Hematocele

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Hematocele
Hemoscrotum.JPEG
A massive hemoscrotum (scrotal hematoma) which occurred as a complication of inguinal hernia repair. The scrotum was explored surgically, and a drain was left behind (seen on the right thigh). A Foley catheter is in place to prevent urinary retention.
Specialty Urology

A hematocele is a collections of blood in a body cavity or potential space. [1] The term most commonly refers to the collection of blood in the tunica vaginalis around the testes, known as a scrotal hematocele. [2] [3] Hematoceles can also occur in the abdominal cavity [4] and other body cavities. [5] [6] Hematoceles are rare, making them harder to diagnose and treat. [7] They are very common especially as slowly growing masses in the scrotum usually in men older than 50 years. [8]

Contents

A scrotal mass is a lump or bulge that can be felt in the scrotum. [2] The scrotum is the sac that contains the testicles. [2] A scrotal mass can be noncancerous (benign) or cancerous (malignant). [2] Benign scrotal masses will include hematocele which is a blood collection in the scrotum. [2]

A scrotal hematocele is also called a hemoscrotum (or haemoscrotum in British English). Scrotal masses are abnormalities in the bag of skin hanging behind the penis (scrotum). [7] The scrotum contains the testicles and related structures that produce, store and transport sperm and male sex hormones. [7]

Hemoscrotum can follow trauma (such as a straddle injury) or can be a complication of surgery. It is often accompanied by testicular pain. It has been reported in patients with hemophilia and following catheterization of the femoral artery. If the diagnosis is not clinically evident, transillumination (with a penlight against the scrotum) will show a non-translucent fluid inside the scrotum. Ultrasound imaging may also be useful in confirming the diagnosis. In severe or non-resolving cases, surgical incision and drainage may be required. To prevent recurrence following surgical drainage, a drain may be left at the surgical site.[ citation needed ]

Signs and Symptoms

Variation in signs and symptoms will depend on the abnormality present and medical history. [8] [7] Variation exists in hematoceles due to the location of the lesion and onset of the hematocele. [9] It is important to seek emergency medical care if developing sudden pain in the scrotum to avoid damage to the testicle that can be permanent. [7] The signs and symptoms listed below are relating to hematoceles and associated conditions that can be due to other causes such as testicular cancer or testicular torsion: [7]

If the cause of the scrotal mass is due to infection then signs and symptoms may be the following: [7]

Cause

Scrotal masses might be an accumulation of fluids, the growth of abnormal tissue, or normal contents of the scrotum that have become swollen, inflamed or hardened. [7] Scrotal masses could be cancerous or caused by another condition that affects testicular function and health. [7] A hematocele is one of the most common sequelae of testicular trauma. [8] A traumatic hematocele usually results from testicular rupture (80% of cases) or a tear in the pampiniform plexus veins. [8] Testicular rupture and testicular torsion are also common causes of scrotal hematocele. [8] It can also be caused by kidney injury, pancreatitis, hematological dysfunction, or vasculitis. [8]

There are different disorders that can result as a consequence or a hematocele which include: [7]

Pathophysiology

Chronic hematocele is rare. The direct cause of hematoceles is still unknown. [10] Hematoceles can be classified into idiopathic and secondary ones. [10] Idiopathic or spontaneous hematoceles give no history of testicular cancer or past trauma to testis, no pain in the organ, and seems to be more common the older population. [10] Secondary hematoceles are usually associated with trauma, surgery, or neoplasm, but can also be caused by hematological alterations, or vasculitis. [8]

Presumably minor trauma results in rupture of dilated microvessels beneath the fibrous capsule.[ citation needed ]

Hematoceles present as slowly progressing. [10] The duration of swellings of hematoceles can last months to decades. [10] Usually there is no pain, but discomfort and heavyness is most common in the scrotum. [10] In hematocele of recent occurrence the tunica sac contains coagulated fresh blood. A hematocele that begins bleeding into itself, becoming a hemorrhagic cyst, can easily rupture and cause a number of problems. [11] If the hematocele is older, the tunica sac appears filled with spongy material several times larger than the testicular volume. [8] Most of this material is fibrin and cholesterol granulomas . [8] In chronic hematocele the blood clot is totally or partially consisting of connective tissue that contains numerous newly formed blood vessels and hemosiderin-laden macrophages. [8] Connective tissue facing the tunica cavity is lined by fibrin remnants. In its final stages the lesion consists of a thickened, fibrosed, and calcified tunica sac which may also show osseous metaplasia. [8]

Scrotal ultrasonography of a hematocele, a couple of weeks after appearance, as a fluid volume with multiple thick septations. The hematocele displays no blood flow on Doppler ultrasonography. A pyocele has a similar appearance, but was excluded by lack of inflammation. Scrotal Doppler ultrasonography of hematocele.jpg
Scrotal ultrasonography of a hematocele, a couple of weeks after appearance, as a fluid volume with multiple thick septations. The hematocele displays no blood flow on Doppler ultrasonography. A pyocele has a similar appearance, but was excluded by lack of inflammation.

Diagnosis

Hematoceles can be a challenge to diagnose since they can mimic cysts or neoplasms. [10] There can different exams used in combination to make a final diagnosis: [10]

Differential diagnosis of hematocele includes testicular tumor, testicular torsion, and epididymitis. [8] In a blood test or urine test, serum levels of tumor markers such as (alpha-fetoprotein, carcinoembryonic antigen, β-human chorionic gonadotropin) can help to reveal if testicular cancer is present which can help with the differential diagnosis. [12] When there is no certain cause, a diagnosis of idiopathic scrotal hematocele will be made. [8] In the case of chronic idiopathic scrotal hematocele, a history of trauma to the perineum is usually denied, which is a key evidence for the diagnosis of scrotal hematocele that is idiopathic. [8] If no evidence of hematological alterations or vasculitis is present, that can indicate for another possible cause of scrotal hematocele. [8]

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. [8]

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. [11] In more severe cases, surgical intervention may become necessary. [11] Surgery may be performed to drain the accumulated blood from the scrotum. [11] 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. [11] If surgery becomes necessary to treat the hematocele, it may take several weeks for the patient to recover fully from the procedure. [11] This is due to the fact that the scrotum tends to swell after the surgery. [11] This swelling can cause discomfort or pain that does not easily go away. [11] Prescription medications are often given to help the patient recover from the surgery. [11]

Regular medical checkups can help a doctor to look out for any type of hematocele. [11] Early detection is the key in treating most medical conditions. [11] With different types of hematoceles, complications can develop very quickly so it is particularly important to receive an early diagnosis. [11] In order to prevent hematoceles, it is important to have testicular self-exams to help find abnormalities sooner. [11] Doing this can help to understand what is normal in the body and be able to detect abnormalities in the body. [11] This can include examining testicles once a month, especially if the person has had previous testicular cancer or a history of testicular cancer. [7]

Prognosis

The life expectancy of all individuals with hematoceles will depend on the severity and the underlying causes that could have led to hematoceles. [8] Not all hematoceles will result in long term complications. [11] However they can affect the health or function of the testicle that can lead to: [7]

The hematocele severity will depend on whether it is symptomatic or asymptomatic. [11] If surgically removed, the recovery can take weeks, causing such a procedure to be performed only in extreme cases. [11]

Epidemiology

Hematoceles should be cleared quickly to avoid pressure of the atrophy of the parenchyma. [8] Rare complication can results such as infection, suppupation, and scrotal gangrene. [8]

Research Directions

Hematoceles are rare, making them harder to diagnose and treat.[ citation needed ]

Another case study presents an 18 male that presented with huge painless right sided scrotal mass which was gradually increasing in size and associated with dragging sensation. [12] The case study presents the patient with no history of any trauma or previous surgery, and general physical condition being normal. [12] On examination, right testis was enlarged, hard and non tender with loss of testicular sensation. [12] The pathological diagnosis was consistent with chronic hematocele. [12]

Current research is ongoing for proper diagnosis and helping to differentiate among other conditions. Doppler ultrasound in a retrospective study was shown to be helpful for differential diagnosis of patients with acute scrotum. [13] Accuracy of imaging studies is higher for the differential diagnosis of testicular torsion and epididmo-orchitis, which there can still be the possibility of misdiagnosis for hematoceles due to testicular torsion. [13] Further research in this area shows importance for surgical decision making in hematoceles. [13]

Scrotal masses are a common presentation in primary care, and a painful scrotum accounts for 1% of emergency department visits. [14] As of 2017, there has only been 35 cases reported so far in the known world literature, few scattered case reports published in medical journals of different languages.[ citation needed ]

Related Research Articles

<span class="mw-page-title-main">Testicle</span> Internal organ in the male reproductive system

A testicle or testis is the male reproductive gland or gonad in all bilaterians, including humans. It is homologous to the female ovary. The functions of the testes are to produce both sperm and androgens, primarily testosterone. Testosterone release is controlled by the anterior pituitary luteinizing hormone, whereas sperm production is controlled both by the anterior pituitary follicle-stimulating hormone and gonadal testosterone.

<span class="mw-page-title-main">Testicular torsion</span> Medical condition

Testicular torsion occurs when the spermatic cord twists, cutting off the blood supply to the testicle. The most common symptom in children is sudden, severe testicular pain. The testicle may be higher than usual in the scrotum and vomiting may occur. In newborns, pain is often absent and instead the scrotum may become discolored or the testicle may disappear from its usual place.

<span class="mw-page-title-main">Testicular cancer</span> Medical condition

Testicular cancer is cancer that develops in the testicles, a part of the male reproductive system. Symptoms may include a lump in the testicle or swelling or pain in the scrotum. Treatment may result in infertility.

<span class="mw-page-title-main">Cryptorchidism</span> Medical condition

Cryptorchidism, also known as undescended testis, is the failure of one or both testes to descend into the scrotum. The word is from Greek κρυπτός 'hidden' and ὄρχις 'testicle'. It is the most common birth defect of the male genital tract. About 3% of full-term and 30% of premature infant boys are born with at least one undescended testis. However, about 80% of cryptorchid testes descend by the first year of life, making the true incidence of cryptorchidism around 1% overall. Cryptorchidism may develop after infancy, sometimes as late as young adulthood, but that is exceptional.

<span class="mw-page-title-main">Hydrocele testis</span> Medical condition

A hydrocele testis is an accumulation of clear fluid within the cavum vaginale, the potential space between the layers of the tunica vaginalis of the testicle. It is the most common form of hydrocele and is often referred to simply as a "hydrocele". A primary hydrocele testis causes a painless enlargement in the scrotum on the affected side and is thought to be due to the defective absorption of fluid secreted between the two layers of the tunica vaginalis. A secondary hydrocele is secondary to either inflammation or a neoplasm in the testis.

<span class="mw-page-title-main">Epididymitis</span> Medical condition

Epididymitis is a medical condition characterized by inflammation of the epididymis, a curved structure at the back of the testicle. Onset of pain is typically over a day or two. The pain may improve with raising the testicle. Other symptoms may include swelling of the testicle, burning with urination, or frequent urination. Inflammation of the testicle is commonly also present.

<span class="mw-page-title-main">Cremasteric reflex</span> Human reflex affecting the testicles

The cremasteric reflex is a superficial reflex observed in human males.

<span class="mw-page-title-main">Orchiopexy</span> Surgery to fix a testicle into the scrotum

Orchiopexy is a surgery to move and/or permanently fix a testicle into the scrotum. While orchiopexy typically describes the operation to surgically correct an undescended testicle, it is also used to resolve testicular torsion.

<span class="mw-page-title-main">Inguinal hernia</span> Medical condition in which contents of the abdominal cavity protrude through the inguinal canal

An inguinal hernia or groin hernia, is a hernia (protrusion) of abdominal cavity contents through the inguinal canal. Symptoms, which may include pain or discomfort especially with or following coughing, exercise, or bowel movements, are absent in about a third of patients. Symptoms often get worse throughout the day and improve when lying down. A bulging area may occur that becomes larger when bearing down. Inguinal hernias occur more often on the right than left side. The main concern is strangulation, where the blood supply to part of the intestine is blocked. This usually produces severe pain and tenderness of the area.

<span class="mw-page-title-main">Spermatocele</span> Medical condition

Spermatocele is a fluid-filled cyst that develops in the epididymis. The fluid is usually a clear or milky white color and may contain sperm. Spermatoceles are typically filled with spermatozoa and they can vary in size from several millimeters to many centimeters. Small spermatoceles are relatively common, occurring in an estimated 30 percent of males. They are generally not painful. However, some people may experience discomfort such as a dull pain in the scrotum from larger spermatoceles. They are not cancerous, nor do they cause an increased risk of testicular cancer. Additionally, unlike varicoceles, they do not reduce fertility.

<span class="mw-page-title-main">Testicular atrophy</span> Reduction in the size and function of the testicles

Testicular atrophy is a medical condition in which one or both testicles diminish in size and may be accompanied by reduced testicular function. Testicular atrophy is not related to the temporary shrinkage of the surrounding scrotum, which might occur in response to cold temperature.

<span class="mw-page-title-main">Hydrocele</span> Accumulation of fluid in a body cavity

A hydrocele is an accumulation of serous fluid in a body cavity. A hydrocele testis, the most common form of hydrocele, is the accumulation of fluids around a testicle. It is often caused by fluid collecting within a layer wrapped around the testicle, called the tunica vaginalis, which is derived from peritoneum. Provided there is no hernia present, it goes away without treatment in the first year. Although hydroceles usually develop in males, rare instances have been described in females in the canal of Nuck.

<span class="mw-page-title-main">Testicular pain</span> Medical condition

Testicular pain, also known as scrotal pain, occurs when part or all of either one or both testicles hurt. Pain in the scrotum is also often included. Testicular pain may be of sudden onset or of long duration.

<span class="mw-page-title-main">Appendix of testis</span> Part of the testis

The appendix testis is a vestigial remnant of the Müllerian duct, present on the upper pole of the testis and attached to the tunica vaginalis. It is present about 90% of the time and is homologous to the fallopian tubes in females.

Testicular rupture is a rip or tear in the tunica albuginea resulting in extrusion of the testicular contents, including the seminiferous tubules. It is a rare complication of testicular trauma, and can result from blunt or penetrating trauma, although blunt trauma is more likely to cause rupture.

Testicular trauma is an injury to one or both testicles. Types of injuries include blunt, penetrating and degloving.

<span class="mw-page-title-main">Sperm granuloma</span> Lump of extravasated sperm found in some vasectomized men

A sperm granuloma is a lump of leaked sperm that appears along the vasa deferentia or epididymides in vasectomized individuals. While the majority of sperm granulomas are present along the vas deferens, the rest of them form at the epididymis. Sperm granulomas range in size, from one millimeter to one centimeter. They consist of a central mass of degenerating sperm surrounded by tissue containing blood vessels and immune system cells. Sperm granulomas may also have a yellow, white, or cream colored center when cut open. While some sperm granulomas can be painful, most of them are painless and asymptomatic. Sperm granulomas can appear as a result of surgery, trauma, or an infection. They can appear as early as four days after surgery and fully formed ones can appear as late as 208 days later.

<span class="mw-page-title-main">Orchiectomy</span> Surgical removal of one or both testicles

Orchiectomy is a surgical procedure in which one or both testicles are removed. The surgery can be performed for various reasons:

<span class="mw-page-title-main">Scrotal ultrasound</span> Medical ultrasound examination of the scrotum.

Scrotalultrasound is a medical ultrasound examination of the scrotum. It is used in the evaluation of testicular pain, and can help identify solid masses.

Male genital examination is a physical examination of the genital in males to detect ailments and to assess sexual development and is normally included in an annual physical examination. The examination includes checking the penis, scrotum, and urethral meatus. A comprehensive assessment of the male genitals assesses the pubic hair based on Sexual Maturity Rating and the size of the testicles and penis. The exam is conducted to detect various ailments, measure sexual development, or verify a person's age and biological sex. The genitourinary system can also be assessed as part of the male genital examination. During a genital examination, the doctor can detect any of the following: structural abnormalities, urethral opening abnormalities, problems related to uncircumcision, lumps, tumors, redness, excoriation, edema, lesions, swelling, cancer, hair-related issues and many others. In some instances where a physical examination of the male genitals is not sufficient to diagnose an individual than an internal genital examination using imaging or ultrasounds will be needed for further evaluation.

References

  1. ↑ "Dorlands Medical Dictionary:hematocele".
  2. 1 2 3 4 5 "Scrotal masses: MedlinePlus Medical Encyclopedia". medlineplus.gov. Retrieved 2020-12-18.
  3. ↑ Hematocele. Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health, Seventh Edition. © 2003 by Saunders.
  4. ↑ Ma, Z; Xu, B; Wang, L; Mao, Y; Zhou, B; Song, Z; Yang, T (5 January 2019). "Anticoagulants is a risk factor for spontaneous rupture and hemorrhage of gallbladder: a case report and literature review". BMC Surgery. 19 (1): 2. doi: 10.1186/s12893-018-0464-6 . PMC   6321697 . PMID   30611267.
  5. ↑ Manson, F. Ectopic pregnancy with negative serum hCG level. Archived 2020-04-06 at the Wayback Machine SonoWorld.com. 2006.
  6. ↑ Bedi, D., et al. (1984). Chronic ectopic pregnancy. J Ultrasound Med 3 347-52.
  7. 1 2 3 4 5 6 7 8 9 10 11 12 "Scrotal masses - Diagnosis and treatment - Mayo Clinic". www.mayoclinic.org. Retrieved 2020-11-12.
  8. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 "Hematocele - an overview | ScienceDirect Topics". www.sciencedirect.com. Retrieved 2020-11-12.
  9. ↑ Kühn, Anna L.; Scortegagna, Eduardo; Nowitzki, Kristina M.; Kim, Young H. (July 2016). "Ultrasonography of the scrotum in adults". Ultrasonography. 35 (3): 180–197. doi:10.14366/usg.15075. ISSN   2288-5919. PMC   4939719 . PMID   26983766.
  10. 1 2 3 4 5 6 7 8 Bibi, Mokhtar; Sellami, Ahmed; Taktak, Tarek; Kassar, Alia Zehani; Chehida, Mohamed Ali Ben; Chaker, Kays; Abid, Karem; Rhouma, Sami Ben; Nouira, Yassine (2018-08-01). "Idiopathic chronic hematocele mimicking a mesothelioma of the tunica vaginalis testis". Urology Case Reports. 20: 104–105. doi:10.1016/j.eucr.2018.07.022. ISSN   2214-4420. PMC   6083900 . PMID   30116715.
  11. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 "Hematocele - MediGoo - Health Tests and Free Medical Information". MediGoo - Health Medical Tests and Free Health Medical Information. Retrieved 2020-12-18.
  12. 1 2 3 4 5 Jain, Sunila; Garg, Richa; Sarangi, Rathindra (2015-03-01). "Chronic hematocele of testis – A mimicker of tumor". Current Medicine Research and Practice. 5 (2): 72–74. doi:10.1016/j.cmrp.2015.03.003. ISSN   2352-0817.
  13. 1 2 3 Ayvaz, Olga Devrim; Celayir, Aysenur Cerrah; Moralioglu, Serdar; Bosnali, Oktav; Pektas, Osman Zeki; Pelin, Ahmet Koray; Caman, Sefik (2016-01-10). "Four-year retrospective look for acute scrotal pathologies". Northern Clinics of Istanbul. 2 (3): 182–188. doi:10.14744/nci.2016.16768. ISSN   2536-4553. PMC   5175104 . PMID   28058365.
  14. ↑ Paul F. Crawford, I. I. I.; Crop, Justin A. (2014-05-01). "Evaluation of Scrotal Masses". American Family Physician. 89 (9): 723–727. ISSN   0002-838X. PMID   24784335.
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