Hematocele is hemorrhage into the tunica vaginalis space, usually as a result of traumatic or surgical injury or testis tumor. Spontaneous hematocele is a known complication of arteriosclerosis, scurvy, diabetes, syphilis, neoplasia, and inflammatory conditions of the testis, epididymis, or tunica vaginalis. Hematocele may occur from birth injury and may also develop in various blood dyscrasias. Following injury, hematocele is accompanied by scrotal edema, as the hematoma permeates the skin and subcutaneous tissues, lending the scrotal and penile skin a black appearance. A slowly developing hematocele may be indistinguishable from hydrocele except by its opacity to transillumination. Aspiration of bloody, rather than clear, fluid leads to a definitive diagnosis. If the diagnosis and etiology of hematocele are in doubt, surgical exploration is warranted to determine the underlying condition.
Axial rotation or torsion of the spermatic cord results in infarction and gangrene of the testicle. A 720-degree rotation is required for most cases of clinical torsion. Torsion occurs with equal frequency on either testis side, and also in the setting of cryptorchidism. The main predisposing factor is abnormal mobility of the testis, usually due to a high insertion of the tunica on the spermatic cord, also termed the “bell clapper” deformity. The extent of the damage to the testicle depends upon the degree and duration of the torsion. If uncorrected torsion persists for longer than 8 hours, complete testis infarction is likely. The success of surgical detorsion procedures is directly related to the duration of torsion. Although manual detorsion using palpation alone is possible, torsion is normally treated by open surgery, at which time the testis is either removed if unviable or fixed to the scrotal wall or septum to preclude recurrence.
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