Scrotal Enlargement in Boys with a History of Scrotal Trauma: Two Unusual Findings.

ABSTRACT: The presentation of a boy with an acutely painful scrotum is often associated with a history of trauma. Two recent patients with a history of scrotal trauma and an enlarged hemiscrotum were found on surgical exploration to have unusual causes for the scrotal enlargement. In the first case, there was bleeding from omentum in an incarcerated inguinal hernia, and in the second, there was bleeding into a scrotal cystic lymphangioma. Fewer than 40 cases of scrotal lymphangioma have been reported.

Acute painful scrotal enlargement in a boy is often associated with a history of trauma. The differential diagnosis includes torsion of the testes or their appendices, incarcerated indirect inguinal hernia, testicular rupture, scrotal hematoma, epididymo-orchitis, and acute idiopathic lymphedema. (1,2) Two recent patients with a history of scrotal trauma and an enlarged hemiscrotum were unique; one boy was found to have bleeding from incarcerated omentum in an indirect inguinal hernia, while the other had bleeding into a cystic lymphangioma.

CASE REPORTS

Case 1. An 8-year-old boy was brought to the emergency room because of an enlarged right hemiscrotum and pain of 12 hours' duration. The child had arthrogryposis that necessitated leg braces and a walker for ambulation. While walking, he had fallen, striking his scrotum against the metal walker; this was followed by scrotal swelling and pain. On examination, the right hemiscrotum was enlarged. The enlargement, though marked, was soft and did not transilluminate. The right testis itself was uninvolved and was normal to palpation and nontencler. A color Doppler ultrasound examination of the scrotum showed good blood flow to the testis. A high-resolution ultrasonic scrotal examination showed a large mass with frond-like wavy, echogenic strands suggestive of bowel or omentum (Fig 1). On reexamination, the inguinal canal was unremarkable and showed no evidence of a hernia.

Inguinal exploration revealed an indirect inguinal hernia that contained incarcerated omentum. The caudal aspect of the incarcerated omentum showed evidence of ecchymosis with free clot in the caudal aspect of the sac, but no active bleeding. After careful inspection, the omentum was returned into the abdominal cavity, and the hernia was repaired. The patient's postoperative course was unremarkable.

Case 2. A 3 1/2-year-old African American boy was brought to the emergency room because of acute onset of scrotal swelling and pain after a sharp blow to the scrotum incurred while scuffling with his brother. Examination of the scrotum showed an enlarged right hemiscrotum measuring 4 x 4 cm. Due to the dark pigmentation of the skin, no discoloration was evident. The surface by palpation seemed slightly bosselated. There was minimal transillumination and no evidence of extension into the inguinal canal. High-resolution ultrasonography of the scrotum and groin, along with a color Doppler study of the testes, showed good blood flow to the testis. The scrotal mass contained cystic areas with multiple septations and evidence of hemorrhage (Fig 2). Because of the indeterminate nature of the lesion, initial inguinal exploration was done to isolate the cord. It was evident that there was indeed a mass composed of multiple cysts, which could be clearly seen in the medial aspect of the incision. Therefore, a transscro tal incision was made to further expose the compound lesion, which was found to be comprised of multiple cysts with evidence of old and new hemorrhage. The tunica vaginalis was not involved, nor was the testis. The cystic mass was adherent to much of the lateral scrotal skin but was excised completely. Histologically, it was confirmed to be a cystic lymphangioma. The patient healed well, and at 1-year follow-up there had been no recurrence of the lesion.

DISCUSSION

Generally, the diagnosis of traumatic acute painful scrotal masses is made preoperatively. History, physical examination, and ultrasonic imaging studies, coupled with a knowledge of the most frequent possibilities, result in correct management decisions. In a boy with a history of trauma but with classic physical findings of testicular torsion, that is, a high-riding, hard testis with severe pain, a transcrotal exploration can generally be done without imaging studies of the scrotum and its contents. Less classic findings on physical examination should prompt imaging studies of the scrotum to include high-resolution ultrasonography coupled with color Doppler examination. Not only is a preoperative diagnosis possible, but also an informed decision can be made regarding whether to initially proceed to an inguinal exploration as opposed to a transcrotal approach. In our Case 1, there was not an antecedent history of an inguinal hernia, and indeed the physical examination gave no specific evidence of a hernia, m uch less an incarcerated indirect inguinal hernia. The ultrasonographic finding of omentum within the scrotum resulted in the correct preoperative diagnosis of an inguinal hernia. (3)

In Case 2, the diagnosis of cystic lymphangioma was not specifically made preoperatively, but the finding of septated cystic areas on ultrasonography indicated that an unusual, perhaps neoplastic lesion was present and therefore an initial isolation of the cord through an inguinal approach was deemed prudent. The high approach served to clarify the cranial extent of the lesion and aided in its complete excision. Perhaps because of its rarity in a scrotal site, a scrotal cystic lymphangioma is frequently preoperatively misdiagnosed. We found fewer than 40 reported cases of scrotal cystic lymphangioma. (4) Misdiagnosis is not surprising, since the diagnosis is not always made intraoperatively. In a series of 7 recently reported cases, 5 patients with a scrotal mass had ultrasonic examination, which showed a complex cystic structure, a multilocular cyst, or other septated structures with either hypoechoic areas or echogenic material. (4) Still a correct preoperative diagnosis was not made. A cystic or septate sc rotal mass discovered intraoperatively should not be dismissed as a complex hydrocele, since cystic lymphangiomas predictably recur if incompletely resected. Indeed, the scrotal cysts may represent only a part of a much more extensive disease process. (4,5)

From the Departments of Urology and Radiology, University of Arkansas College of Medicine and Arkansas Children's Hospital, Little Rock.

Reprint requests to John F. Redman, MD, University of Arkansas College of Medicine, Department of Urology, 4301 W Markham, Slot 540, Little Rock, AR 72205-7199.

References

(1.) Bloom DA, Wan J, Key D: Disorders of the male external genitalia and inguinal canal. Clinical Pediatric Urology. Kelalis PP, King LK, Belman AD (eds). Philadelphia, WB Saunders Go, 3rd Ed, 1992, pp 1015-1049

(2.) Jefferson RI-I, Perez LM, Joseph DB: Critical analysis of the clinical presentation of acute scrotum: a 9-year experience at a single institution. J Urol 1997; 158:1198-1200

(3.) Subramanyam BR, Baithazar EJ, Raghavendra BN, et al: Sonographic diagnosis of scrotal hernia. AJR 1982; 139:535-538

(4.) Hurwitz RS. Shapiro E, Hulbert WC, et al: Scrotal cystic lymphangioma: the misdiagnosed scrotal mass. J Urol 1997; 158:1182-1185

(5.) Garrett JE, Cartwright PC, Snow BW, et al: Cystic testicular lesions in the pediatric population. J Urol 2000; 163:928-936

RELATED ARTICLE: KEY POINTS

* The presentation of a boy with an acutely painful sorotum is often associated with a history of trauma.

* Scrotal trauma may be associated with intrascrotal bleeding.

* Scrotal bleeding may be from unusual sites as in this report: from incarcerated omentum or a cystic lymphangioma.