling are findings that suggest significant scrotal injury. (See "Trauma management: Approach to the unstable child", section on 'Initial approach' and "Trauma management: Approach to the unstable child", section on 'Primary survey'.)

Analgesia for moderate to severe pain (eg, intranasal fentanyl or morphine intravenously and, in some instances, procedural sedation) may be necessary to obtain an accurate physical examination. If sedation is contemplated, the clinician may want to contact an appropriate surgeon, if available, to assist with the physical assessment. (See "Procedural sedation in children: Approach".)

A focused scrotal examination includes the following:

●Inspection of the skin integrity and extent of any defects, lacerations, or ecchymosis

●Determination of entrance and exit wounds in boys with penetrating trauma

●Location of any swelling

●Assessment of the testicle and intrascrotal structures, including location of testicle and lie, location of swelling, tenderness on palpation, testicular integrity, and cremasteric reflex

●Rectal examination and stool testing for occult blood to evaluate for associated abdominal and perineal injury or a high riding prostate in an adolescent patient

●Palpation of femoral vessels, particularly in patients with penetrating trauma

If the testicle is not palpable in the hemiscrotum, transillumination may be helpful, as is palpation for inguinal hernias or masses.

Significant testicular tenderness with swelling raises the possibility of testicular rupture, although most patients with this finding will have an intact testicle upon ultrasound. Focal testicular swelling may indicate a hematocele, a collection of blood outside the tunica albuginea, but contained by the tunica vaginalis and is also associated with testicular rupture. Thus, these findings are indications for testicular ultrasound. The relatively small prepubertal testicle in the setting of any significant swelling or pain may make palpation of the testicle and reliable localization of any fluid collection clinically difficult. Overlying hematomas may obscure reliable evaluation of the underlying testicle. Swelling without pain also warrants sonographic imaging and surgical consultation as testicular rupture can still be present [3]. (See 'Ancillary studies' below.)

Severe scrotal pain and swelling in the setting of minor trauma should raise suspicion for testicular torsion. In contrast, painless scrotal swelling or hematoma after multiple trauma may indicate intraabdominal trauma and extravasation of blood into the scrotum. (See "Causes of scrotal pain in children and adolescents", section on 'Testicular torsion' and "Pediatric blunt abdominal trauma: Initial evaluation and stabilization" and "Pediatric blunt abdominal trauma: Initial evaluation and stabilization", section on 'Physical examination'.)

A lack of a cremasteric reflex (testicular retraction when the ipsilateral thigh is gently stroked) is most often secondary to anxiety when bilateral, but particularly when unilateral, can be a sign of significant testicular injury or traumatic torsion.

When evaluating patients with significant scrotal injury marked by moderate to severe pain or swelling, clinicians should pay particular attention to the penis, abdomen, and pelvis:

●Assessment of the penis and corporal integrity is important as the corpus cavernosum and bulbous urethral lie deep to the median raphe and septum of the scrotum. Blood at the meatus indicates urethral injury. Ecchymosis of the penis, perineum, or scrotum can occur with anterior and posterior urethral injuries. (See "Blunt genitourinary trauma: Initial evaluation and management", section on 'Clinical features'.)

●Injuries to the foreskin or lacerations to the penis in association with blunt or penetrating scrotal injury can indicate physical and/or sexual abuse [10]. Other concerning findings for inflicted injury include scrotal or penile burns, patterned skin bruises, fractures, mouth injuries, and anal trauma. (See "Physical child abuse: Recognition", section on 'Red flag physical findings'.)

●In a patient with a patent processus vaginalis, scrotal swelling may develop as the result of significant intraabdominal injury and hemorrhage. Abdominal tenderness and/or bruising are key findings. (See "Pediatric blunt abdominal trauma: Initial evaluation and stabilization", section on 'Abdomen'.)

●Pelvis deformity or tenderness upon palpation suggests pelvic fractures in patients with scrotal trauma. Pelvic fractures should be identified during the primary survey because associated hemorrhage often causes hemodynamic instability. (See "Trauma management: Approach to the unstable child", section on 'Hemorrhage control'.)

Ancillary studies

Multiple trauma — In children with multiple trauma laboratory studies and imaging should be obtained according to mechanism of injury and physical findings. In such patients, pelvic computed tomography (CT) for associated major injuries can provide information about scrotal contents if the images are extended through the upper thigh. However, testicular ultrasound as described for below for isolated scrotal trauma is still necessary when CT findings suggest significant injury. (See "Trauma management: Approach to the unstable child", section on 'Adjuncts to the primary survey' and "Trauma management: Approach to the unstable child", section on 'Adjuncts to the secondary survey'.)

Isolated scrotal trauma — In most patients with isolated scrotal trauma, the history and physical examination suggest trivial scrotal injury, which requires no further testing. Males with scrotal trauma and findings of significant injury (eg, marked scrotal pain and swelling) should undergo the following studies:

●Urinalysis – Hematuria suggests injury to the urethra, bladder, ureter, and/or kidney. A positive test for blood by urine dipstick requires microscopic urinalysis. (See "Blunt genitourinary trauma: Initial evaluation and management", section on 'Urinalysis'.)

●Sonographic imaging – Color Doppler ultrasound (US) imaging of the scrotum is the preferred method for evaluating scrotal contents [3,11-13]. Decreased blood flow is an indication for emergency surgical exploration and repair. Imaging should not be delayed even though repair of testicular rupture within 72 hours has preserved function in some cases. US is an especially useful adjunct to the difficult or inconclusive physical examination [14]. The accuracy of US in children is operator-dependent and should be performed by a radiologist or technician with pediatric expertise. In the presence of clinical findings suggesting injuries that warrant surgical exploration, equivocal or negative US findings should not delay surgical care.

For patients with equivocal findings on color Doppler US cases or when a hematoma or hematocele obscures visualization of the testis, contrast-enhanced ultrasound (CEUS), when available, facilitates dynamic vascular imaging by using nonnephrotoxic contrast agents [15-17]. Similar to MRI, CEUS can delineate perfused, viable testicular tissue, readily define the interrupted border of the tunica albuginea in testicular rupture, and distinctly define the fracture plane in testicular fracture [18].

Analgesia for moderate or severe pain (eg, intranasal fentanyl or intravenous morphine) and, in some instances, procedural sedation may be necessary to obtain sonographic imaging. (See "Procedural sedation in children: Approach".)

Findings suggestive of significant scrotal trauma include [13,19-26]:

•Heterogeneous echo pattern of the testicular parenchyma with loss of contour – This finding indicates testicular rupture with a sensitivity of 90 to 100 percent and specificity of 65 to 94 percent.

•Disruption/discontinuity of the tunica albuginea – This sign also suggests testicular rupture, but in isolation has a sensitivity and specificity of only 50 and 75 percent, respectively, for testicular injury.

•Testicular fracture – This injury appears as a linear hypoechoic defect in the parenchyma with an intact testicular shape and tunica albuginea.

•Decreased blood flow – This sign may occur with testicular rupture or traumatic testicular torsion.

•Scrotal wall thickening – This finding, although usually nonspecific in isolation, may accompany other signs of testicular rupture.

•Hematocele – Acutely echogenic or isogenic fluid representing blood in the potential space between the parietal and visceral layers of the tunica vaginalis suggests testicular rupture (figure 2).

•Empty hemi-scrotum – This finding occurs in patients with a dislocated testes.

•Large scrotal hematoma – The presence of a large scrotal hematoma may make ultrasonographic evaluation unreliable. It can mimic a neoplasm without internal vascularity on Doppler. In addition, testicular compression by the hematoma may interfere with assessment of the testicle or tunica albuginea or definitive documentation of testicular blood flow. Therefore, the ultrasonographic findings alone should not be the sole indicator for surgical exploration.

●Magnetic resonance imaging (MRI) – MRI may be a useful alternative to sonographic imaging when hematoceles and hematomas obscure both examination and ultrasound visualization of the testicle and tunica albuginea. It can demonstrate disruption of the tunica albuginea, which appears as a distinct break in the dark signal intensity line on T2-weighted imaging. While limited literature exists regarding MRI use for scrotal pathology, in a small prospective study of seven cases of blunt trauma, Kim et al found MRI to have 100 percent diagnostic accuracy for testicular rupture [27]. The exam is reported to take 15 minutes to complete. In select cases, if readily available, MRI may help avoid surgical exploration and costs.

●Retrograde urethrography – Retrograde urethrography is indicated for children with suspected urethral injury such as those with blood at the tip of the urethral meatus. (See "Blunt genitourinary trauma: Initial evaluation and management", section on 'Retrograde urethrogram'.)

Radionuclide scans are costly, time-inefficient, and have no role in evaluating scrotal trauma.

INDICATIONS FOR SUBSPECIALTY CONSULTATION OR REFERRAL — Children with significant testicular pain or scrotal swelling after trauma warrant prompt evaluation by an appropriate surgeon with pediatric urologic expertise as do patients with the following injuries:

●Penetrating scrotal trauma with wounds extending into or through the dartos layer (see 'Anatomy' above)

●Testicular rupture

●Large testicular hematoma

●Hematocele (blood in the tunica vaginalis) (figure 2)

●Large scrotal hematoma or ultrasonographic findings of testicular compression or decreased blood flow

●Testicular dislocation

●Traumatic testicular torsion

●Scrotal avulsion

The close proximity of the scrotum and penis contribute to injuries involving both. Penile deformity, pain, and/or blood at the meatus are additional indications for urologic consultation in children with scrotal trauma. (See "Blunt genitourinary trauma: Initial evaluation and management", section on 'Disposition and definitive management'.)

MANAGEMENT

Stabilization and initial management — Life-threatening injuries that compromise airway, breathing, or circulation in children with scrotal trauma should be treating first according to the principles of Advanced Trauma Life Support (table 1).

Once stabilized, children who have clinical or sonographic findings of significant scrotal injury should not be allowed any oral intake and should receive prompt consultation with a pediatric urologist or surgeon with similar expertise. (See 'Clinical features' above and 'Indications for subspecialty consultation or referral' above.)

Other important measures include:

●Analgesia – Pain is frequently severe after scrotal trauma and parenteral analgesia (eg, intravenous morphine or fentanyl) may be required. (See "Procedural sedation in children: Approach".)

●Tetanus prophylaxis – Patients with penetrating scrotal trauma or bite wounds should receive tetanus prophylaxis, as indicated (table 2).

●Rabies prophylaxis after animal bites to the scrotum – Rabies is a frequent concern with animal bites, especially when the attack is unprovoked or the animal appears ill, is wild, or is a stray. In the United States, the Centers for Disease Control provides guidance regarding the risk for rabies and the need for postexposure prophylaxis based upon the type of animal exposure at https://www.cdc.gov/rabies/exposure/type.html. Early wound cleansing is an important prophylactic measure in addition to timely administration of rabies immune globulin (RIG) and vaccine, although infiltration of RIG directly into the scrotal wound may not be feasible (table 3). (See "Rabies immune globulin and vaccine".)

●Viral prophylaxis after human bites to the scrotum – Any unvaccinated patient or individual negative for anti-HBs antibodies who is bitten by an individual positive for HBsAg should receive both hepatitis B immune globulin (HBIG) and hepatitis B vaccine (table 4). If the source is unknown or not available for testing, the clinician should initiate the hepatitis B vaccine series. In addition, although the risk for transmitting HIV through saliva is extremely low, infection is of concern if there is blood in the saliva. Counseling regarding postexposure HIV prophylaxis is appropriate in this setting (table 5). (See "Hepatitis B virus immunization in adults", section on 'Indications' and "Management of health care personnel exposed to HIV".)

Antibiotic prophylaxis for scrotal wounds — Evidence regarding the benefit of prophylactic antibiotics for scrotal wounds other than animal bites is very limited and consists of isolated case reports and case series [28]. We suggest that children with penetrating scrotal injuries receive empiric treatment with parenteral antibiotics. The regimen should include agents active against Staphylococcus aureus (including methicillin-resistant organisms), Streptococcus species, anaerobic bacteria, Enterococcus, and Escherichia coli. The initial empiric regimen should be adjusted according to clinical response and the results of wound culture. Suggested regimens should have aerobic Gram-negative and anaerobic organism coverage.

Potential medications include [29]:

●Ampicillin-sulbactam alone if methicillin-resistant Staphylococcus aureus (MRSA) is not prevalent in the region

●Gentamicin plus clindamycin for patients allergic to penicillin or if coverage for MRSA is desired, depending upon the sensitivities of MRSA isolates in the region

Single versus combined regimens have not been specifically studied for penetrating scrotal trauma but evidence suggests that they are equally effective when used in patients with penetrating abdominal trauma [30].

Children with human, dog, or cat bites to the scrotum should receive prophylactic antibiotics tailored to the typical pathogenic organisms isolated from bite wounds. The first dose should be given parenterally as soon as possible after the injury. Regimens for dog and cat bites (table 6) and human bites (table 7) are provided in the tables. (See "Animal bites (dogs, cats, and other mammals): Evaluation and management" and "Human bites: Evaluation and management".)

Child protection — Diagnosis of scrotal trauma with a questionable or absent mechanism, or the finding of associated penile or anal injuries, remote bruising, or fractures in patients who have not experienced multiple trauma (eg, MVC, fall from a tree) should prompt involvement of an experienced child protection team (eg, social worker, nurse, physician with expertise in the management of child abuse), if available. In many parts of the world (including the United States, United Kingdom, and Australia), a mandatory report to appropriate governmental authorities is also required for cases of suspected abuse. (See "Child abuse: Social and medicolegal issues", section on 'Reporting suspected abuse'.)

In addition, the medical care team should ensure that children under two years of age with suspected intentional trauma undergo funduscopic examination by an ophthalmologist to assess for retinal hemorrhages and skeletal survey to identify other injuries once the patient's clinical status is stabilized. Local Child Protective Services should be consulted to ensure the safety of other children in the home. (See "Physical child abuse: Diagnostic evaluation and management" and "Child abuse: Eye findings in children with abusive head trauma (AHT)".)

Definitive care — Definitive management of scrotal trauma is based upon the type and extent of injury.

Blunt scrotal trauma — Categorization of the degree of blunt trauma provides guidance to treatment:

●Mild – When pain and scrotal swelling are minimal and if the testes are normal upon physical examination with an intact scrotum, treatment consists of bed rest, ice packs as tolerated, supportive underwear (briefs instead of boxers), and nonsteroidal antiinflammatory medications (eg, ibuprofen). No further testing or surgical consultation is necessary for these patients. Most children with blunt scrotal trauma will fall into this category.

Follow-up with the primary care provider within 48 hours is advisable even for such minor injuries. A concerning examination or worsening symptoms at that point warrants referral to an appropriate surgeon.

●Moderate – When the child has moderate pain and scrotal swelling, sonographic imaging, if available, is advisable to identify potential testicular injuries. Serious injuries warrant urgent evaluation by an appropriate surgeon.

Those patients with a normal ultrasound do not require surgical consultation. However, close follow-up with the primary care provider within 48 hours is advisable and a concerning examination or worsening symptoms at that point necessitates referral to an appropriate surgeon.

●Severe – Children with significant testicular pain, scrotal swelling, and/or an equivocal or difficult examination should undergo sonographic imaging by an operator with pediatric expertise. These patients also warrant prompt evaluation by a surgeon with appropriate expertise [3]. (See 'Indications for subspecialty consultation or referral' above.)

●Surgical exploration – Potential indications for surgical exploration after early recognition of blunt scrotal trauma include [3,31]:

•Testicular rupture

•Testicular fracture

•Testicular torsion

•Testicular dislocation (if manual reduction is unsuccessful)

•Testicular avulsion

•Scrotal hematoma with testicular compression

•Hematocele (some surgeons prefer to observe hematoceles <5 cm in diameter and hematoceles that are >72 hours old)

Children with testicular torsion or avulsion require emergency surgery to restore blood flow. (See "Causes of scrotal pain in children and adolescents", section on 'Management'.)

In patients with testicular rupture, surgical exploration and repair within 72 hours is associated with a significantly higher rate of testicular salvage than if operative care occurs after 72 hours (80 to 90 percent versus 32 to 45 percent) [3,32,33]. (See 'Outcomes' below.)

Nonsurgical management may have equivalent outcomes to surgical exploration in boys with delayed presentation of testicular rupture with normal blood flow on Doppler ultrasound. As an example, seven boys with testicular rupture and presentation up to five days after injury had complete healing without testicular atrophy [34]. Treatment consisted of scrotal support, empiric antibiotics, restriction of activities, and analgesia. However, return to sports was delayed between one to three months in some instances.

Penetrating trauma — Penetrating scrotal trauma into or through the dartos scrotal layer (figure 1) has a very high rate of associated testicular injury. These injuries warrant prompt referral to a surgeon with pediatric urologic expertise for surgical exploration [31]. (See 'Scrotal anatomy' above.)

Superficial scrotal wounds that only involve the skin should undergo local wound care and closure with absorbable sutures (eg, 4.0 or 5.0 fast-absorbing gut or plain gut). Although not directly studied, the groin is a frequently contaminated region and the author typically provides empiric treatment with amoxicillin/clavulanate acid or, for penicillin allergic patients, ciprofloxacin or clindamycin. (See "Minor wound evaluation and preparation for closure" and "Skin laceration repair with sutures".)

OUTCOMES — Testicular salvage depends upon the timing of operative repair and the type of injury:

●The best salvage rates for spontaneous torsion of the testicle, a condition involving vascular compromise to the testicle much like compressive hematomas, have been determined to be within 6 to 12 hours from injury. Depending upon the nature of testicular trauma, the salvage times may be even shorter, further necessitating rapid identification of injury and appropriate surgical consultation in patients with vascular compromise of the testicle after scrotal trauma.

●In cases of early recognition of testicular rupture, hematocele, and large hematomas that are potentially compressive to the testicle, salvage rates have been reported in the adult literature as high as 95 percent when treated within 72 hours [21,22,35]. In long-term follow-up, testicular atrophy related to the original testicular insult can still occur despite apparent salvage. Diagnosis and treatment of testicular rupture beyond 72 hours is associated with salvage of only 50 to 79 percent of testicles.

●In cases of penetrating testicular trauma, the salvage rates are typically 50 percent with the remaining patients undergoing orchidectomy [8].

PREVENTION — Clinicians should encourage boys to wear a protective cup when participating in sports that have a significant risk for scrotal injury (eg, lacrosse, baseball, hockey, American football) [36].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Human bites" and "Society guideline links: Pediatric trauma".)

SUMMARY AND RECOMMENDATIONS

●Life-threatening injuries that compromise airway, breathing, or circulation in children with scrotal trauma should be treated first according to the principles of Advanced Trauma Life Support (table 1). (See 'Management' above.)

●Initial management of scrotal trauma includes analgesia and, in patients with penetrating scrotal trauma including human or animal bites to the scrotum, tetanus prophylaxis (table 2), and if indicated, rabies and other viral prophylaxis. (See 'Stabilization and initial management' above.)

●Clinical findings that suggest significant scrotal trauma include marked testicular pain, scrotal swelling, laceration into or through the dartos layer, or a large scrotal hematoma. Blood at the meatus or ecchymosis of the penis, perineum or scrotum suggest urethral injury. (See 'History' above and 'Physical examination' above.)

●In gunshot related injuries, injuries other than genitourinary, particularly lower extremity injuries, are commonly associated with scrotal wounds. In children with blunt abdominal trauma, scrotal trauma may accompany pelvic fractures, urethral injuries, and bladder injuries. (See 'Adjacent structures' above.)

●Boys with significant pain and swelling after scrotal trauma should receive a urinalysis and undergo color Doppler ultrasound of the scrotum. Retrograde urethrography is indicated for children with suspected urethral injury based on findings such as blood at the tip of the urethral meatus. (See 'Ancillary studies' above and "Blunt genitourinary trauma: Initial evaluation and management", section on 'Retrograde urethrogram'.)

Other laboratory studies and imaging should be obtained in children with multiple trauma according to mechanism of injury and physical findings. (See "Trauma management: Approach to the unstable child", section on 'Adjuncts to the primary survey' and "Trauma management: Approach to the unstable child", section on 'Adjuncts to the secondary survey'.)

●Children with significant testicular pain and scrotal swelling after blunt scrotal trauma warrant prompt scrotal ultrasound and evaluation by an appropriate surgeon as do patients with the following injuries (see 'Indications for subspecialty consultation or referral' above):

•Testicular rupture, fracture, or hematoma

•Testicular torsion or dislocation

•Hematocele (blood in the tunica vaginalis) (figure 2)

•Large scrotal hematoma

•Scrotal avulsion

●Definitive management of blunt scrotal trauma is based upon the type and extent of injury. For the majority of children, pain or scrotal swelling is minimal and the testes are normal. For these patients, treatment consists of (see 'Definitive care' above):

•Rest

•Ice packs as tolerated

•Supportive underwear (briefs instead of boxers)

•Nonsteroidal antiinflammatory medications (eg, ibuprofen) as needed for pain

●Definitive management of penetrating scrotal trauma depends upon wound depth. Superficial scrotal wounds that only involve the skin should undergo local wound care and closure with absorbable sutures. Penetrating scrotal trauma into or through the dartos layer (figure 1) requires surgical exploration. (See 'Penetrating trauma' above.)

●We suggest that children with penetrating scrotal injuries receive empiric treatment with parenteral antibiotics (Grade 2C). Potential regimens for wounds other than bite wounds include ampicillin-sulbactam alone in regions where methicillin-resistant Staphylococcus aureus (MRSA) is not prevalent (<10 percent of isolates) or gentamicin combined with clindamycin if coverage for MRSA is desired and in penicillin-allergic patients.

Children with human, dog, or cat bites to the scrotum should receive prophylactic antibiotics tailored to the typical pathogenic organisms isolated from bite wounds (table 6 and table 7). (See 'Antibiotic prophylaxis for scrotal wounds' above.)

●Potential indications for surgical exploration of the scrotum include scrotal wounds into or through the dartos layer; testicular rupture, fracture, torsion, or dislocation; acute hematocele (blood in the tunica vaginalis); or large scrotal hematomas with testicular compression. (See 'Blunt scrotal trauma' above.)