Traumatic Superficial Subcutaneous Testicular Dislocation

Clinical History

32-year-old male patient with history of fall from a motorcycle presented to the casualty department with a tender swelling in left upper thigh and pain in the scrotum and lower abdomen. On examination, the left testis was not palpable in the left hemiscrotum.

Imaging Findings

Ultrasound examination revealed presence of an intact left testis and epididymis in the subcutaneous plane of the anteromedial aspect of left upper thigh lying superficial to the anterior aspect of the left adductor group of muscles. Doppler evaluation of the testis showed normal vascularity. The left spermatic cord was traced up to the testis and showed normal vascularity with no evidence of disruption.

The left hemiscrotum was empty with evidence of avascular heterogeneous collection suggestive of haematoma. The right testis and spermatic cord were present in the right hemiscrotum.

Intraoperative findings showed the left testis in the upper thigh with an intact vascular pedicle. The scrotal haematoma was evacuated and an orchidopexy was performed.

Discussion

The first case of testicular dislocation was documented by Claubry in 1818 [1, 2, 3].
Dislocation of testes is a rare entity defined as displacement of one or both normally located testes into a location other than the scrotum [1, 4].

Goulding initially classified the entity into:
(1) Internal dislocation- Testis displaced through the external inguinal ring into the inguinal canal or abdominal cavity
(2) Superficial dislocation- Subcutaneously dislocated testis in an area with the external inguinal ring as the centre and length of spermatic cord from it as the radius
(3)Complex / Compound dislocation- External displacement of testes through lacerated scrotum [1, 3, 4, 5].

It is commonly unilateral with 30% cases demonstrating bilateral dislocation [4, 6].
Most common locations include superficial inguinal (50%), pubic (18%), canalicular (8%), penile (8%), intra abdominal (6%), perineal (4%) and crural (2%) [2, 7, 8]

Majority of the dislocations occur due to straddle injuries occurring during motorcycle accidents as the rider’s perineum is impacted against the gasoline tank [1, 3, 9, 10, 11].
For dislocation to occur, the testes requires to cleave through the internal cremastric and external spermatic fascia with an intact tunica vaginalis and gubernaculum [2, 6].
Additional factors such as wide superficial inguinal ring, inguinal hernia, atrophic testes and cremasteric reflex also contribute to the dislocation [7, 10].

Colour Doppler ultrasonography is initial investigation of choice which is helpful in assessing the vascularity, location of the testes and identification of rupture / torsion of testes. An empty hemiscrotum/scrotal hematoma can also be demonstrated. It is also valuable for deciding further management and in post operative follow up [1, 3, 4, 6, 10].
CT evaluation can also be done to assess the integrity of the dislocated testes, relationship to adjacent structures and image associated injuries if any [1, 4].

Manual closed reduction is recommended at the time of presentation preferably under sedation/general anaesthesia if the vasularity is normal and the testis is intact [1, 2, 9].
Open surgical reduction and orchidopexy is done if manual reduction is unsuccessful. In the presence of rupture or torsion of the dislocated testes, surgical exploration is mandatory [1, 2, 9, 7, 11].

Delayed reduction of testes can result in irreversible testicular changes (seminiferous tubule atrophy) leading to some degree of infertility and possibly malignant changes [1, 4].

In conclusion, absent testes in the scrotum should raise suspicion regarding traumatic dislocation. Assessment by ultrasonography should be followed by repositioning of testes to preserve the organ [4].

Differential Diagnosis List

Final Diagnosis

Traumatic superficial subcutaneous testicular dislocation

URL:	https://www.eurorad.org/case/10256
DOI:	10.1594/EURORAD/CASE.10256
ISSN:	1563-4086