Haematocele

Haematocele is a collection of blood within the tunica vaginalis surrounding the testis. It is usually caused by trauma, and is a sign of possible testicular rupture.

It also follows scrotal surgery, anticoagulation, bleeding into a tumour or hydrocele, and rarely occurs spontaneously. A chronic, organised haematocele can calcify and compress the testis.

Pathophysiology. Bleeding fills the potential space of the tunica vaginalis, raising pressure and compressing the testis. Clot then organises, with a thickened, fibrotic wall that may calcify.

Infection of the clot forms a pyocele. Prolonged compression can cause ischaemic atrophy of the testis.

Causes:

• Blunt or penetrating trauma, with or without testicular rupture.
• Hydrocelectomy, hernia repair, vasectomy, varicocelectomy and aspiration or biopsy.
• Anticoagulants, antiplatelet drugs and bleeding disorders.
• Haemorrhage into a testicular tumour.

Painful or tense scrotal swelling and bruising after injury or surgery, a testis that cannot be felt separately, and a swelling that does not transilluminate. Rapid enlargement suggests ongoing bleeding. A chronic haematocele gives a heavy, hard, painless scrotal swelling. Fever and erythema suggest infection.

• Doppler ultrasound: complex fluid with echogenic debris and septations, a thickened tunica, and assessment of the testis for rupture (disrupted contour) and flow.
• MRI when ultrasound is unclear. CT for associated injury in major trauma.
• Full blood count, coagulation screen and medication review. Tumour markers (AFP, beta-hCG, lactate dehydrogenase) when there is no history of injury.
• Tetanus status. Urinalysis and, if there is blood at the meatus, urethrography.

Differential diagnosis.

• Hydrocele
• Pyocele
• Testicular rupture or haematoma
• Testicular tumour with haemorrhage
• Inguinal hernia
• Spermatic cord haematoma
• Thrombosed varicocele

• Small haematocele (under about 5 cm), no rupture and normal flow: conservative care with rest, ice, scrotal support, paracetamol 1 g every 6 hours (maximum 4 g daily) and ibuprofen 400 mg every 8 hours with food. Review at 48 to 72 hours and at 1 to 2 weeks.
• Surgery when the haematocele is large or expanding, painful and tense, associated with rupture or penetrating injury, infected, or has not resolved by 2 to 3 weeks:
  • Evacuate clot, achieve haemostasis, repair any tunical laceration with absorbable 4/0 suture, and excise or evert the sac. Place a drain for 24 to 48 hours.
  • Perioperative cefazolin 2 g intravenously (3 g if over 120 kg) as a single dose.
• Chronic organised haematocele: excision of the thickened sac.
• Infected haematocele (pyocele): drainage and culture directed antibiotics, with ceftriaxone 2 g intravenously once daily as empirical treatment.
• Anticoagulated patients: adjust treatment with the prescriber, balancing bleeding against thrombotic risk.
• Tetanus prone wounds: tetanus toxoid 0.5 mL intramuscularly if vaccination is incomplete or the last dose was over 5 years ago, and immunoglobulin 250 IU intramuscularly (500 IU if over 24 hours since injury or heavy contamination) when status is unknown or incomplete.
• Complications: infection, atrophy, chronic pain, and recurrent bleeding.

Monitoring. Ultrasound at 2 to 4 weeks, with review for resolution of swelling over about 4 to 8 weeks. Persistent mass beyond 6 to 8 weeks needs tumour markers and exploration.

Referral and escalation. Refer to urology. Urgent referral for suspected rupture, an expanding collection, a penetrating injury, or infection.