Acute spontaneous scrotal haematoma presenting with haemorrhagic shock: a case report

Abstract

A 78-year-old man presented to the accident and emergency department with a 12-hour history of sudden onset, rapidly progressive swelling of the scrotum followed by collapse. He was clammy (temperature: 36º Celsius), tachycardic (110/ min) and hypotensive (90/60mmHg). There was no history of trauma to the scrotum. The patient was on anticoagulants for a metallic valve replacement but the international normalised ratio (INR) on admission was only 1.08.A pelvic x-ray did not show a fracture or any other bony pathology but only mild degenerative joint changes. Ultrasonography showed a large haematoma in the scrotum. Post-contrast computed tomography (CT) revealed a large (15.0cm x 12.2cm x 9.7cm) right-sided haematocoele of mixed attenuation consistent with acute haemorrhage and evidence of extravasation of contrast (sign of active bleeding) at the superior pole of the haematocoele (Fig 1A). There was no evidence of any abdominal, pelvic or testicular pathology. The left testicle was displaced further laterally along with displacement of the posterior urethra ( Fig 1B). The right testicle could not be visualised on either CT or ultrasonography.Emergency scrotal exploration was carried out on account of an expanding tense scrotal haematoma (Fig 2A), a significant drop in haemoglobin levels (from 12g/dl to 8g/ dl) on serial monitoring over six hours and signs of haemorrhagic shock. There was an extensive haematoma in the layers of the scrotal wall, septum and tunica vaginalis. There was minimal reactive hydrocoele of the tunica with a non-traumatised testis but considerably contused cord structures. A litre of haematoma was evacuated and an inguinal orchidectomy was performed because of the contused cord structures (Fig 2B), thereby removing any possible or potential source of intrascrotal bleeding. Histology revealed normal cord structures, epididymis and testis with no evidence of malignancy. DiscussionAcute scrotal haemorrhage with haematoma formation is a rare phenomenon and a non-traumatic scrotal haematoma presenting with haemorrhagic shock is even rarer. Scrotal haemorrhage is characterised by sudden onset of pain, swelling and mass in the scrotum. It has been misdiagnosed as torsion of the testis, a spermatic cord tumour and an incarcerated hernia. [1][2][3][4][5][6] Spontaneous haemorrhage can occur in all organ systems and is frequently the cause of diagnostic difficulties. Scrotal haematomas caused by haemorrhage in the spermatic cord, 1 varicocoeles 2 and adrenals 3 have been reported in the literature. Within the spermatic cord, bleeding has been associated with Henoch-Schönlein syndrome, 4 trauma and, occasionally, anticoagulant therapy.5 Sometimes other conditions such as lipomas 6 masquerade as scrotal haematomas. A non-traumatic, acutely expanding scrotal wall haematoma leading to haemorrhagic shock has not been described previously.This case report also highlights that although CT can be a very useful diagnostic tool, it does have limitations. In this instance, CT suggested a right haematocoele, ra...

Third-degree burns caused by transcutaneous pacing for third-degree heart block

“… 4 Nine hours of pacing in a 1.1 kg neonate led to large, third-degree burns requiring W-plasty surgical repair. 5 A 7-week-old neonate developed a second-degree burn on the back and a third-degree burn on the chest after 45 hours of pacing. 6 A 5-year-old boy weighing under 15 kg with a history of complex congenital heart disease developed full-thickness burns after only 55 minutes of transcutaneous pacing at 60 mA output.…”

“…While there exists an extensive body of literature on burns from defibrillation, 3 there are only a handful of reports of burns caused by transcutaneous pacing, with most of these observations occurring in the neonatal population. 4 , 5 , 6 Here, we report on a case of third-degree burns from extended transcutaneous pacing and discuss both the mechanisms and approaches to minimize the risk.…”

Two Case Reports of Varicocele Rupture during Sexual Intercourse and Review of the Literature

“…The majority of the patients were at their mid-twenties, but a 78-year-old patient and a 69-year-old patient were also described [2, 21]. The side of the hematoma seems to be of importance, as in all of the reported cases the hematoma was left sided except in one case in which it was at the right hemiscrotum [2]. There is a clear correlation with the side of the varicocele which is usually (up to 80%) left sided [22].…”

“…In cases where testicular torsion or incarcerated inguinal hernia was suspected or in presence of hemodynamic instability the first treatment option was surgery [2, 15, 16, 20, 25]. Both scrotal and inguinal approach was used, and evacuation of the hematoma and control of the bleeding vessels was performed.…”

“…Timely diagnosis of varicocele rupture is challenging as the symptoms are nonspecific and resemble other conditions such as torsion of the testis or one of the testicular appendages, hydrocele, trauma, tumor, idiopathic scrotal edema, and incarcerated inguinal hernia [1]. Although these conditions are rarely fatal, they may carry a risk of morbidity [2]. These two cases of varicocele rupture were diagnosed by ultrasound and MRI in the first case and only by ultrasound in the second.…”