Idiopathic intratesticular hemorrhage is a rare disease that was first described in 1914 [1]. Only a few cases have been reported in the literature [1,2,3,4,5]. Most patients present with acute onset of unilateral scrotal pain associated with swelling [1,2,3,4,5]. The differential diagnosis for this presentation is wide and includes epididymitis, torsion, trauma, or testicular tumors, and this rare entity should also be taken into consideration.

Scrotal sonography is the gold standard imaging modality for evaluating patients with testicular pain and swelling, especially since it is fast, simple, and noninvasive. It helps in determining the nature of the swelling, and whether it is solid or cystic [3]. The addition of color Doppler imaging aids in the identification of the lesion’s vascularity [3]. In the present case, the distinction between intratesticular hemorrhage and testicular torsion was not possible, especially since color Doppler ultrasonography shows absent blood flow. Despite the fact that sonography is the gold standard for diagnosing intratesticular masses, there are no pathognomic findings for this rare entity as reported in different cases reported in the literature [2,3,4,5]. An echogenic solid or cystic mass with no internal color Doppler flow signals is the most likely appearance [3,4,5]. Absence of blood flow is caused by this spontaneous hemorrhage that lead to compression of blood vessels, moreover, it is one of the signs that make the distinction between this entity and testicular torsion very difficult and challenging [5].

Magnetic resonance imaging (MRI) may be used to evaluate an acute scrotum when the results of color Doppler are equivocal. Intratesticular hematomas appear as a homogeneous mass with a moderate to intermediate signal intensity on T1- and T2-weighted sequences. To exclude the possibility of malignant tumors, a dynamic MRI contrast enhancement approach can be applied to distinguish the intratesticular hemorrhage that can be treated conservatively from tumors that require surgery since malignant tumors exhibit contrast enhancement with good diagnostic accuracy [3].

The gross features, absence of blood flow and the black discoloration of the testis in idiopathic intratesticular hemorrhage could resemble the necrotic testicle as in our case, and mandates its removal. However, one of the cases reported the normal color of the involved spermatic cord, which would lessen the likelihood of testicular torsion [1]. Additionally, this entity could mimic testicular neoplasm [2, 3], because malignancy cannot be ruled out at an early stage of diagnosis, the majority of patients and healthcare professionals choose surgical exploration with a potential orchiectomy.

The final diagnosis for most of the cases was made only after surgical exploration and unilateral orchiectomy [1, 3, 4], but the best course of action might be to quickly remove the affected tissue for a frozen section in order to potentially save the testicle [2, 5]. This is decisive but invasive as well, and it may be prevented if the diagnosis of spontaneous intratesticular hemorrhage is determined with certainty by other diagnostic modalities. One of the reported cases in the literature discussed the first testicular salvage in an adult with idiopathic spontaneous testicular hemorrhage based on sonographic and perioperative findings, accordingly, the testicle was preserved [2]. Additionally, there is a similar first case report in the pediatric population [5]. Accordingly, the accurate diagnosis of a spontaneous intratesticular hemorrhage depends on many factors including the physician’s having a high degree of suspicion for this rare entity, in addition to the clinical history and sonographic findings. MRI can be crucial in making the diagnosis of spontaneous intratesticular hemorrhage when sonographic results are inconclusive. It is very crucial to rule out bleeding disorders, predisposing factors, and trauma before the diagnosis of spontaneous intratesticular hemorrhage.