A hematocele is a collections of

blood Blood is a body fluid in the circulatory system of humans and other vertebrates that delivers necessary substances such as nutrients and oxygen to the cells, and transports metabolic waste products away from those same cells. Blood in the c ...

in a

body cavity A body cavity is any space or compartment, or potential space, in an animal body. Cavities accommodate organs and other structures; cavities as potential spaces contain fluid. The two largest human body cavities are the ventral body cavity, and ...

potential space In anatomy, a potential space is a space between two adjacent structures that are normally pressed together (directly apposed). Many anatomic spaces are potential spaces, which means that they are potential rather than realized (with their realiz ...

. The term most commonly refers to the collection of blood in the

tunica vaginalis The tunica vaginalis is the pouch of serous membrane that covers the testes. It is derived from the vaginal process of the peritoneum, which in the fetus precedes the descent of the testes from the abdomen into the scrotum. After its descent, ...

around the

testes A testicle or testis (plural testes) 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 testoster ...

, known as a ''scrotal hematocele''. Hematoceles can also occur in the

abdominal cavity The abdominal cavity is a large body cavity in humans and many other animals that contains many organs. It is a part of the abdominopelvic cavity. It is located below the thoracic cavity, and above the pelvic cavity. Its dome-shaped roof is the th ...

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 The scrotum or scrotal sac is an anatomical male reproductive structure located at the base of the penis that consists of a suspended dual-chambered sac of skin and smooth muscle. It is present in most terrestrial male mammals. The scrotum cont ...

usually in men older than 50 years. A scrotal mass is a lump or bulge that can be felt in the scrotum. The scrotum is the sac that contains the

testicle A testicle or testis (plural testes) 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 testostero ...

s. A scrotal mass can be noncancerous (

benign Malignancy () is the tendency of a medical condition to become progressively worse. Malignancy is most familiar as a characterization of cancer. A ''malignant'' tumor contrasts with a non-cancerous benign tumor, ''benign'' tumor in that a malign ...

) or cancerous (

malignant Malignancy () is the tendency of a medical condition to become progressively worse. Malignancy is most familiar as a characterization of cancer. A ''malignant'' tumor contrasts with a non-cancerous ''benign'' tumor in that a malignancy is not s ...

). Benign scrotal masses will include hematocele which is a blood collection in the scrotum. A scrotal hematocele is also called a hemoscrotum (or haemoscrotum in

British English British English (BrE, en-GB, or BE) is, according to Lexico, Oxford Dictionaries, "English language, English as used in Great Britain, as distinct from that used elsewhere". More narrowly, it can refer specifically to the English language in ...

). Scrotal masses are abnormalities in the bag of skin hanging behind the penis (scrotum). The scrotum contains the testicles and related structures that produce, store and transport sperm and male sex hormones. Hemoscrotum can follow

trauma Trauma most often refers to: * Major trauma, in physical medicine, severe physical injury caused by an external source * Psychological trauma, a type of damage to the psyche that occurs as a result of a severely distressing event *Traumatic i ...

(such as a straddle injury) or can be a complication of surgery. It is often accompanied by

testicular pain 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. Causes range from non serious musc ...

. It has been reported in patients with

hemophilia Haemophilia, or hemophilia (), is a mostly inherited genetic disorder that impairs the body's ability to make blood clots, a process needed to stop bleeding. This results in people bleeding for a longer time after an injury, easy bruising, ...

and following

catheterization In medicine, a catheter (/ˈkæθətər/) is a thin tube made from medical grade materials serving a broad range of functions. Catheters are medical devices that can be inserted in the body to treat diseases or perform a surgical procedure. Cath ...

of the

femoral artery The femoral artery is a large artery in the thigh and the main arterial supply to the thigh and leg. The femoral artery gives off the deep femoral artery or profunda femoris artery and descends along the anteromedial part of the thigh in the fem ...

. If the diagnosis is not clinically evident,

transillumination Transillumination is the technique of sample illumination by transmission of light through the sample. Transillumination is used in a variety of methods of imaging. Microscopy In microscopy transillumination refers to the illumination of a sample ...

(with a penlight against the scrotum) will show a non-translucent fluid inside the

Ultrasound imaging Medical ultrasound includes diagnostic techniques (mainly medical imaging, imaging techniques) using ultrasound, as well as therapeutic ultrasound, therapeutic applications of ultrasound. In diagnosis, it is used to create an image of internal ...

may also be useful in confirming the diagnosis. In severe or non-resolving cases, surgical

incision and drainage Incision and drainage (I&D), also known as clinical lancing, are minor surgical procedures to release pus or pressure built up under the skin, such as from an abscess, boil, or infected paranasal sinus. It is performed by treating the area with an ...

may be required. To prevent recurrence following surgical drainage, a

drain Drain may refer to: Objects and processes * Drain (plumbing), a fixture that provides an exit-point for waste water or for water that is to be re-circulated on the side of a road * Drain (surgery), a tube used to remove pus or other fluids from ...

may be left at the surgical site.

Signs and Symptoms

Variation in signs and symptoms will depend on the abnormality present and medical history. Variation exists in hematoceles due to the location of the lesion and onset of the hematocele. It is important to seek emergency medical care if developing sudden pain in the scrotum to avoid damage to the

that can be permanent. The signs and symptoms listed below are relating to hematoceles and associated conditions that can be due to other causes such as

testicular cancer 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. Risk factors include an u ...

or testicular torsion: * Unusual lump * Sudden pain * Dull aching pain or feeling heavy in the scrotum * Pain radiating throughout the groin, abdomen, or lower back * Tender, swollen, or hardened testicle * Tender, swollen, or hardened epididymis, the soft, comma-shaped tube above and behind the testicle that stores and transports

sperm Sperm is the male reproductive cell, or gamete, in anisogamous forms of sexual reproduction (forms in which there is a larger, female reproductive cell and a smaller, male one). Animals produce motile sperm with a tail known as a flagellum, whi ...

* Swelling in the scrotum * Redness of the skin of the scrotum *

Nausea Nausea is a diffuse sensation of unease and discomfort, sometimes perceived as an urge to vomit. While not painful, it can be a debilitating symptom if prolonged and has been described as placing discomfort on the chest, abdomen, or back of the ...

vomiting Vomiting (also known as emesis and throwing up) is the involuntary, forceful expulsion of the contents of one's stomach through the mouth and sometimes the Human nose, nose. Vomiting can be the result of ailments like Food-poisoning, foo ...

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

Pus Pus is an exudate, typically white-yellow, yellow, or yellow-brown, formed at the site of inflammation during bacterial or fungal infection. An accumulation of pus in an enclosed tissue space is known as an abscess, whereas a visible collection ...

* Pus or blood in the urine *

Fever Fever, also referred to as pyrexia, is defined as having a body temperature, temperature above the human body temperature, normal range due to an increase in the body's temperature Human body temperature#Fever, set point. There is not a single ...

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. Scrotal masses could be cancerous or caused by another condition that affects testicular function and health. A hematocele is one of the most common

sequela A sequela (, ; usually used in the plural, sequelae ) is a pathological condition resulting from a disease, injury, therapy, or other trauma. Derived from the Latin word, meaning “sequel”, it is used in the medical field to mean a complication ...

e of

testicular trauma Testicular trauma is an injury to one or both testicles. Types of injuries include blunt, penetrating and degloving. Because the testes are located within the scrotum, which hangs outside of the body, they do not have the protection of muscles an ...

. A traumatic hematocele usually results from testicular rupture (80% of cases) or a tear in the pampiniform plexus veins.

Testicular rupture Testicular rupture is a rip or tear in the Tunica albuginea of testis, tunica albuginea resulting in extrusion of the testicle, testicular contents, including the seminiferous tubules. It is a rare complication of testicular trauma, and can result f ...

and

testicular torsion Testicular torsion occurs when the spermatic cord (from which the testicle is suspended) 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 u ...

are also common causes of scrotal hematocele. It can also be caused by

kidney The kidneys are two reddish-brown bean-shaped organs found in vertebrates. They are located on the left and right in the retroperitoneal space, and in adult humans are about in length. They receive blood from the paired renal arteries; blood ...

injury,

pancreatitis Pancreatitis is a condition characterized by inflammation of the pancreas. The pancreas is a large organ behind the stomach that produces digestive enzymes and a number of hormones. There are two main types: acute pancreatitis, and chronic pancr ...

hematological Hematology ( always spelled haematology in British English) is the branch of medicine concerned with the study of the cause, prognosis, treatment, and prevention of diseases related to blood. It involves treating diseases that affect the produc ...

dysfunction, or

vasculitis Vasculitis is a group of disorders that destroy blood vessels by inflammation. Both arteries and veins are affected. Lymphangitis (inflammation of lymphatic vessels) is sometimes considered a type of vasculitis. Vasculitis is primarily caused b ...

. There are different disorders that can result as a consequence or a hematocele which include: *

Testicular cancer 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. Risk factors include an u ...

Spermatocele Spermatocele is a fluid-filled cyst that develops at the top of the testicle of 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 ...

Epididymitis 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 ...

Orchitis Orchitis is inflammation of the testes. It can also involve swelling, pains and frequent infection, particularly of the epididymis, as in epididymitis. The term is from the Ancient Greek ὄρχις meaning "testicle"; same root as ''orchid''. S ...

Hydrocele 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 testi ...

* Variocele *

Inguinal hernia An inguinal 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 ...

Testicular torsion Testicular torsion occurs when the spermatic cord (from which the testicle is suspended) 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 u ...

Pathophysiology

Chronic hematocele is rare. The direct cause of hematoceles is still unknown. Hematoceles can be classified into idiopathic and secondary ones. 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. Secondary hematoceles are usually associated with trauma, surgery, or neoplasm, but can also be caused by hematological alterations, or

. Presumably minor trauma results in rupture of dilated

microvessels The microcirculation is the circulation of the blood in the smallest blood vessels, the microvessels of the microvasculature present within organ tissues. The microvessels include terminal arterioles, metarterioles, capillaries, and venules. ...

beneath the fibrous capsule. Hematoceles present as slowly progressing. The duration of swellings of hematoceles can last months to decades. Usually there is no pain, but discomfort and heavyness is most common in the scrotum. 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. If the hematocele is older, the tunica sac appears filled with spongy material several times larger than the testicular volume. Most of this material is

fibrin Fibrin (also called Factor Ia) is a fibrous, non-globular protein involved in the clotting of blood. It is formed by the action of the protease thrombin on fibrinogen, which causes it to polymerize. The polymerized fibrin, together with platele ...

and cholesterol granulomas . In chronic hematocele the blood clot is totally or partially consisting of connective tissue that contains numerous newly formed blood vessels and hemosiderin-laden

macrophage Macrophages (abbreviated as M φ, MΦ or MP) ( el, large eaters, from Greek ''μακρός'' (') = large, ''φαγεῖν'' (') = to eat) are a type of white blood cell of the immune system that engulfs and digests pathogens, such as cancer cel ...

s. 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 Metaplasia ( gr, "change in form") is the transformation of one differentiated cell type to another differentiated cell type. The change from one type of cell to another may be part of a normal maturation process, or caused by some sort of abno ...

Scrotal Doppler ultrasonography of hematocele

Diagnosis

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

Physical exam In a physical examination, medical examination, or clinical examination, a medical practitioner examines a patient for any possible medical signs or symptoms of a medical condition. It generally consists of a series of questions about the patie ...

Ultrasound Ultrasound is sound waves with frequency, frequencies higher than the upper audible limit of human hearing range, hearing. Ultrasound is not different from "normal" (audible) sound in its physical properties, except that humans cannot hea ...

Urine test A urine test is any medical test performed on a urine specimen. The analysis of urine is a valuable diagnostic tool because its composition reflects the functioning of many body systems, particularly the kidneys and urinary system, and specimens a ...

Blood test A blood test is a laboratory analysis performed on a blood sample that is usually extracted from a vein in the arm using a hypodermic needle, or via fingerprick. Multiple tests for specific blood components, such as a glucose test or a cholester ...

* CT scan *

MRI scan Magnetic resonance imaging (MRI) is a medical imaging technique used in radiology to form pictures of the anatomy and the physiological processes of the body. MRI scanners use strong magnetic fields, magnetic field gradients, and radio waves ...

Differential diagnosis of hematocele includes testicular tumor, testicular torsion, and

epididymitis 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 ...

. In a blood test or urine test, serum levels of tumor markers such as (

alpha-fetoprotein Alpha-fetoprotein (AFP, α-fetoprotein; also sometimes called alpha-1-fetoprotein, alpha-fetoglobulin, or alpha fetal protein) is a protein that in humans is encoded by the ''AFP'' gene. The ''AFP'' gene is located on the ''q'' arm of chromosome 4 ...

carcinoembryonic antigen Carcinoembryonic antigen (CEA) describes a set of highly related glycoproteins involved in cell adhesion. CEA is normally produced in gastrointestinal tissue during fetal development, but the production stops before birth. Consequently, CEA is ...

, β-human chorionic gonadotropin) can help to reveal if testicular cancer is present which can help with the differential diagnosis. When there is no certain cause, a diagnosis of idiopathic scrotal hematocele will be made. In the case of chronic idiopathic scrotal hematocele, a history of trauma to the

perineum The perineum in humans is the space between the anus and scrotum in the male, or between the anus and the vulva in the female. The perineum is the region of the body between the pubic symphysis (pubic arch) and the coccyx (tail bone), includi ...

is usually denied, which is a key evidence for the diagnosis of scrotal hematocele that is idiopathic. If no evidence of hematological alterations or vasculitis is present, that can indicate for another possible cause of scrotal hematocele.

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 Parenchyma () is the bulk of functional substance in an animal organ or structure such as a tumour. In zoology it is the name for the tissue that fills the interior of flatworms. Etymology The term ''parenchyma'' is New Latin from the word π ...

is herniated and may already be necrotic. 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.

Prognosis

The life expectancy of all individuals with hematoceles will depend on the severity and the underlying causes that could have led to hematoceles. Not all hematoceles will result in long term complications. However they can affect the health or function of the testicle that can lead to: * Delayed or poor development if at a young age *

Infertility Infertility is the inability of a person, animal or plant to reproduce by natural means. It is usually not the natural state of a healthy adult, except notably among certain eusocial species (mostly haplodiploid insects). It is the normal state ...

Th hematocele severity will depend if symptomatic or asymptomatic. Regardless of the condition, there can be increased conditions that can arise that can worsen the hematocele. If surgically removed, the patient may be partially or completely disabled for a number of weeks following surgery, causing such a procedure to be performed only in the most extreme cases.

Epidemiology

Hematoceles should be cleared quickly to avoid pressure of the atrophy of the

. Rare complication can results such as infection, suppupation, and scrotal

gangrene Gangrene is a type of tissue death caused by a lack of blood supply. Symptoms may include a change in skin color to red or black, numbness, swelling, pain, skin breakdown, and coolness. The feet and hands are most commonly affected. If the ga ...

Research Directions

Hematoceles are rare, making them harder to diagnose and treat. 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. The case study presents the patient with no history of any trauma or previous surgery, and general physical condition being normal. On examination, right testis was enlarged, hard and non tender with loss of testicular sensation. The pathological diagnosis was consistent with chronic hematocele. Current research is ongoing for proper diagnosis and helping to differentiate among other conditions. Doppler ultrasound in a

retrospective A retrospective (from Latin ''retrospectare'', "look back"), generally, is a look back at events that took place, or works that were produced, in the past. As a noun, ''retrospective'' has specific meanings in medicine, software development, popu ...

study was shown to be helpful for differential diagnosis of patients with acute scrotum. Accuracy of imaging studies is higher for the differential diagnosis of

and epididmo-orchitis, which there can still be the possibility of misdiagnosis for hematoceles due to testicular torsion. Further research in this area shows importance for surgical decision making in hematoceles. Scrotal masses are a common presentation in primary care, and a painful scrotum accounts for 1% of emergency department visits. 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.

References

External links

{{Bleeding and clotting disorders, us=y Male genital disorders Scrotum