What is a hemocele?

What is a Hemocele?

A hemocele (also spelled hematocele) is a collection of blood within the scrotum, specifically between the layers of the tunica vaginalis surrounding the testis.

Pathophysiology and Etiology

A hemocele represents an accumulation of blood in the potential space between the parietal and visceral layers of the tunica vaginalis, similar to a hydrocele but containing blood rather than serous fluid 1.

Common Causes

• Blunt scrotal trauma is the most common cause, including athletic injuries and motor vehicle collisions 1
• Testicular rupture is associated with hemocele in approximately 80% of traumatic cases 2
• Penetrating trauma from gunshot wounds or other assault mechanisms 1
• Iatrogenic injury following scrotal procedures 1
• Spontaneous rupture of pre-existing hydroceles, though rare 3

Rare Presentations

• Idiopathic hemoceles can occur without clear trauma history, though these are uncommon 4
• Communicating hemoceles associated with intra-abdominal pathology (such as splenic trauma) through a patent processus vaginalis have been reported, particularly in pediatric patients 5

Clinical Presentation

• Patients typically present with scrotal swelling and pain following trauma 1
• The affected hemiscrotum appears enlarged and may be tender on examination 2
• In cases without clear trauma history, hemoceles may be mistaken for testicular neoplasms 4

Diagnostic Approach

Ultrasound Imaging

Grayscale ultrasound is the first-line imaging modality for evaluating suspected hemocele 6, 1.

• Acute hematomas appear heterogeneous or isoechoic relative to surrounding testicular parenchyma 6
• Chronic hematomas become smaller and relatively hypoechoic to anechoic over time 6
• Color flow and duplex Doppler imaging should be added to assess testicular perfusion and viability 6, 1

Critical Diagnostic Distinction

• The key finding to identify is discontinuity of the echogenic tunica albuginea, which indicates testicular rupture 1
• This distinction is critical because testicular rupture requires emergent surgical exploration 1
• Grayscale ultrasound alone may not differentiate a hematoma from a mass without Doppler evaluation 6

Management

Surgical Indications

Emergent surgical exploration is indicated when testicular rupture is diagnosed, as this results in testicular salvage rates of 80-90% 1.

• Surgical management includes adequate débridement, primary repair of tunical laceration, and Penrose drainage 2
• This approach achieves a salvage rate of approximately 75% in cases of rupture-associated hemocele 2

Conservative Management

• Isolated hemoceles without testicular rupture may be managed conservatively with close monitoring 1
• However, early surgical treatment is generally recommended for hemoceles, particularly when enlarging or associated with uncertain etiology 3

Clinical Pitfalls

• Do not assume benign etiology without imaging: Hemoceles can mimic testicular neoplasms, and malignancy must be excluded 4
• Assess for associated testicular rupture: The high association (80%) between traumatic hemocele and testicular rupture mandates careful evaluation for tunica albuginea disruption 2
• Consider intra-abdominal pathology in pediatric patients: Communicating hemoceles may indicate serious abdominal injury such as splenic trauma 5
• Timely diagnosis is critical: Delayed recognition of testicular rupture significantly reduces salvage rates 1