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
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
Timing of Repair. Explore suspected rupture urgently. Reports of better salvage with repair within 3 days describe outcomes, not permission to wait 72 hours. 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
- 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
- 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.
Penile / Glans Amputation
Traumatic penile or glans amputation is rare but represents a true surgical emergency. Microsurgical replantation is preferred when feasible. 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 inner bag, placed in a second bag on ice
- Minimize warm and cold ischemia; contact the replant team immediately. Published time windows are not guarantees of viability or automatic reasons to discard a potentially salvageable segment[4]
- Hemostasis of the stump with pressure dressing — do not clamp
- Transfer urgently to a microsurgical-capable center if local expertise unavailable (ACS 2025 Best Practices)
- Provide psychological support; obtain urgent psychiatric assessment and protection from further harm when injury was self-inflicted. An individual recurrence percentage cannot be inferred from selected case reports[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]
Suspected abuse alone is not an automatic indication for anesthesia. Specialist pediatric forensic examination is usually external and noninstrumented; suspected intravaginal injury, significant bleeding or a foreign body may require vaginoscopy under anesthesia.[5]
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); assess tetanus vaccination and exposure-specific 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. ACS guideline PDF.
4. European Association of Urology. EAU Guidelines on Urological Trauma, 2026. Genital trauma.
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.