HEMATOCELE

A hematocele is a collections of blood in a body

cavity or potential space.The term most commonly refers
to the collection of blood in the tunica vaginalis around
the testes, known as a scrotal hematocele. Hematoceles
can also occur in the abdominal cavity and other body
cavities. Hematoceles are rare, making them harder to
diagnose and treat. They are very common especially as
slowly growing masses in the scrotum usually in men older
than 50 years
Hematocele is the collection of blood between two layers of
tunica vaginalis [layers of scrotal sac].
A scrotal hematocele is also called a hemoscrotum

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CAUSES
A hematocele is one of the most
common sequelae of testicular trauma.A traumatic
hematocele usually results from testicular rupture (80% of
cases) or a tear in the pampiniform plexus veins.Testicular
rupture and testicular torsion are also common causes of
scrotal hematocele. It can also be caused
by kidney injury, pancreatitis, hematological dysfunction,
1. Trauma: Blunt or penetrating trauma to the scrotum,
such as a blow to the groin area, a fall, or a car accident,
can cause bleeding and lead to a hematocele.
2. Surgical complications: Bleeding during or after
surgical procedures like hernia repair, hydrocelectomy, or
orchiectomy can result in a hematocele.
3. Testicular torsion: Twisting of the testicle can cause
bleeding and lead to a hematocele.
4. Infection: Infections like epididymitis or orchitis can
cause bleeding and lead to a hematocele.
5. Cancer: Testicular cancer or lymphoma can cause
bleeding and lead to a hematocele.
6. Rupture of a testicular cyst: Rupture of a testicular
cyst or a hematocele can cause bleeding and lead to a
hematocele.

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7. Blood clotting disorders: Conditions like hemophilia
or bleeding disorders can increase the risk of bleeding and
lead to a hematocele.
8. Injury during sports: Injury during sports, especially
those that involve blunt trauma to the groin area, such as
football or soccer, can cause a hematocele.
9. Falls: Falls onto the scrotum or groin area can cause
bleeding and lead to a hematocele.
10. Assault: Physical assault or intentional injury to the
scrotum can cause bleeding and lead to a hematocele
or vasculitis.

PATHOPHYSIOLOGY

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The pathophysiology involves a series of events leading to
blood accumulation in the scrotal sac.
1. Injury or trauma: Blunt or penetrating trauma to the
scrotum causes damage to blood vessels, leading to
bleeding.
2. Bleeding: Blood from damaged vessels accumulates in
the scrotal sac, causing swelling and pain.
3. Scrotal sac distension: The scrotal sac expands to
accommodate the blood, leading to increased pressure
and discomfort.
4. Blood clotting: The body's natural response to
bleeding causes blood clots to form, which can further
complicate the condition.
5. Inflammation: The presence of blood in the scrotal sac
triggers an inflammatory response, leading to swelling,
pain, and redness.
6. Fibrosis: Chronic inflammation can cause scarring and
fibrosis, potentially leading to long-term complications like
testicular atrophy or infertility.
7. Testicular damage: Bleeding can cause direct damage
to the testicles, leading to testicular atrophy or dysfunction.
8. Compression of surrounding structures: The
expanding hematocele can compress surrounding

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structures like the testicles, epididymis, and spermatic
cord, causing further complications.

PATHOLOGY

Gross Pathology:
- Hematocele presents as a collection of blood in the
scrotal sac, which can be:
- Acute: Fresh blood, appearing red or purple
- Chronic: Older blood, appearing brown or yellowish
- Scrotal sac is distended, tense, and painful
- Testicles may be difficult to palpate due to the blood
collection

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Microscopic Pathology:
- Blood clotting and fibrin deposition
- Inflammatory response: neutrophils, macrophages, and
lymphocytes
- Fibroblastic proliferation and collagen deposition (in
chronic cases)
- Testicular tissue damage:
- Hemorrhage
- Infarction
- Atrophy
- Epididymal and spermatic cord involvement:
- Hemorrhage
- Inflammation
- Fibrosis

Histopathological Features:
Histological features of a hematocele are as follows;
- Blood collection in the scrotal sac

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- Testicular tissue damage and inflammation
- Fibrosis and scarring (in chronic cases)
- Evidence of bleeding and hemorrhage

SYMPTOMS
 Unusual lump
 Sudden pain
 Dull aching pain
 Feeling heavy in the scrotum
 Pain radiating throughout the groin, abdomen, or lower
back
 Tender, swollen, or hardened testicle
 Tender, swollen, or hardened epididymis,
 Swelling in the scrotum

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 Redness of the skin of the scrotum

SIGNS
 Oval\pear shaped
 Rugosities absent
 Local temp normal
 Tense swelling
 Tender\Non tender
 Skin freely mobile
 Testis not separately palpable
 Can get above the swelling
 Non reducible
 Impulse on coughing +nt
 Dull on percussion
 Fluctuation +nt
 Transillumation –ve

DIAGNOSIS
1. Physical Examination:
Inspection: Scrotal swelling, bruising, or discoloration

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Palpation: Tenderness, scrotal mass, or abnormal
testicular consistency
Transillumination: May help identify fluid collection

2. Imaging Studies:
- Ultrasound (USG): Confirms fluid collection, rules out
testicular rupture or torsion
- Computed Tomography (CT) scan: Useful in complex
cases or suspected underlying conditions
- Magnetic Resonance Imaging (MRI): May help identify
underlying testicular pathology

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3. Laboratory Tests:
- Complete Blood Count (CBC): Evaluates for infection or
inflammation
- Blood Urea Nitrogen (BUN) and Creatinine: Assesses
renal function
- Urinalysis: Rules out urinary tract infection or other
conditions

4. Scrotal Exploration:
- Surgical exploration to confirm diagnosis and evacuate
blood clot

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5. Diagnostic Criteria:
- Acute hematocele: Sudden onset, severe pain, and
swelling
- Chronic hematocele: Gradual onset, mild pain, and
swelling

6. Imaging Findings:
- Ultrasound: Anechoic or hypoechoic fluid collection
- CT scan: Fluid collection with or without testicular
enhancement
- MRI: Fluid collection with or without testicular signal
changes
Accurate diagnosis is crucial to guide appropriate
management and prevent complications. A combination of
physical examination, imaging studies, and laboratory
tests helps confirm the diagnosis of hematocele.

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INVESTIGATIONS

1. Ultrasound (USG):

 - Confirms fluid collection in the scrotum

 - Rules out testicular rupture or torsion
 - Guides needle aspiration or surgical exploration

2. Computed Tomography (CT) scan:

 Useful in complex cases or suspected underlying

conditions
 Evaluates for testicular trauma, tumor, or
inflammation

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3. Magnetic Resonance Imaging (MRI):

 Helps identify underlying testicular pathology

 Assesses testicular viability and function

4. Color Doppler US:

 Evaluates testicular blood flow and rules out torsion

5. Fine-Needle Aspiration (FNAC):

Contraindicated

6. Testicular Biopsy:
Histopathological evaluation of testicular tissue

Investigations are chosen based on the severity and

duration of symptoms, physical examination findings, and
suspected underlying conditions. A combination of
imaging studies, laboratory tests, and surgical exploration
helps confirm the diagnosis and guide appropriate
management.

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DIFFERENTIAL DIAGNOSIS

1) INGUINAL HERNIA

Inguinal hernia is the protrusion of abdominal

contents through the inguinal canal.

 We can’t get above the swelling

 Reducibility +ve

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2)HYDROCELE

Hydrocele is the abnormal fluid collection in the

scrotum between the visceral and parietal layers of tunica
vaginalis
 Transillumination test is +ve

3)TESTICULAR TUMOR

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A testicular tumor is an abnormal growth or mass that develops
in the testicles, which are part of the male reproductive system.
Testicular tumors can be benign (non-cancerous) or malignant
(cancerous).
 Swelling is hard
 Nodular testis
 Firm to hard in consistency

4)EPIDIDYMOORCHITIS

Epididymoorchitis is a medical condition characterized by

inflammation of the epididymis (a tube that stores and
transports sperm) and the testicle (orchitis). It is usually caused
by a bacterial infection, typically originating from a urinary tract
infection (UTI) or sexually transmitted infection (STI).
 Tenderness +ve
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  Structure appears red and black
 Skin over the swelling is adherent to the structure

5)TORSION OF TESTIS

Torsion of the testis, also known as testicular torsion, is a

medical emergency characterized by the twisting of the
spermatic cord, which supplies blood to the testicle. This
twisting causes the testicle to rotate and cuts off its own blood
supply, leading to ischemia and potential infarction (death) of
the testicle.
 Severe pain and tenderness
 Scrotum is empty
 Structure appears red and black

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6)VARICOCELE

Torsion of the testis, also known as testicular torsion, is a

medical emergency characterized by the twisting of the
spermatic cord, which supplies blood to the testicle. This
twisting causes the testicle to rotate and cuts off its own blood
supply, leading to ischemia and potential infarction (death) of
the testicle
 Soft boggy type of swelling
 Reducibility +ve (inverted ink bottle appearance)

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7)EPIDIDYMAL CYST OR SPERMATOCELE

Fluid filled swellings connected with the epididymis.

If cyst contains clear fluid it is known as epididymal cyst.
However, if the fluid is grey opaque and contains few
spermatozoa, it is called as spermatocele.

 Lies above and slightly behind the testis

 Testis can be felt separately
 Transillumination test is +ve

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COMPLICATIONS

1. Infection: Bacterial or fungal infection can occur, leading to

abscess formation, sepsis, or testicular abscess.

2. Testicular atrophy: Prolonged compression or ischemia can

cause testicular shrinkage or atrophy.

3. Infertility: Hematocele can affect sperm production, count,

or quality, leading to infertility or subfertility.

4. Chronic pain: Persistent pain or discomfort in the scrotum or

testicle can occur.

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5. Recurrence: Hematocele can recur if the underlying cause is
not treated or if there is a new injury.

6. Testicular rupture: Delayed or inadequate treatment can

lead to testicular rupture, requiring emergency surgery.

7. Scrotal abscess: Infected blood collection can form an

abscess, requiring drainage or surgical intervention.

8. Sepsis: Bacterial infection can spread through the

bloodstream, leading to life-threatening sepsis.

9. Testicular gangrene: Ischemia can cause testicular tissue

death, requiring orchiectomy (testicular removal).

10. Psychological impact: Hematocele can cause anxiety,

depression, or emotional distress due to pain, discomfort, or
fertility concerns.

11. Increased risk of testicular cancer: Chronic inflammation or

testicular damage may increase the risk of testicular cancer.
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12. Hydrocele formation: Hematocele can lead to hydrocele
(fluid collection) due to testicular damage or inflammation.

13. Epididymitis: Inflammation can spread to the epididymis,

causing epididymitis.

14. Orchitis: Inflammation can spread to the testicle, causing

orchitis.

15. Systemic complications: Sepsis, shock, or multi-organ

failure can occur in severe cases.

PROGNOSIS
The prognosis for hematocele is generally good, but it depends
on the underlying cause and severity of the condition . Here are
some possible outcomes:
- Most cases can be treated easily: Hematocele can be treated
with minor or more serious medical procedures, depending on
the severity of the condition.

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- Long-term complications are possible: Hematocele can affect
the health or function of the testicle, leading to delayed or poor
development, infertility, or other complications.
- Recovery can take weeks: After surgical treatment, it may take
several weeks for the patient to recover fully from the
procedure.
- Early detection is key: Regular medical checkups can help
detect hematocele early, which is important for effective
treatment and preventing long-term complications.
- Life expectancy depends on severity and underlying cause:
The life expectancy of individuals with hematocele will depend
on the severity of the condition and any underlying causes that
may have contributed to its development.

TREATMENT
Most hematoceles will require minor or more serious
medical procedures depending on the severity.
The repair of a hematocele rupture may be difficult,
especially if it is circumferential. This is because in such
cases a large portion of parenchyma is herniated and may
already be necrotic.

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If the hematocele is relatively small and does not cause a
lot of pain, conservative treatment such as foot elevation
and bed rest may be sufficient.
In more severe cases, surgical intervention may become
necessary. Surgery may be performed to drain the
accumulated blood from the scrotum.
If a testicular tumor is found to be the cause of the
bleeding, the entire testicle is generally removed to
prevent cancer from spreading to other parts of the body.
If surgery becomes necessary to treat the hematocele, it
may take several weeks for the patient to recover fully
from the procedure. This is due to the fact that the scrotum
tends to swell after the surgery. This swelling can cause
discomfort or pain that does not easily go away.
Prescription medications are often given to help the
patient recover from the surgery.
Regular medical checkups can help a doctor to look out
for any type of hematocele.
Early detection is the key in treating most medical
conditions. With different types of hematoceles,
complications can develop very quickly so it is particularly
important to receive an early diagnosis.
In order to prevent hematoceles, it is important to have
testicular self-exams to help find abnormalities sooner.
Doing this can help to understand what is normal in the
body and be able to detect abnormalities in the body.
This can include examining testicles once a month,
especially if the person has had previous testicular cancer
or a history of testicular cancer.
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SURGICAL TREATMENT
 EVERTION OF SAC
Jaboulay’s procedure

Before doing Jaboulay's Procedure (Eversion of sac) it is

important to exclude testicular tumor as the scrotal
approach is contra-indicated in testicular tumors.

Steps:
Patient in supine position, the parts are cleaned and
draped. If the hydrocoele is large it is recommended to do
the surgery in spinal or general anaesthesia. In case of
small hematocoeles it can done in local anaesthesia.
Local anaesthesia is infiltrated at the proposed incision
site and cord block is also given. It is important to use only
plain lignocaine without adrenaline. Adrenaline is contra-

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indicated for cord block at the testicular arteries are the
end arteries.
1. Vertical paramedian incision is given
2. Incision is deepened and sub-dartos plane developed.
3. Hydrocoele sac delivered from the incision.
4. Hydrocoele fluid drained and excess sac excised
5.Eversion of the tunica vaginalis sac

6. Wound is closed in layers after achieving hemostasis

7. Scrotal bandage or coconut bandage applied for scrotal
support.

Steps in details
The scrotum is firmly grasped by the assistant to make the
skin tense. The incision is given in paramedian plane to
the median raphe anteriorly. The testis lies posterio-
inferior. In small hydrocoeles transverse incision can also
be given. The transverse incision has advantage of less
bleeding and more cosmetic (Langer's line run
transversely over the scrotum). Around 5 to 6 cm long
incision is given depending on the size of the
hematocoele. Skin, dartos and thin cremasteric fascia are
incised and reflected back together as a single layer from

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the underlying parietal layer of the tunica vaginalis which
is the outer wall of the hematocoele. If this plane is not
developed prior to the fluid removal and delivering of the
testis it become difficult to avert the sac and reposition the
testis back after surgery. The hematocoele sac is
delivered out of the incision. When hematocoele well
separated laterally and medially from overlying layers, it is
grasped with 2 Babcock’s forceps and incision is given
over the delivered hematocoele sac to drain the fluid. If the
hematocoele sac has not been completely dissection
before the drainage of the fluid, then with one finger inside
the sac, dissect it free from the overlying scrotum so that
spermatic cord and testicle with attached hematocoele lie
free in operative field. Hematocoele sac is then opened
completely. Testicle is then carefully inspected and
palpated. Redundant wall sac is trimmed leaving a margin
of 2cm. Great care must be taken with haemostasis. Sac
is then averted behind testis with interrupted suture.
Wound is closed in layers.

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Lord’s placation procedure

Lord's plication is a surgical procedure that

involves bunching the tunica into a ruff with a series of
interrupted chromic catgut sutures to form fibrous
tissue. It's often used for small to medium-sized
hydroceles or hematoceles with thin sacs and has a lower
risk of hematoma than the Jaboulay procedure.

Here are some steps in the Lord's plication procedure:

 Make a small skin incision to open the hydrocele

 Reduce the hydrocele sac by suturing it
 Evert the sac behind the testis with an interrupted
suture
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  Close the wound in layers

Lord's plication has a lower complication rate because it

minimizes dissection. However, there is a risk of
hematocele recurrence if the edges of the tunica vaginalis
grow back.

Sharma and Jhawer’s Procedure

The Sharma and Jhawer technique is a surgical procedure

for treating hydroceles, which are fluid-filled sacs around
the testicles that cause swelling in the scrotum. The
procedure involves:

 Making a 4 cm incision in the scrotum, avoiding

subcutaneous vessels
 Using tissue forceps to pick up the sac and fascial
layers together
 Emptying the sac with a trocar and cannula
 Extending the incision on either side, avoiding blood
vessels

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  Creating a space between the scrotal subcutaneous
layer and the testicular fascial layers to lodge the
testis with its sac.

A CASE STUDY ON HEMATOCELE

Patient Information:
- Name: Raghav Tyagi
- Age: 32
- Occupation: Construction worker
- Medical History: No previous surgeries or medical
conditions
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Presentation:
- Raghav presented to the emergency department with a
2-day history of sudden onset of severe left scrotal pain
and swelling.
- He reported a traumatic injury to the scrotum while
working on a construction site.
- Physical examination revealed a large, tender, and
ecchymotic (bruised) left scrotum.

Diagnosis:
- Ultrasound and CT scans confirmed a large left
hematocele (blood collection) surrounding the testicle.
- The testicle itself appeared normal.

Treatment:
- John underwent emergency surgical exploration and
evacuation of the hematocele.
- The procedure revealed a significant amount of blood
and clot surrounding the testicle, which was removed.
- The testicle was found to be intact and viable.

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Post-Operative Course:
- Raghav recovered well from the surgery, with significant
improvement in pain and swelling.
- He was discharged from the hospital on post-operative
day 2.
- Follow-up appointments revealed normal testicular
function and no long-term complications.

Discussion:
- Hematocele is a rare but potentially serious condition
that requires prompt medical attention.
- Trauma is a common cause of hematocele, as seen in
this case.
- Surgical intervention is often necessary to evacuate the
blood collection and prevent long-term complications such
as testicular atrophy or infertility.
- Early detection and treatment can lead to excellent
outcomes, as seen in this case.

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Conclusion:
- Raghav’s case highlights the importance of prompt
medical attention for scrotal trauma and the potential for
excellent outcomes with appropriate treatment.
- Hematocele is a rare but significant condition that should
be considered in the differential diagnosis of scrotal pain
and swelling.

- Hematocele is a rare but potentially serious condition

that requires prompt medical attention.
- Trauma is a common cause of hematocele, as seen in
this case.
- Surgical intervention is often necessary to evacuate the
blood collection and prevent long-term complications such
as testicular atrophy or infertility.
- Early detection and treatment can lead to excellent
outcomes, as seen in this case.

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 REFERENCES

 SRB,s MANUAL OF SURGERY

 MANIPAL MANUAL OF SURGERY
 BAIELY,S AND LOVE SHORT PRACTICE OF
SURGERY
 A MANUAL ON CLINICAL SURGERY BY S DAS
 SLIDESHARE PPT
 SCRIBD.COM
 HEALTHLINE.COM
 NATIONAL INSTITUTE OF HEALTH.GOV
 META AI
 SCIENCE DIRECT.COM
 WIKIPEDIA.COM
 WWW.YOUTUBE.COM
 RADIOPAEDIA.COM
 CLASSWORK NOTES
 LONG CASES IN GENERAL SURGERY BY
RAJMAHENDRAN
 SURGERY ESSENCE BY PRITESH SINGH
 URODYNAMICS MADE EASY BY CHRISTOPHER
CHAPPLE

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