Testicular Haematoma

Testicular haematoma is a collection of blood within the testicular parenchyma, with the tunica albuginea intact. It follows blunt trauma, and also occurs after surgery or biopsy, and rarely from bleeding into a tumour or from a coagulopathy.

Its importance is in distinguishing it from rupture, which needs surgery, and from a haemorrhagic tumour, which needs oncological treatment.

Pathophysiology. Contusion damages vessels within the testis. Blood remains confined by the tunica, raising pressure and sometimes compromising flow. Over weeks the haematoma liquefies, shrinks and may leave a cyst or scar.

Causes:

• Blunt trauma, and sporting injuries.
• Anticoagulants, antiplatelet drugs, thrombocytopenia and clotting disorders.
• Spontaneous bleeding into a tumour (about 10% of testicular tumours show haemorrhage).
• Vasculitis, infarction, biopsy and surgery.

Pain, a firm swollen tender testis and scrotal bruising after trauma, with normal contour. Spontaneous haematoma may present with a painless or mildly painful mass. Absence of an adequate history of trauma, or an evolving mass over weeks, suggests tumour.

• Doppler ultrasound: an acute haematoma is heterogeneous or hyperechoic, later hypoechoic or cystic, and avascular, with the tunica intact. A tumour shows internal vascularity. Repeat ultrasound at intervals to show shrinkage.
• MRI when ultrasound is unclear: haematoma is hyperintense on T1 and does not enhance.
• Tumour markers (AFP, beta-hCG, lactate dehydrogenase) when the diagnosis is not clear, and before any surgery for a mass.
• Full blood count, platelets, coagulation screen and medication review.

Differential diagnosis.

• Testicular tumour with haemorrhage
• Testicular rupture
• Infarction
• Abscess
• Orchitis
• Haematocele
• Epididymal haematoma

• Intact tunica and normal perfusion: 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.
• Anticoagulants and antiplatelet drugs: review the indication with the prescriber, and hold or adjust where it is safe. Warfarin with major bleeding: vitamin K 5 to 10 mg intravenously by slow injection and prothrombin complex concentrate at 25 to 50 IU/kg, directed by the INR and haematology. Correct thrombocytopenia.
• Surgical exploration for suspected rupture, an expanding or large haematoma (over about 5 cm, or over a third of testicular volume), severe pain, infection, or a mass that does not shrink. When tumour is possible, use an inguinal incision with early cord control and frozen section, and never a scrotal incision.
• Infected haematoma: drainage and culture directed antibiotics, with ceftriaxone 2 g intravenously once daily as empirical treatment.
• Return to sport after 4 to 6 weeks, with a protective cup.
• Complications: atrophy, abscess, chronic pain, hypogonadism and infertility.

Monitoring. Ultrasound at 2 to 4 weeks, and again at 6 to 8 weeks to document shrinkage. A lesion that persists or grows after 6 to 8 weeks needs tumour markers and exploration. Semen analysis and testosterone at 3 to 6 months after significant injury.

Referral and escalation. Refer to urology for any intratesticular haematoma. Urgent referral for suspected rupture, expansion, absent flow, or suspected tumour.