Hematocele (Scrotal Hematocele)

What a hematocele is

The testicle sits inside a thin double-layered sac called the tunica vaginalis. A small amount of fluid normally lets it move freely. When blood collects in this space, it forms a hematocele. This is different from:

• a hydrocele, which is clear fluid in the same space
• a scrotal hematoma, blood in the scrotal wall itself, which often looks like extensive bruising
• an intratesticular hematoma, bleeding inside the testicle

Causes

• Blunt trauma: kicks, sports injuries, falls astride a bar or bicycle, motor vehicle accidents
• Surgery: inguinal hernia repair, hydrocele or varicocele surgery, vasectomy, testicular biopsy
• Penetrating injury
• Spontaneous bleeding: rare, linked to blood thinners, bleeding disorders, or a testicular tumor that bleeds
• Torsion of the testicle or its appendages, which can cause bleeding into the sac

Symptoms

• swelling of one side of the scrotum, sometimes large
• pain or aching, often worse with movement
• bruising of the scrotum, penis or groin
• a firm, heavy feeling, and the testicle may be hard to feel separately
• unlike a hydrocele, a hematocele does not glow when a light is shone through it

Diagnosis

A doctor will ask about the injury or surgery and examine the scrotum. The key test is a scrotal ultrasound with Doppler, which shows:

• the size of the blood collection
• whether the testicle's outer coat (tunica albuginea) is torn, meaning testicular rupture
• blood flow to the testicle, to rule out torsion
• any underlying tumor

Urine tests check for blood if the urethra may be injured. If a hematocele appears without injury, tumor markers and follow-up imaging look for testicular cancer.

Treatment

Small hematoceles

If the testicle is intact and the collection is small and stable:

• rest and limited activity for several days
• ice packs wrapped in a cloth, 15 to 20 minutes at a time, for the first 48 hours
• scrotal support with snug underwear or an athletic supporter
• pain relief: acetaminophen (paracetamol). NSAIDs may be avoided initially because they can increase bleeding; ask your doctor
• follow-up examination and sometimes a repeat ultrasound

Small hematoceles are usually reabsorbed over several weeks.

Large or expanding hematoceles

Many urologists recommend early surgical exploration for large hematoceles, even without a visible tear, because:

• conservative treatment of large collections often fails, needing later surgery
• clotted blood can press on the testicle and reduce blood flow
• early surgery shortens recovery and lowers the risk of losing the testicle

Surgery involves draining the blood, inspecting the testicle, and repairing any tear.

Testicular rupture

A ruptured testicle needs surgery as soon as possible, ideally within 72 hours, to repair the tear and save the testicle.

Complications

• infection of the collected blood (abscess)
• pressure damage and shrinking (atrophy) of the testicle
• chronic pain
• a chronic, calcified hematocele that can mimic a tumor
• loss of the testicle in severe or delayed cases

Prevention

Wear a protective cup for contact sports, cricket, baseball and martial arts. After scrotal surgery, follow advice on support, ice and activity restrictions.

Frequently asked questions

What is a hematocele?

A hematocele is a collection of blood in the sac around the testicle. It is usually caused by an injury to the scrotum or by surgery in the groin or scrotum. It causes swelling, pain and bruising.

How is a hematocele treated?

Small hematoceles with an intact testicle are treated with rest, ice, scrotal support and pain relief, and usually resolve over weeks. Large or expanding hematoceles and any testicular rupture are treated with surgery.

How long does a scrotal hematocele take to heal?

A small hematocele usually takes several weeks to be reabsorbed, with swelling gradually decreasing. Bruising fades in 1 to 3 weeks. After surgical drainage, most men recover within 2 to 4 weeks.

Is a hematocele dangerous?

It can be. The injury that causes a hematocele may also rupture the testicle, which needs surgery to save it. Large collections can press on the testicle. An ultrasound is important after any significant scrotal injury.

What is the difference between a hematocele and a hydrocele?

Both are collections around the testicle. A hematocele contains blood, usually after injury or surgery, and is often painful. A hydrocele contains clear fluid, is usually painless and develops gradually. Light shines through a hydrocele but not a hematocele.