I will warn you there are some NASTY pictures below the fold. They are NSFW once you realize what you're looking at. Odds are, no one WILL be able to tell what you're looking at, but just in case.
Simhan, et al. "Gunshot wounds to the scrotum: a large single-institutional 20-year experience" BJUI, 2011.
And now, none of you will ever want to go to Philadelphia. You will give Ben Franklin a sad.
This was a bunch of surgeons based out of Temple University in Philadelphia, examining gunshot wounds to the scrotum. It seems like this would be kind of a rare event, but in fact, over a 20 year period they had 97 total wounds, with an average of about 5 per year! That's a lot of gunshots to the scrotum. I suppose that ANY gunshot wound to the scrotum might be considered "a lot".
Anyway, over a 20 year period, they collected a total of 97 wounds to the genital area. Many times they couldn't "get to" the wounds for a while, as the gunshot victim had other wounds that were a bit more pressing (shocking as it seems, dudes, you can in fact live without your junk. Your lungs, on the other hand...). But if they detected swelling or obvious gunshot markers, they took a look at the sugar lumps.
The first thing they are looking for is damage to the penis, specifically to the tunica. You see, the penis is built like this:
This is a picture of a cutaway of the penis (looks like it's got bug eyes, doesn't it?). the bottom center contains the urethra, and the two large sections on either side are the corpus cavernosa. These are the things that fill with blood when you get an erection. The fibrous covering surrounding the corpus cavernosa is the tunica albuginea. The tunica is very tough, and it needs to be. Without it there to keep the blood where it's supposed to stay during an erection, you're going to get one very odd shaped tool. Not only that, but the rigidity of the tunica helps maintain the penis shape even when the penis is not erect, and this is very important for things like, you know, peeing. Which you need to do.
Unfortunately, it's very hard to tell if there's damage to the balls or the tunica using just an ultrasound. Observe:
(That could be a disruption of the tunica, but it could also be the Higgs Boson...)
When you've got damage to the tunica, you need to check for damage to the very nearby scrotum. But that's almost impossible to tell from an ultrasound. You gotta go in there. I believe the medical terminology is "scrotal exploration", which sounds like you've got dudes with flashlights and expensive snowgear hiking into the unknown...of your balls. Narrated by David Attenborough, obviously.
But the scrotal exploration was often warranted. Over 50% of the cases had some testicular damage. This is not for the faint of heart.
That, my friends, is a gunshot fracture of the testicle. It's hard to see what you're looking at, but suffice to say they shaved/waxed the whole area, opening the scrotum and pulling the testicle out from within it. In about half the cases like this, they could debride the injured tissue (debriding is removal of dead or injured tissue in the interest of saving the rest. This can be done in a lot of ways, including maggots, chemicals, lasers, or just yanking off the gauze, but in this case probably meant cutting off the dangling bits), sew it up, and move on, but 48% of the cases required orchiectomy. That's ball removal. In most of these cases, the tunica was also damaged, and so they then had to go in a sew that up, often re-approximating what they thought was originally there.
Results were pretty good (with 97 patients, I would imagine the surgeons got pretty well experienced).
Now you might think this whole thing sounds kind of odd. Why would you report it in the medical literature? I mean, ow, sure, but WHY? Well, these studies provide support FOR scrotal exploration, and state that if you feel something, you should go in. Previously, some hospitals had taken the idea of "if it's obviously injured, cut it off", with 65% orchiectomy rates. It turns out that many of those testicles could have been saved by cutting off the injured tissues. It also turns out that a lot of testicular injury goes relatively unnoticed, because it's so hard to tell from the ultrasounds. The authors argue that when the ultrasound is fine, but you're suspicious, you should go in there. It may not be appealing, but it could save balls. Because the surgery itself isn't particularly dangerous, and despite the squeamishness, better safe than sorry.
Simhan, J., Rothman, J., Canter, D., Reyes, J., Jaffe, W., Pontari, M., Doumanian, L., & Mydlo, J. (2011). Gunshot wounds to the scrotum: a large single-institutional 20-year experience BJU International DOI: 10.1111/j.1464-410X.2011.10631.x
Ok, that was a lot of blood, and a lot of shots to the scrotum. Ow. 🙁
I'd like to make it up to you.
Here's a kitten.