In recent years, the number of individuals carrying firearms in the so-called “appendix carry position”—which is located in the waistband halfway between the pants pocket and the waistband button—has increased. Whereas approximately 90 percent of the population is right-handed, most people place the firearm in the vicinity of the appendix. However, placement of a firearm in this location can have some serious consequences.
Prompt surgical exploration recommended
The anatomic location of the scrotum leaves it vulnerable to penetrating trauma that primarily occurs in the form of knife wounds, gunshot wounds (GSWs), and self-mutilation.1 While rare, isolated scrotal GSWs comprise 55 percent of all penetrating external genital injuries.2 Prompt surgical exploration is the general rule for penetrating trauma as it is often associated with concomitant injuries to the testicles and less commonly the urethra and penis.3
Multiple case series have revealed that 71 to 91 percent of patients presenting with penetrating scrotal injuries undergo scrotal exploration.2,4,5 A large single-institution study shows that gunshot wounds are explored 78 percent of the time.2 This aggressive approach to promptly diagnosing potential testicular injury has led to a negative exploration rate of up to 39 percent.5 While nonoperative management with serial ultrasound imaging has been shown to be beneficial in select situations, no prospective data are available, given the scarcity of the injury, to suggest this technique replaces early scrotal exploration.5
Testicular salvage rates after penetrating trauma is between 39 percent and 49 percent after prompt exploration, according to the literature.2,4,5 GSW salvage rates, however, have been reported to be as high as 75 percent, with the caveat that these injuries are more likely to be promptly explored and less likely to involve the blood supply or the spermatic cord.2 Primary management of testicular injury includes debridement of nonviable tissue and closure of the tunica albuginea around viable seminiferous tubules when possible.3 It also is important that the clinician recognize that concomitant urethral injuries are possible given the scrotum’s close proximity to the base of the penis and urethra.3 While rare, scrotal GSWs are important to recognize and explore promptly for the best cosmetic, reproductive, and endocrine outcomes.
To examine the occurrence of patients with scrotal gunshot wounds in the National Trauma Data Bank® (NTDB®) admission year 2017, medical records were searched using the International Classification of Diseases, 10th Revision Clinical Modification codes. Specifically searched were records that contained one of 192 nonwar-related E codes for penetrating injury and a diagnosis code of s31.3 (open wound of scrotum and testes). A total of 801 records were found; 687 records contained a discharge status, including 588 patients discharged to home, 34 sent to acute care/rehab, 34 sent with law enforcement, 10 sent to skilled nursing facilities; 21 died (see Figure 1). All of these patients were men, on average 29.8 years of age, had an average hospital length of stay of 6.2 days, an intensive care unit length of stay of 4.5 days, an average injury severity score of 9.6, and were on the ventilator for an average of 3.7 days. Of those patients undergoing operative exploration, 66 orchiectomies were performed.
When patients present with penetrating injuries below the belt, it is best to check for a possible scrotal injury and consider the need for operative exploration.
Throughout the year, NTDB data are highlighted through brief monthly reports in the Bulletin. The NTDB Annual Report can be found on the American College of Surgeons website as a PDF file at facs.org/ntdb. In addition, information is available on the website about how to obtain NTDB data for more detailed study. If you are interested in submitting your trauma center’s data, contact Melanie L. Neal, Manager, NTDB, at firstname.lastname@example.org.
Statistical support for this column was provided by Ryan Murphy, Data Analyst, NTDB.
- Morey AF, Metro MJ, Carney KJ, Miller KS, McAninch JW. Consensus on genitourinary trauma: External genitalia. BJU Int. 2004;94(4):507-515.
- Phonsombat S, Master VA, McAninch JW. Penetrating external genital trauma: A 30-year single institution experience. J Urol. 2008;180(1):192-196.
- Morey AF, Brandes S, Dugi DD, et al. Urotrauma: AUA guideline. J Urol. 2014;192(2):327-335.
- Simhan J, Rothman J, Canter D, et al. Gunshot wounds to the scrotum: A large single-institutional 20-year experience. BJU Int. 2012;109(11):1704-1707.
- Mohr AM, Pham AM, Lavery RF, Sifri Z, Bargman V, Livingston DH. Management of trauma to the male external genitalia: The usefulness of American Association for the Surgery of Trauma organ injury scales. J Urol. 2003;170(6 pt 1):2311-2315.