Treatment of Spermatic Cord Hematoma
Conservative management is the first-line treatment for spermatic cord hematoma, consisting of rest, scrotal support, oral analgesics, and close monitoring, with surgical exploration reserved for cases with severe pain, expanding hematoma, or diagnostic uncertainty.
Diagnostic Approach
When evaluating a suspected spermatic cord hematoma, consider:
- Ultrasound examination is the primary diagnostic tool to confirm the diagnosis and rule out other conditions like testicular torsion or tumor
- MRI may provide additional information about the extent of the hematoma and surrounding structures
- Clinical presentation typically includes acute scrotal pain and swelling, often with a history of physical exertion, anticoagulation therapy, or trauma
Treatment Algorithm
1. Conservative Management (First-Line)
- Rest and limitation of physical activity
- Scrotal elevation and support
- Oral analgesics (NSAIDs or acetaminophen) for pain control
- Ice packs to reduce swelling in the first 24-48 hours
- Close monitoring for resolution of symptoms
2. Indications for Surgical Exploration
- Severe, uncontrolled pain despite conservative measures
- Expanding hematoma
- Diagnostic uncertainty (cannot rule out testicular torsion or tumor)
- Signs of infection or abscess formation
- Failure of conservative management after 2-3 weeks
3. Surgical Approach When Indicated
- Inguinal approach is preferred over scrotal approach
- Evacuation of hematoma
- Identification and control of bleeding source
- Preservation of testicular blood supply
Special Considerations
Anticoagulation-Related Hematomas
- Consider temporary discontinuation of anticoagulants if safe to do so
- More aggressive monitoring may be needed
- Lower threshold for surgical intervention if hematoma continues to expand
Post-Traumatic Hematomas
- Rule out associated testicular or scrotal injuries
- More likely to require surgical exploration to assess extent of damage
Follow-up Care
- Regular follow-up until complete resolution of symptoms
- Ultrasound to confirm resolution of hematoma
- Gradual return to normal activities as symptoms improve
Potential Complications
- Secondary infection
- Chronic pain
- Testicular atrophy (rare)
- Recurrence (particularly in cases of underlying varicocele)
Evidence and Limitations
The evidence for management of spermatic cord hematoma is limited to case reports and small case series 1, 2, 3. Most reported cases were initially misdiagnosed as other conditions such as incarcerated inguinal hernia or testicular torsion 1. The etiology may be idiopathic, traumatic, secondary to anticoagulation therapy, or as an extension of retroperitoneal hemorrhage 1.
In one case report, a patient with non-traumatic rupture of varicocele presenting with scrotal swelling and pain was successfully managed with conservative treatment using oral analgesics for several weeks 2. This suggests that non-surgical management can be effective in stable patients.
For cases requiring surgical intervention, the approach should follow principles similar to those used in testicular cancer surgery, with an inguinal approach preferred to minimize risk of complications 4.