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Case Report
Scrotal Hematocele as an Unusual
Presentation of Blunt Abdominal Trauma in
Three Male Infants
Chrisoula Koumanidou, MD, Evangelia Manopoulou, MD, John Pantazis, MD,
Vaso Dermentzoglou, MD, Peter Georgoulis, MD, Marina Vakaki, MD, Konstantinos Kakavakis, MD
Radiology Department, Children’s Hospital “Agia Sophia,” Thivon and Mikras Asias 1, 11527 Goudi,
Athens, Greece
Received 23 July 1999; accepted 12 November 1999
ABSTRACT: Three infants presented with bluish discoloration and swelling of the scrotum with no history
of scrotal trauma. Sonography revealed unilateral hematoceles in 2 cases and bilateral hematoceles in the
third. All 3 infants had intact testes. The communicating hematoceles were the result of hemoperitoneum
due to splanchnic hematoma. © 2000 John Wiley &
Sons, Inc. J Clin Ultrasound 28:190–193, 2000.
Keywords: hematocele; infant; blunt abdominal trauma;
ultrasonography
R
eports of acute scrotal swelling as the first
clinical sign of blunt abdominal trauma are
rare.1–5 In most cases, the cause of the swelling
was identified only after unnecessary surgical exploration of the scrotum. We present 3 cases of
abdominal trauma manifesting as scrotal swelling that highlight the importance of both scrotal
and abdominal sonography for scrotal swelling,
even in the absence of a history of abdominal
trauma or abuse.
CASE 1
A 3-month-old boy was admitted to our hospital
with bluish discoloration and swelling of the right
hemiscrotum and groin. Two days earlier, the
mother and the patient had fallen with no apparent injury to the patient. Physical examination
revealed a mass anterior to the right testis exCorrespondence to: C. Koumanidou, Aiantos 41, Pal Phaliro,
GR 17562 Athens, Greece
© 2000 John Wiley & Sons, Inc.
190
tending into the groin. The size of the mass did
not change with compression.
Sonography was performed using an Ultramark 4 ultrasound scanner (Advanced Technology Laboratories, Bothell, WA) with 5.0- and
7.5-MHz convex and 7.5-MHz linear-array transducers. Sonography of the scrotum revealed a normal right testis and a large hydrocele in the right
hemiscrotum containing echogenic material (Figure 1A). Color Doppler sonography was not performed because of the size of the testes and the
infant’s distress. Testicular scintigraphy was not
available. Longitudinal sonograms of the inguinal
region showed a dilated processus vaginalis peritonei on the right side containing echogenic fluid
(Figure 1B). Because the diagnosis of testicular
torsion could not be excluded, the infant underwent surgical exploration of the scrotum.
Surgery revealed the right processus vaginalis
to be dilated with blood. The right hemiscrotum
contained clotted blood, and the ipsilateral testis
appeared to be normal. Postoperative abdominal
sonography demonstrated a small splenic laceration (Figure 1C) to have been the cause of the
blood in the right processus vaginalis and hemiscrotum. The laceration was treated conservatively and had healed completely 2 months later.
CASE 2
A 13-month-old boy presented with acute swelling
and bluish discoloration of the scrotum. The
medical history was suggestive of child abuse.
The physical examination revealed a mild bilatJOURNAL OF CLINICAL ULTRASOUND
BLUNT ABDOMINAL TRAUMA IN MALE INFANTS
FIGURE 1. Case 1. (A) Transverse sonogram of the scrotum demonstrates anechoic fluid surrounding the right testis and small echogenic clots within the hydrocele. (B) Longitudinal sonogram of the
right groin reveals a dilated processus vaginalis peritonei containing echogenic fluid (arrows). (C) Longitudinal sonogram of the
spleen demonstrates a small linear area of decreased echogenicity
representing a splenic laceration (arrow).
eral hydrocele, scrotal tenderness on palpation,
and poor light transmission.
Sonography revealed mild, echogenic hydroceles bilaterally and normal testes (Figure 2A).
Again, color Doppler sonography was not performed owing to the size of the testes and the
child’s distress, and scrotal scintigraphy was not
available.
Surgical exploration of the scrotum revealed
blood in the processus vaginalis peritonei that
continued to ooze from the peritoneal cavity. The
scrotum contained unclotted blood. Postoperative
abdominal sonography revealed a moderate
splenic hematoma to be the cause of the communicating hematocele (Figure 2B). The hematoma
was treated conservatively and followed by serial
sonography until it had healed 45 days later.
CASE 3
A 6-month-old boy with acute scrotal swelling after a fall 2 days earlier was referred for sonographic examination. Laboratory studies showed
a hemoglobin level of 158 g/l and a bilirubin level
VOL. 28, NO. 4, MAY 2000
of 220 ␮mol/l. Physical examination revealed a
tense right hydrocele, the size of which did not
change with compression. Light transmission
through the scrotum was poor.
Scrotal sonography revealed the presence of
slightly echogenic fluid surrounding the normal
right testis (Figure 3A). Abdominal sonography
showed a small hematoma in the right lobe of the
liver (Figure 3B) and a small amount of free echogenic blood in the hepatorenal recess (Morison’s
pouch).
No surgery was performed because of the small
size of the hematoma. Serial follow-up sonography showed gradual regression of the hepatic hematoma.
DISCUSSION
Scrotal hematoceles usually result from rupture
or laceration of the testis due to direct scrotal
trauma. The rare cases in which scrotal hematoceles are not associated with a history of scrotal
trauma should raise suspicion of intraperitoneal
or retroperitoneal bleeding. Intraperitoneal bleed191
KOUMANIDOU ET AL
FIGURE 2. Case 2. (A) Transverse sonogram of the scrotum shows
that both testes are surrounded by echogenic fluid (arrows). (B) Longitudinal sonogram of the spleen reveals a small, hypoechoic, welldefined hematoma (arrow) within the splenic parenchyma.
ing in newborns may be due to incomplete occlusion of umbilical vessels or adrenal hemorrhage6;
the most common cause in infants is blunt abdominal trauma. In intraperitoneal hemorrhage,
the blood reaches the scrotum through a patent
processus vaginalis peritonei, an extension of the
peritoneal cavity into the scrotum along the inguinal canal. This process remains patent in 50%
of normal boys at the age of 1 year.7 Incomplete
obliteration of the processus vaginalis peritonei
may cause communicating hydroceles, hematoceles, and hernias.7 In retroperitoneal hemorrhage, blood from the retroperitoneum reaches
the scrotum either along the tissue planes and
through the inguinal canal or through a tear in
the posterior parietal peritoneum.
Communicating hematoceles are most often
caused by adrenal hemorrhage, with 12 cases re192
FIGURE 3. Case 3. (A) Longitudinal sonogram of the right hemiscrotum demonstrates slightly echogenic fluid surrounding the normal
testis. (B) Longitudinal sonogram of the right hepatic lobe reveals a
small anechoic hematoma (arrow).
ported 6,8–14 ; other causes are trauma to the
spleen (3 cases reported)1–3 or liver (2 cases reported).4,5 Communicating hematoceles resulted
from splenic lacerations in 2 of our patients and
from a hepatic hematoma in the third. Both infants with splenic lacerations underwent unnecessary surgical exploration of the scrotum, which
revealed a patent processus vaginalis peritonei
with clotted blood in 1 case. The diagnosis in the
third case was made without surgery on the basis
of the first 2 cases as well as on the history suggestive of abdominal trauma. The small hepatic
hematoma was revealed on abdominal sonography.
Hematoceles present clinically as unilateral or
bilateral swelling and bluish discoloration of the
JOURNAL OF CLINICAL ULTRASOUND
BLUNT ABDOMINAL TRAUMA IN MALE INFANTS
scrotum, sometimes with swelling of the ipsilateral groin. Abdominal distention and anemia are
usually present but may not be evaluated correctly, especially when there is no clinical history
of abdominal trauma and the splanchnic hematoma is relatively small. Our patients had no
signs of abdominal or peripheral circulatory problems, and the hematomas were so small that they
did not require surgery or transfusion but rather
were followed up with serial abdominal sonography and hematocrit measurements. Physical examination may not be helpful if a hematocele is
tense and the testis cannot be palpated. Poor
transmission of light through the scrotum does
not necessarily indicate a hematocele, as the finding may be due to the presence of opaque fluid (eg,
pus or meconium) or other structures (eg, omentum or bowel loop) within the scrotum.
Sonography is the method of choice for investigating the various causes of painless scrotal
swelling. Both unclotted and clotted blood in hematoceles can be identified accurately with sonography, and tense hematoceles can be evaluated
whether the testis is palpable or not. The possibility of coexisting testicular abnormalities such
as testicular torsion5 should be sonographically
investigated in any case of communicating hematocele. Even when scrotal swelling is not associated with a history of scrotal trauma, abdominal
sonography rather than CT1,9 is required to exclude the possibility of a splanchnic hematoma or
adrenal hemorrhage. We believe that sonography
can be used effectively to diagnose splanchnic hematomas without the need for sedation and without exposing the child to radiation.
Physicians should bear in mind that even mild
traumas that may not have been recognized as
such by the parents can cause hematoceles, as can
unreported child abuse. Abdominal and scrotal
sonographic examinations allow the correct diagnosis of hemoperitoneum with scrotal hematocele
to be established. This condition can then be
treated conservatively, without surgical exploration of the scrotum.
VOL. 28, NO. 4, MAY 2000
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