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).
