Management of 2 cm Intratesticular Hematoma After Blunt Scrotal Trauma
Conservative management with close ultrasound surveillance is appropriate for an isolated 2 cm intratesticular hematoma when the tunica albuginea is intact, there is no hematocele, and testicular blood flow is preserved. 1, 2
Initial Assessment and Imaging
Your ultrasound evaluation must specifically document:
- Integrity of the tunica albuginea (no disruption or discontinuity) 3, 4
- Absence of hematocele (fluid collection outside the testis but within tunica vaginalis) 4, 2
- Preserved testicular blood flow on color Doppler imaging 3, 1
- No extrusion of seminiferous tubules through the tunica 4, 2
- Maintenance of testicular contour (not heterogeneous or irregular) 5, 3
Decision Algorithm: Conservative vs. Surgical
Proceed immediately to surgical exploration if ANY of the following are present: 5, 6, 3
- Loss of testicular contour or irregular contour 5, 3
- Disruption or discontinuity of tunica albuginea 3, 4
- Presence of hematocele (especially large) 4, 2
- Heterogeneous testicular parenchyma suggesting rupture 5, 3
- Extrusion of seminiferous tubules 4, 2
- Absent or compromised testicular blood flow 1
Conservative management is appropriate when: 1, 2
- Isolated intratesticular hematoma without tunica albuginea breach 2
- Intact testicular contour 4
- Preserved blood flow to the affected testis 1
- No hematocele or only minimal fluid 4, 2
Conservative Management Protocol
When conservative management is selected, implement the following: 1, 2
- Scrotal support and rest 1
- Analgesics for pain control 1
- Prophylactic antibiotics to prevent abscess formation 1
- Serial ultrasound examinations to document resolution 1, 2
- First follow-up ultrasound at 1-2 weeks, then as clinically indicated 1
Evidence Supporting Conservative Management
The literature demonstrates that purely intratesticular hematomas without tunica albuginea rupture can resolve successfully without surgery. 1, 2 A case series of 7 adolescent boys (ages 11-14) with testicular rupture treated conservatively showed complete resolution of hematocele, normalization of echogenicity, and no testicular atrophy at >6 months follow-up. 1 However, these patients presented 1-5 days after injury, suggesting delayed presentation may favor conservative management in select cases. 1
Importantly, early surgical intervention (within 72 hours) increases testicular salvage rates to 80-90% when rupture is present, so the threshold for exploration should remain low. 3, 7
Critical Pitfalls to Avoid
Do not delay surgical exploration if clinical suspicion for rupture remains high despite equivocal imaging. 5, 6 The AUA guidelines emphasize that surgical exploration offers safe and rapid diagnosis with very low complication rates. 5
Do not assume a small hematoma is benign without documenting intact tunica albuginea. 4 Three patients with operatively confirmed testicular rupture had only swelling on examination without tenderness, demonstrating that clinical exam alone is insufficient. 4
Ensure adequate Doppler assessment of blood flow. 3, 1 In prepubertal boys, adequate waveforms may be difficult to obtain, which should not be misinterpreted as absent flow. 1
When to Convert to Surgical Management
Immediate surgical exploration is indicated if: 1, 7
- Pain or swelling worsens during observation 1
- Follow-up ultrasound shows enlarging hematoma or new findings suggesting rupture 1, 2
- Signs of infection or abscess develop 1
- Testicular atrophy begins to develop 6, 8
Long-Term Monitoring
Follow patients beyond initial resolution to assess for: 8, 1