Abstract
The aim of our study was to determine the frequency and nature of testicular and paratesticular lesions in forensic autopsies. A retrospective study was carried out on 495 adult male cases that underwent forensic autopsy from January 2008 to December 2011 in our Department. For each case, the following parameters were reported: age, body mass index, nature of testicular and paratesticular lesions, associated lesions in external genitalia, testicle weight, cause of death, manner of death, resuscitation attempts and prior medical history. Mean age of the studied population was 47.8 years (range 18–96). Mean body mass index was 25.3 kg/m2 (range 15–46.2). Testicular lesions and/or paratesticular were found in 16.4% of the cases (n = 81). The most frequent lesions were, respectively, testicular atrophy (n = 38) and trauma (n = 28). In three cases showing traumatic lesions, associated traumatic lesions were found in external genitalia. Most frequent cause of death was blunt trauma (19.9% of the cases). Manner of death most frequently associated with testicular trauma was, respectively, road traffic accident (n = 11) and suicidal fall (n = 6). Mean testicular weight was, respectively, 17.9 g for the right and 20.8 g for the left (range 2–38). Atrophy was associated with testicular weight less than 10 g. A significant association between testicular atrophy and age was found, the risk of atrophy increasing quite linearly with age. No significant statistical link between prior medical history and testicular pathology was found. There was also no influence of body mass index. Resuscitation attempts were not statistically associated with testicular traumatic lesions.
Introduction
Testicles are easy to sample at autopsy time. The testes are pushed upwards through the inguinal canals, which are widened with the knife. 1 Next, the testicle is released by section of the spermatic cord. After opening of the tunica vaginalis, the testis is isolated from tunica vaginalis and epididymis and then weighed. A sharp knife is next used to bisect the testis along its axis in a plane that extends into the testicular hilum. In spite of the technical ease of sampling testes, most forensic pathologists do not routinely dissect testicles. In order to know whether systematic examination of testes is useful in routine practice, we decided to determine the frequency and nature of testicular and paratesticular lesions in forensic autopsies.
Methods
A retrospective study was carried out on 495 adult male cases that underwent forensic autopsy from January 2008 to December 2011 in our Department. During this period, 1884 forensic autopsies have been carried out. For each case included, following parameters were reported: Age, body mass index (BMI), nature of testicular and paratesticular lesions, associated lesions in external genitalia, testicle weight, cause of death, manner of death, resuscitation attempts and prior medical history. In case of macroscopic lesions found at autopsy, histology study of the testicles was carried out to confirm the nature of the lesions.
Bodies showing an advanced state of putrefaction were excluded from the study.
Statistical analysis
Frequency distribution (%) and mean ± standard deviation (SD) were computed according to qualitative and continuous variables. We analyzed testicular atrophy in relation to some pathologies according to prior medical history of the deceased (chronic alcoholism, drug abuse and diabetes). First, we carried out a univariate analysis using Chi-square or Fisher’s exact tests. Variables studied included age (years), height (m), body mass index (BMI, kg/m2), chronic alcoholism, drug abuse and diabetes. Age and height were first considered using classes corresponding at the quartiles of their distributions, for BMI, WHO’s BMI classification was used, with respect to at least 10% in frequency. A multivariate logistic regression was then performed, including variables with a p < 0.20 in univariate analysis. We first took into account all autopsies, and then, for pathologies with very low frequencies, considered only autopsies that had at least one testicular lesion. All calculations were performed with SAS procedures (version 9.2; SAS Institute, Cary, NC).
Results
The percentage of testicular examination was about 26% of the cases whose autopsy was performed during the period of the study.
Characteristics of the studied population.
1: Mean (SD) [Min–Max]; 2: % (n); 2: Body Mass Index; 3: 3 cases showed 2 distinct causes of death
The most frequent causes of death were, respectively, blunt trauma (19.9% of the cases), asphyxia (17.5%) and cardiovascular pathology (16.7%). Manner of death most frequently associated with testicular trauma was, respectively, road traffic accident (n = 11) and suicidal fall (n = 6). The majority of road traffic accidents cases involved motorcycle drivers (n = 7). The other cases included respectively five suicide cases of railway fatalities, one case of work-related crushing injuries, one sudden death case secondary to acute aortic dissection associated with a fall from a low height (due to collapse of the victim) and one case of aviation accident involving a pilot. Trauma was also found in three homicide cases, including two cases of stab injuries. The other homicide case died from gunshot wounds. Testicular trauma was not related to gunshot wounds but was linked to brawling injuries. Nature of trauma was the following one: haemorrhage around tunica albuginea in 5 cases, intratesticular contusion (Figures 1 and 2) in 19 cases, testicular rupture in 2 cases (Figure 3), stab wound with complete section of the spermatic cord in one case and complete amputation of one testicle in one railway fatality. No gunshot wounds were found. No avulsion injuries were also found. In only three cases showing traumatic lesions, associated traumatic lesions were found in external genitalia.
Large testicular foci of fresh contusion found in a 64 year-old man who died after a fall from a height (12 m). Two discrete foci of fresh contusion in a road traffic accident involving a 34-year-old motorcycle driver. Testicular rupture with complete avulsion of the tunica albuginea in a 22-year-old pilot victim of an aircraft accident.
Mean testicular weight was, respectively, 17.9 g for the right (range 2–38) and 20.8 g for the left (range 2–38). Testis weight was available in 289 cases. Atrophy was associated with testicular weight less than 10 g. Atrophy was often associated with intratesticular fibrosis macroscopically seen.
According to prior medical history (available in 225 cases), chronic alcoholism was found in about 60% of the cases (n = 133). Drug abuse and diabetes were, respectively, found in 12% of the cases (n = 27) and 7% of the cases (n = 15).
Due to the small number of cases of drug abuse and diabetic cases, 5% and 3% of the whole sample, respectively, a Fisher’s exact test was used to compare the percentage of testicular atrophy in the drug abuse or diabetic groups with the percentage of testicular atrophy in the non ones. In both cases, no differences were found (p = .45, p = .32, respectively).
We found that risk in testicular atrophy increased, quite linearly, with age. Indeed, compared to the lower class of age, the upper class of age has a significant 3.5 times larger risk (OR = 3.53; 95%CI = [1.27–9.89], p = .004). Except for chronic alcoholism, no other variables studied had a risk with p < .20. Thus, final logistic model included age, as continuous variable, and presence or not of chronic alcoholism. A significant association with age was estimated, with an increase year of age, the risk of a testicular atrophy is multiplied by 1.04 (OR = 1.04, 95%CI = [1.02–1.07]; p < .0001). A marginally significant risk of testicular atrophy was estimated for those showing chronic alcoholism (OR = 1.96; 95%IC = [.95–4.02]; p = .07). No interaction was found between both variables.
We have reduced the sample to only those showing testicular and/or paratesticular lesion to study addict and diabetic variables. In that case, testicular atrophy was marginally significantly associated with drug abuse (Fisher’s exact; p = 0.10, respectively). The percentage of testicular atrophy was equal 100% (3 cases) in the drug abuse group versus 45% in the non drug-abuse group. No association was found with diabetic variable. No influence of BMI on testicular atrophy was found. Resuscitation attempts were not statistically associated with testicular traumatic lesions.
Discussion
Our study showed that testicular and/or paratesticular lesions are found in about 16% of the cases in a forensic autopsy series. Trauma lesions were found in 5.6% of the cases. The testicles are protected by the mobility and elasticity of the scrotal tissues from most injuries.2,3 Testicular trauma most commonly occurs in young men aged 15–40 years. 2 The range was larger in our series, between 18 and 63 years. The mechanism of testicular rupture is a direct blow to the testicle, bringing about forceful compression, trapped between the pubic bone and the crushing object, and hence tearing the usually strong tunica albuginea covering the mobile intrascrotal testicle. 2 According to Ahmed and Mbibu, 3 genital injuries resulted mainly from road traffic accidents (68%) and gunshot wounds (16%). According to Lee et al., 2 the main cause of scrotal trauma was, respectively, assault (42%) followed by sports activities (26%), mostly when practising martial arts, road traffic accidents (12%) and falls (12%). In our series, we found no testicular lesions secondary to gunshot wounds. Gunshots affecting the genitourinary system in civilians are uncommon. 4 In a series of 309 patients who sustained penetrating trauma to the genitourinary system because of gunshot wounds, testicle injuries were found in 12% of the cases. 4 Gunshot wounds are not always associated with penetrating trauma. Blunt injuries including testicle fracture have been found in one non-lethal case in the injury pattern of the police bean bag. 5 In case of road traffic accidents involving motorcycle occupants, testicular lesions are of great medico-legal importance. 6 Scrotal trauma may arise from fuel-tank impact to genitalia. Such post mortem findings may help in the identification of the driver in two-rider motorcycle accidents. 6 Other characteristic lesions include traumatic testicular displacement6,7 and contusion-laceration from groins to the perineum. 8
In our series, we had no autopsy case for which the cause of death was related to a testicular pathology, especially a malignant tumour. Saukko and Lignitz reported three cases of young males who suddenly died of pulmonary embolism caused by metastazing tumour of the testis. 9 Such cases remain extremely rare in forensic autopsy material.9,10 Another mechanism of sudden death has been recently reported in a young male with metastatic teratocarcinoma of the right testis. Cause of death was a myocardial ischemia secondary to tumor emboli in the coronary arteries. 11 No sign of malignancy was found in our series. This finding is similar to those of Giwercman et al. who found no sign of malignancy in 399 men 18 to 50 years old who died suddenly and unexpectedly. 12 According to these authors, the overall prevalence of testicular neoplasia is low. 12 The absence of testicular neoplasia in our cases cannot be asserted as no systematic histology was performed. Non-tumoral testicular pathology as a primary cause of death was not found in our series. No case report was also found in a review of the literature. When orchitis lesions were found, the main cause of death was in another location, such as the case reported by Smith et al. who died of West Nile virus encephalitis associated with orchitis. 13
According to our results, a significant association between testicular atrophy and age was found, the risk of atrophy increasing quite linearly with age. Such finding confirms previous studies that have reported decreased testicular weight and/or volume in older men. 14 Ageing is associated with testicular histomorphological changes that develop gradually. 15 Degenerative changes within seminiferous tubules have been described. 14 With progression of fibrosis, the germinal epithelium becomes increasingly separated from the blood supply. 14 A decrease in Sertoli cell number and function with ageing may also correlate with a decreasing sperm count. 15
According to our results, a marginally significant risk of testicular atrophy was estimated for the cases showing a history of chronic alcoholism. Excessive use of alcohol is often associated with disorders of spermatogenesis and testicular damage. 16 Alcohol abuse can induce testicular atrophy, but it only occurs in some alcoholics. 17 Genetic polymorphism of alcohol dehydrogenase may be associated with such atrophy. 17 Ethanol appears to have a dual effect: locally on the gonads and centrally on the hypothalamus-pituitary axis, causing an adverse effect on spermatogenesis. 18
We found no significant association between drug abuse and testicular atrophy. This finding agrees with the morphological study of Kringsholm and Christoffersen who found interstitial fibrosis and groups of lymphocytes in a few cases of addicts. 19 In case of sudden death occurring during sport activities, the autopsy finding of testicular atrophy may be useful to raise the question of anabolic steroid misuse. Indeed, it has been shown that steroid users showed decreased mean testicular length, 20 as anabolic steroids cause testicular atrophy.
As testes are easy to remove at autopsy time and can be very informative to determine cause and manner of death, systematic examination of testicles should be done during forensic autopsy. It is very important to perform such examination in homicide case in order to rule out testicular and/or paratesticular trauma which can be related to brawling injuries. Indeed, paratesticular and/or testicular injury can be found without any external genitalia lesion according to our study. As male sex glands do not easily undergo post-mortem changes, 21 such examination could also be considered even in putrefied bodies.
Footnotes
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflict of interest
The authors declare that they have no conflict of interest.
Contributorship statement
Jéhanne Marchaut and Zakia Médiouni recorded the study data from autopsy reports. Statistical analysis was carried out by Laurence Watier. Geoffroy Lorin de la Grandmaison and Philippe Charlier designed the study and were both involved in the writing of the manuscript. Geoffroy Lorin de la Grandmaison is nominated as a guarantor for the work. All authors approved the final manuscript.