Testicular torsion in neonates is a rare urological condition that requires prompt diagnosis and intervention to preserve testicular viability. However, certain conditions such as scrotal hematoma can mimic the clinical presentation of torsion, posing a diagnostic challenge. Here we report a case of a newborn presenting with a scrotal swelling with suspicion of testicular torsion and was ultimately confirmed as a scrotal hematoma.

A male preterm infant was delivered via cesarean section at 30+2 weeks of gestation, with a birth weight of 1310 grams. At birth, mild ecchymosis over the left hemiscrotum was observed without swelling, suggesting birth trauma-related hematoma. However, on day four, progressive swelling and discoloration of the left scrotum were noted. Bedside ultrasonography revealed absent Doppler flow and an irregular contour of the left testis, raising suspicion for testicular torsion. Given these findings, surgical exploration was performed.

A midline scrotal incision approximately 2 cm in length was made. Upon opening the tunica vaginalis, a large hematoma and organized blood clots were identified. After evacuating the hematoma, the testis appeared viable and intact. Active bleeding was noted from the spermatic artery within the spermatic cord and hemostasis was successfully achieved under microscopy. Intraoperative Doppler ultrasonography confirmed restored blood flow to the left testis. A surgical drain was placed, and postoperative recovery was uneventful. Follow-up imaging demonstrated normal testicular perfusion and morphology.

Differentiating neonatal testicular torsion from scrotal hematoma, particularly in preterm infants, remains a diagnostic challenge. The incidence of perinatal testicular torsion is estimated at 6 per 100,000 live births, with approximately 72-81% occurring prenatally. Scrotal hematoma in neonates is even rarer, often associated with birth trauma or idiopathic causes. In ambiguous cases, timely surgical exploration is crucial to establish an accurate diagnosis and preserve testicular function. Awareness of non-torsion causes of acute scrotum, including birth trauma-related hematoma, is essential in neonatal surgical decision-making.