Neonatal scrotal haematoma: mimicker of neonatal testicular torsion


  • Presented at the ESPU, Budapest 2002

D.A. Diamond, Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.



To describe the clinical features of neonatal scrotal haematoma and distinguish them from those of neonatal testicular torsion.


Five neonates presenting with an acute scrotum and initial diagnosis of neonatal testicular torsion were found to have neonatal scrotal haematoma. In one case the diagnosis was surgical and in four subsequent cases the diagnosis was by colour Doppler ultrasonography, and surgery was avoided. Four of the five children had risk factors associated with neonatal scrotal haematoma, including bleeding diathesis, birth trauma and high birth weight.


The importance of including haematoma in the differential diagnosis of the acute neonatal scrotum is emphasized, as is the value of contemporary Doppler ultrasonography in making this diagnosis.


In the neonatal male the findings of a solid scrotal mass and discoloration suggest neonatal torsion until proven otherwise [1]. Because Doppler ultrasonography (DUS) in the small neonatal testis has previously been regarded as inconsistently diagnostic, scrotal exploration was considered necessary for the diagnosis and treatment of these neonates.

We report our experience with five neonates over a 5-year period presenting with examinations initially suggestive of neonatal testicular torsion, but diagnosed instead with scrotal haematoma at surgery (one) or on DUS (four). The importance of including scrotal haematoma in the differential diagnosis of the acute scrotum in the neonate and the value of contemporary DUS in confirming this diagnosis is discussed.


From 1996 to 2001, five neonatal males presented with a firm unilateral scrotal mass accompanied by scrotal discoloration within the first 48 h of life; the mass was right-sided in all (Fig. 1). Scrotal transillumination was attempted in all cases and in only one did the mass partly transilluminate, because there was an accompanying hydrocele. Scrotal DUS was used in all neonates and in the final four abdominal US was also used. Scrotal DUS was undertaken with a high-frequency linear-array transducer (usually 7–10 MHz or greater), used to optimize image resolution and detect low-velocity flow. Both hemiscrota were assessed so that the size and echogenicity of the intrascrotal contents could be compared. Grey-scale images were obtained in transverse and longitudinal planes (Fig. 2). Colour and power Doppler gain were maximized to improve the sensitivity to low-volume, low-velocity flow (Fig. 3). Spectral analysis of the testicular arteries was always attempted to analyse the Doppler waveform (Fig. 4).

Figure 1.

The clinical appearance of a neonate with right scrotal haematoma, showing the induration and bluish discoloration.

Figure 2.

Transverse ultrasonogram of the right hemiscrotum showing the presence of a large hydrocele surrounding a normal-appearing testis. The epididymis is enlarged. Between the outer margin of the hydrocele and the thickened skin and subcutaneous tissue there is a layer of echogenic fluid consistent with haematoma.

Figure 3.

Longitudinal colour Doppler ultrasonogram shows hyperaemia of the testis and epididymis.

Figure 4.

Spectral analysis of a testicular parenchymal vessel depicts low-resistance arterial flow.


In the first case, DUS was undertaken but could not confirm flow to either the normal- or abnormal-appearing testis, and therefore the testes was explored surgically. In the four later patients (from 1998 to 2001), DUS depicted the scrotal haematoma and normal flow to the adjacent testis. A retrospective review showed potential risk factors for scrotal haematoma in four of the five neonates. In one there was evidence of maternal gestational diabetes and a high birth weight, possibly predisposing to delivery-related scrotal trauma. A second neonate had a forceps delivery and presented with multiple bruises; two had findings consistent with a bleeding diathesis and one presented with a scrotal haematoma at 48 h old, after documentation of intraventricular and subarachnoid haemorrhages. The second patient presented at 6 h old with a persistently bleeding heel stick; he was subsequently diagnosed with factor VIII deficiency. The final four patients were spared surgical exploration on the basis of an unequivocal DUS diagnosis of scrotal haematoma. In four of the five the DUS results excluded adrenal haemorrhage as a potential cause of the scrotal haematoma. All patients were followed, for a mean (range) of 31 (6–72) months; in each there was complete resolution of the haematoma, and testicular volume and perfusion were symmetrical.


While solid neonatal scrotal masses other than testicular torsion have been reported, e.g. tumour, epididymitis or meconium peritonitis, these are remarkably rare [1]. Given the high likelihood of torsion, a relatively emergent process, and the historically inconsistent reports of DUS in detecting flow to the neonatal testis, surgical exploration has generally been prompt for diagnosis and treatment.

Because of the potential risks of anaesthesia in the neonate, the ability to diagnose a lesion without surgery, e.g. a scrotal haematoma, is particularly appealing. As ultrasound scanners have improved dramatically over the past decade, it is now expected that blood flow to the normal testis can be routinely confirmed with DUS. When flow can be detected unequivocally and the testes are symmetrical in size and echotexture, neonatal torsion can safely be excluded.

In most children, state-of-the-art ultrasound equipment can be used to identify the main testicular artery, and capsular and centripetal arterial branches, using colour and power Doppler with spectral analysis. Intratesticular vessels are more difficult to identify in children than in adults, particularly in small prepubertal testes [1–5]. Vascular impedance of the intratesticular vessels is variable, but tends to remain high until puberty, when diastolic flow increases [2,6]. The Doppler signal in the testes should be bilaterally symmetrical. Absence of flow in an asymptomatic prepubertal testis usually results from insensitivity of the ultrasound equipment to low flow, or inappropriate technical factors such as low transducer frequency, low gain, high pulse-repetition frequency or high wall filter, rather than because of intrinsic testicular abnormality [7].

There appear to be several potential causes of neonatal scrotal haematoma. Birth trauma is one obvious cause [8]; while breech presentation has been a suggested risk factor, all of the present patients had a vertex delivery. For the present children in particular, the avoidance of surgery as a result of DUS diagnosis might be particularly important, as further bleeding may have been potentially problematic. Unfortunately surgery was unavoidable for the patient with intracranial bleeds, but proceeded uneventfully.

In four of the present patients careful US of the abdomen was used to exclude an intraperitoneal cause of scrotal haematoma. In previous reports adrenal haemorrhage and subcapsular haematomas of the liver have been documented as causes of scrotal haematoma (the latter in conjunction with a patent processus vaginalis) [9–11]. Therefore, careful abdominal US should be part of the evaluation of these neonates.

In conclusion, the diagnosis of neonatal scrotal haematoma should be considered in the setting of a solid scrotal swelling and mass with discoloration. Some risk factors can be identified, e.g. evidence of bleeding diatheses, maternal gestational diabetes and high birth weight, with evidence of delivery-related trauma or predisposing intra-abdominal lesions (adrenal haemorrhage, subcapsular liver haematoma) on US. Current DUS equipment is generally capable of making an accurate diagnosis, sparing some children surgical exploration.


Doppler ultrasongraphy.