Scrotal hematoma: A serious vasectomy complication
October 27, 2024
Anyone considering vasectomy should be aware of a serious vasectomy complication: scrotal hematoma.
Scrotal hematomas occur in approximately 1 out of every 100 patients (1%) who have a vasectomy procedure. Hematomas are more common when you have traditional scalpel vasectomy.
A scrotal hematoma is the result of bleeding inside the scrotum after a vasectomy procedure.
The blood collects inside the scrotum and forms a blood clot. The blood clot causes scrotal swelling. The scrotum will become painful and bruised until the condition is resolved.
In previous articles we explained other more common vasectomy complications:
- Pain after vasectomy (100%)
- Bruising after vasectomy (30%)
- Non-painful vasectomy nodules (25%)
- Vasectomy regret (10%)
- Vasovagal syncope/fainting (<10%)
- Inflammatory reactions after vasectomy (5%)
Scrotal hematomas are less common than the vasectomy complications listed above; however, a scrotal hematoma causes more problems when trying to recover from a vasectomy procedure.
Although scrotal hematomas after vasectomy are not common, scrotal hematomas are significant because they cause significant pain, anxiety, and concern for patients unfortunate enough to have this complication.
Most scrotal vasectomy hematomas will resolve without treatment, but patients will be uncomfortable until full resolution occurs. Some scrotal hematomas may require a second procedure to remove the blood clot.
What is a scrotal hematoma? A helpful analogy
A scrotal hematoma is a collection of blood inside the scrotum. Initially, the blood is liquid but within minutes to hours the liquid blood transforms into a solid, jelly like blood clot.
You can best understand a scrotal hematoma by comparing this complication to a water balloon.
Your scrotal sac is similar to a balloon. The blood that has collected inside your scrotum is comparable to the water. The only difference is liquid blood will transform itself into a solid blood clot within minutes.
A scrotal hematoma is like a water balloon in which the water slowly turns to jello with the passage of time.
A scrotal hematoma occurs when you have bleeding inside your scrotum after significant scrotal trauma. The blood collects inside the scrotum. Bleeding continues inside the scrotum and will eventually stop.
Bleeding will eventually stop because the coagulation cascade (blood’s ability to form a solid blood clot) will be able to plug the bleeding blood vessel or, in the case of a large scrotal hematoma, the increased pressure inside the scrotum will cause the bleeding to stop.
The liquid blood will then form a solid blood clot. This blood clot will then remain in this state until the body slowly begins the process of dissolving the clot. The key word is ‘slowly’!
Is a scrotal hematoma dangerous?
A scrotal hematoma is not dangerous. Scrotal hematomas are serious because they cause pain and discomfort until the hematoma resolves.
If you have a scrotal hematoma, you will walk funny and decrease your activity level until the hematoma resolves. You will be that person who tells the story of how they ‘swole up like a grapefruit’ after their vasectomy and had to lie on the couch with a ice pack for several days. A scrotal hematoma will not kill you.
Most people hear ‘blood clot’ and will immediately relate this to other more serious ‘blood clots’ they have heard about.
Blood clots within blood vessels are serious and potentially deadly because they cause blockage of the blood vessels and interfere with important biological functions.
- Blood clots in your leg veins (deep vein thrombus or DVT) can cause leg swelling and break off and go to your lungs.
- Blood clots in your lungs (pulmonary embolus or PE) interfere with breathing and absorption of oxygen. Blood clots in your lungs can kill you.
- Blood clots inside the arteries of your heart will cause myocardial infarction (heart attacks).
- Blood clots inside the blood vessels of your brain cause cerebral ischemia (stroke).
Blood clots inside your blood vessels prevent your circulatory system from delivering oxygen, glucose, and nutrients to vital human tissue.
A blood clot inside your scrotum will just sit there until it is either surgically evacuated or slowly absorbed by your body.
A scrotal hematoma will not harm your testicles or impair the blood flow to the testicles unless the hematoma is extremely large (size of a cantaloupe)
A scrotal hematoma is, quite simply, a blood clot in a bag.
Why do you get a scrotal hematoma?
Any trauma to the scrotum can cause bleeding. A small amount of bleeding will cause visible bruising in the skin. A large amount of blood will cause scrotal enlargement/swelling. Visible bruising is usually observed several days later.
The most common reason for a scrotal hematoma is from major scrotal trauma, ie taking a baseball to the groin, getting kicked or punched, or falling on a fence post or bike frame. Vasectomy is a surgical procedure that can best be thought of as a ‘controlled form of scrotal trauma’.
Minor scrotal trauma in patients with bleeding disorders or taking prescription blood thinning medication can also lead to a scrotal hematoma.
A scrotal hematoma occurs after vasectomy because of either continued bleeding or new onset bleeding within the first 24 hours of the vasectomy procedure.
It is very rare to have new onset bleeding > 48 hours after vasectomy unless you are taking a prescription blood thinner or have a bleeding disorder.
- Continued bleeding: a small blood vessel(s) around the vasectomy site(s) continues to bleed after completion of the vasectomy. This bleeding vessel may not be recognized at the time of the vasectomy procedure.
- New bleeding: a patient lifts something heavy or traumatizes the area to start bleeding. Increases in abdominal pressure occur from lifting, coughing, sneezing, vomiting etc and this pressure can be transmitted directly to the scrotum and could be the cause of the bleeding.
If the bleeding is a small amount the patient may not notice anything. The larger the amount of bleeding then the more noticeable and more symptomatic the scrotal hematoma will become.
Keep in mind you can have bleeding from your nose or in the whites of your eyes just from the increase pressure caused by sneezing or vomiting. The same is possible inside the scrotum after a vasectomy.
This is one reason why we recommend no heavy lifting, bending, or straining the first 48 hours after a vasectomy procedure.
When would you notice a scrotal hematoma?
You do not need to be a doctor to diagnose a scrotal hematoma after vasectomy. You will have significant scrotal swelling. Significant means you can see the swelling from across the room.
Scrotal hematomas happen within the first 24 hours of the vasectomy procedure. On rare occasions a hematoma could occur between 24 to 48 hours after a vasectomy procedure but this is not common. The vast majority of scrotal hematomas will be noticed within the first 24 hours.
You will not develop a scrotal hematoma beyond 48 hours of your vasectomy procedure unless you are taking a prescription blood thinner or have a bleeding disorder.
Small scrotal hematoma
A small hematoma would be about the size of testicle. It would feel like you have a third testicle.
They are usually located on one side of the scrotum (ie right sided swelling or left sided swelling). Small hematomas are usually from a low volume, venous bleed.
Small hematomas are detected 12 to 24 hours after a vasectomy procedure. Usually patients will detect small hematomas the day after their vasectomy procedure. Pain is usually mild to moderate. Scrotal bruising will usually show up later (within 3 days).
Large scrotal hematoma
A large hematoma could be the size of a lemon, orange, grapefruit or cantaloupe. They are usually so large they take up the entire scrotum and the entire scrotum will feel enlarged.
Large hematomas are usually from brisk venous bleeding. The largest hematomas are usually from arterial bleeding into the scrotum.
The bleeding is brisk and of a large amount. The scrotum will grow rapidly in size and could be very large. These are usually detected by patients within the first 12 hours.
Patients with large scrotal hematomas will usually experience severe scrotal pain. They may require narcotic pain medications. Usually the pain will resolve slowly within the first 7 to 10 days as the brain learns to adapt.
An arterial scrotal hematoma will usually be noticed before nightfall. The pain will usually be moderate to severe. Bruising is delayed and usually shows up 24 to 72 hours after the hematoma.
Scrotal hematoma treatment: What should you do?
Most scrotal hematomas do not require treatment. Some will need surgical evacuation.
After the bleeding stops, the blood will slowly turn from liquid to solid. This happens over the first several hours. Bruising is a late manifestation of a hematoma because it takes time for the blood to work its way to the surface skin tissues to be visible.
After the liquid blood turns to a solid blood clot the hematoma will sit and be stable for approximately 10 to 14 days. Nothing will happen. The clot is actually going through a process we refer to as organization. This is when the blood clot becomes firmer and harder.
After organization is complete the body will slowly start dissolving the blood clot from the outer surface. Slowly the blood clot will become softer and start decreasing in size. The color of the bruising visible on the skin will change from purple to brown to yellow. The bruising will eventually go away completely.
Most scrotal hematomas are small. Small hematomas will usually be completely absorbed within 4 weeks.
A large hematoma, one the size of a grapefruit or cantaloupe, may require 3 to 5 months to completely resolve.
Most scrotal hematomas can be treated with expectant management. The body will slowly absorb the blood clot.
How long does it take? The key word is slowly. It is never as fast as you would like it to be.
Is surgery required for treatment of a scrotal hematoma?
Surgery is not required to treat most scrotal hematomas. Most hematomas will resolve slowly by absorption over time.
Surgery for hematoma treatment can be more trouble than it is worth because the blood clot becomes sticky and works its way through the tissue layers. It can be very challenging to remove an organized blood clot.
Surgery is only required for large hematomas causing severe, excruciating pain. Typically these hematomas are cantaloupe size, cause severe pain, and greatly interfere with walking and sitting. If you were unfortunate enough to get a large symptomatic scrotal hematoma after vasectomy then you may require a trip to the operating room for a procedure to remove the hematoma.
Do ice packs or frozen peas prevent scrotal hematomas after vasectomy?
There are no convincing medical studies that support the routine usage of ice packs to prevent the development of a scrotal hematoma.
Ice packs (or using frozen peas) is more of an ‘old school’ recommendation from the days of traditional, scalpel vasectomy. These older vasectomy techniques caused more pain. Older doctors also believed ibuprofen could increase the risk of bleeding and they advised patients not to take this helpful medication. As a result, they commonly recommended the use of ice packs to minimize pain and prevent a bleeding complication.
We have found that ice packs and frozen peas do not prevent scrotal hematomas. This treatment is only helpful for the treatment of pain after vasectomy if over the counter anti-inflammatory medications are not providing enough pain relief.
How long does it take for a scrotal hematoma to go away?
Hematomas will slowly be absorbed by the body. The problem is that you will need to be patient because it will take time.
The amount of time it takes depends on the volume of blood that need to be resorbed. Initially the blood will form a gelatinous like clot. The clot will then slowly become solidified and organized over 7 to 14 days. Only after consolidation will the clot slowly be absorbed.
- A small hematoma (size of a third testicle) will resolve in less than a month.
- A large hematoma (size of a grapefruit or cantaloupe) may take 3 to 4 months to resolve.
When patients ask us “How long will it take for a scrotal hematoma to go away?” We like to be realistic and honest. We will usually tell them it will never go away as quickly as you would like. What we are trying to emphasize when we say this is that it will require time and patience.
When you have a condition that is uncomfortable and unsightly it will always seem longer than it will actually take to disappear.
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