Obliteration of the Processus Vaginalis After Testicular Descent

The testis develops in the abdominal cavity and descends into the scrotum. Although numerous theories have been proposed, the mechanism of descent and the reason for its inhibition remain unknown. Furthermore, none of the explanations account for the other occurrences related to the descent, such as failed obliteration of the processus vaginalis, or the reasons for the decrease in fertility and increase in the risk of malignancy associated with an undescended testis. The gubernaculum is a primitive mesenchymal tissue that was first described in 1786. However, the role of the gubernaculum in the descent process remains obscure. The testis descends through the processus vaginalis. Although the processus vaginalis (PV) is usually defined as a simple peritoneal protrusion, it actively develops into the gubernaculum. The gubernaculum gives rise to the smooth muscles that surround the processus vaginalis. The striated cremaster muscle (CM) is also derived from the gubernaculum. Because the testis descends through the processus vaginalis, the muscles develop to propel the testis. After propelling the testis, the smooth muscle (SM) undergoes programmed cell death. The initiation of programmed cell death through the intrinsic pathway requires activation of phospholipase C. A transient shift in the autonomic balance via a decrease in the sympathetic tonus and an increase in the parasympathetic tonus is essential for initiating this programmed cell death. Programmed cell death in the SM is the physiological pathway for the obliteration of the processus vaginalis. Differences in the timing, intensity, or duration of this physiological pathway result in pathological conditions. A shift before testicular descent diminishes the SM content that is required to propel the testis, and thus inhibits descent. The early shift persists throughout childhood and results in the decrease in fertility and increase in the risk of malignancy because of the differences in signal transduction. Despite a successful descent, persistence of the shift alters the contractility of the CM by increasing the cytosolic calcium levels. Contracted CMs retracts or even ascends the testis. Inadequate intensity or duration of the shift of autonomic tonus causes failure of the programmed cell death. Persistence of the SM hinders the obliteration of PV and gives rise to hydroceles or inguinal hernias depending on the amount of residual smooth muscles. Similar findings from different countries support these explanations. Thus, our proposed mechanism satisfactorily explains the process of descent while considering all the factors related to the process of testicular descent.

Mesothelioma of the tunica vaginalis testis

Mesothelioma of the tunica vaginalis testis (MTVT) is a rare tumour and a cause of hydrocele. This case report concerns a 26-year-old male with hydrocele treated with left hydrocelectomy. Histopathology revealed MTVT, and left radical orchiectomy was performed followed by chemotherapy. Fluorescence in situ hybridization, DNA and RNA next-generation sequencing showed no mesothelioma-associated tumour suppressor gene mutations, but deletion of CDKN2A and a rare TFG-ADGRG7 fusion both reported in pleural mesotheliomas, were detected. Clinicians should consider malignancy in case of discrepancy between symptoms and objective findings in scrotal conditions.

Eggshell calcified hydrocele sac: a case report

INTRODUCTION

Hydrocele, an abnormal fluid collection between parietal and visceral layers of the tunica vaginalis, is the commonest cause of scrotal swelling, and it affects all age groups. Calcification of hydrocele sac/wall is a rare clinical entity. The etiology of calcification of hydrocele sac is not clear, but most literature proposes that calcification is secondary to chronic irritation. Trauma and infectious diseases including Schistosoma haematobium, filariasis, and tuberculosis can also cause calcification of the hydrocele sac.

CASE PRESENTATION

A 74-year-old Ethiopian male patient presented with left side scrotal swelling of 3 years duration, which was initially small but progressively increased. He had no history of trauma, and he had no history of swelling on the contralateral side. Scrotal ultrasound (US) showed a large echodebrinous left-side scrotal collection with calcifications, bilateral testis appear normal in size, echogenicity, and color Doppler flow with the index of likely chronic hematocele. Therefore, with a diagnosis of left-sided calcified hydrocele, the patient was operated on and the calcified sac was excised and sent for histopathology. Finally, the patient was discharged improved after 2 days of hospital stay.

CONCLUSION

Calcification of the tunica vaginalis is very rare and is probably due to chronic irritation of the wall from the coexisting hydrocele. Surgical excision of calcified hydrocele sac is the treatment of choice.

Abdominoscrotal Haematocele in an Adult and Its Successful Treatment

Abdominoscrotal hydrocele (ASH) is a variant of hydrocele that rarely occurs in adults. ASH has two sacs, one in the scrotum and one in the abdomen connected through the inguinal canal. Abdominoscrotal haematocele is a rare complication of ASH. We report a 57-year-old male patient who presented to a tertiary care hospital in Puducherry, India, in 2019 with complaints of swelling in the scrotum for 15 years and abdominal pain for two months. Both the swellings were soft and cross fluctuation was present. Imaging confirmed the diagnosis of ASH. During a diagnostic laparoscopy, the abdominal sac was decompressed and found to have thick brownish fluid suggestive of haematocele. It was demonstrated that both sacs were connected. Due to difficulty in the dissection of the sac, the procedure was converted to an open procedure. Both the sacs were excised and Lytle’s repair was done for the dilated internal ring. The patient recovered and no recurrence of any swelling in the abdomen or scrotum was found at the end of a one-year follow-up. Keywords: Testicular Hydrocele; Scrotal Hydrocele; Testicular Haematocele; Scrotal Haematocele; Laparoscopic Surgical Procedure; Laparoscopic Surgery; Case Report; India.  

Well-differentiated papillary mesothelioma of tunica vaginalis testis of unknown malignant potential: Sonographic appearance

Paratesticular mesothelioma is a rare differential diagnosis in the presence of scrotal hydrocele. A 17-year-old boy presented with a 3-year history of progressive hydrocele. Sonography revealed a large left paratesticular mass within the hydrocele. Serum tumor markers were negative. Left hydrocelectomy was performed and pathological analysis of the epididymal mass revealed a well-differentiated papillary mesothelioma. We discuss the sonographic and pathological findings of this rare neoplasm.

Lymphatic filariasis patient identification in a large urban area of Tanzania: An application of a community-led mHealth system

BACKGROUND

Lymphatic filariasis (LF) is best known for the disabling and disfiguring clinical conditions that infected patients can develop; providing care for these individuals is a major goal of the Global Programme to Eliminate LF. Methods of locating these patients, knowing their true number and thus providing care for them, remains a challenge for national medical systems, particularly when the endemic zone is a large urban area.

METHODOLOGY/PRINCIPLE FINDINGS

A health community-led door-to-door survey approach using the SMS reporting tool MeasureSMS-Morbidity was used to rapidly collate and monitor data on LF patients in real-time (location, sex, age, clinical condition) in Dar es Salaam, Tanzania. Each stage of the phased study carried out in the three urban districts of city consisted of a training period, a patient identification and reporting period, and a data verification period, with refinements to the system being made after each phase. A total of 6889 patients were reported (133.6 per 100,000 population), of which 4169 were reported to have hydrocoele (80.9 per 100,000), 2251 lymphoedema-elephantiasis (LE) (43.7 per 100,000) and 469 with both conditions (9.1 per 100,000). Kinondoni had the highest number of reported patients in absolute terms (2846, 138.9 per 100,000), followed by Temeke (2550, 157.3 per 100,000) and Ilala (1493, 100.5 per 100,000). The number of hydrocoele patients was almost twice that of LE in all three districts. Severe LE patients accounted for approximately a quarter (26.9%) of those reported, with the number of acute attacks increasing with reported LE severity (1.34 in mild cases, 1.78 in moderate cases, 2.52 in severe). Verification checks supported these findings.

CONCLUSIONS/SIGNIFICANCE

This system of identifying, recording and mapping patients affected by LF greatly assists in planning, locating and prioritising, as well as initiating, appropriate morbidity management and disability prevention (MMDP) activities. The approach is a feasible framework that could be used in other large urban environments in the LF endemic areas.

A systematic review and meta-analysis concerning single-site laparoscopic percutaneous extraperitoneal closure for pediatric inguinal hernia and hydrocele

BACKGROUND

Single-site laparoscopic percutaneous extraperitoneal closure (SLPEC) of hernia sac/processus vaginalis has been widely performed for repair of inguinal hernia/hydrocele in children. However, a variety of surgical instruments and techniques were used, and significant differences existed among the SLPEC reports.

METHODS

A literature search was performed for all available studies concerning SLPEC for pediatric inguinal hernia/hydrocele in PubMed, Embase and Cochrane library. The surgical details and operative outcomes were pooled and analyzed with software StataSE 12.0.

RESULTS

49 studies fulfilled the predefined inclusion criteria of this review and 37 studies were finally included in the meta-analysis. The mean incidence of CPPV was 29.1% (range 5.73-43.0%). The average of mean operative time was 19.56 min (range 8.30-41.19 min) for unilateral SLPEC and 27.23 min (range 12.80-48.19 min) for bilateral SLPEC. The total incidence of injury, conversion, recurrence, hydrocele formation, knot reaction, severe pain, and scrotal swelling was 0.32% (range 0-3.24%), 0.05% (range 0-0.89%), 0.70% (range 0-15.5%), 0.23% (range 0-3.57%), 0.33% (range 0-3.33%), 0.05% (range 0-4.55%), and 0.03% (range 0-1.52%), respectively. There was no development of testicular atrophy. Subgroup analyses showed an inverse correlation between the injury incidence and adoption of assisted forceps, hydrodissection, and blunt puncture device, between the conversion rate and adoption of hydrodissection, between the recurrence/hydrocele incidence and adoption of assisted forceps, hydrodissection, nonabsorbable suture and the preventive measures to avoid ligating the unnecessary subcutaneous tissues, and between the rate of knot reaction and adoption of assisted forceps, hydrodissection, and the preventive measures.

CONCLUSIONS

SLPEC was a well-developed procedure for repair of pediatric inguinal hernia/hydrocele. Adoption of assisted forceps, hydrodissection, nonabsorbable suture, and the preventive measures to avoid ligating the unnecessary subcutaneous tissues could significantly reduce the intra- and postoperative complications.

Paratesticular Rhabdomyosarcoma Presenting With a Giant Abdominoscrotal Hydrocele in a Toddler

Rhabdomyosarcoma (RMS) is the most common soft tissue sarcoma in infants and children. Paratesticular RMS accounts for approximately 7% of all RMSs. It commonly presents as a painless scrotal mass, which is usually distinct from the testis. We report an unusual case of paratesticular RMS presenting with a giant abdominoscrotal hydrocele in a toddler. To the best of our knowledge, this is the first case of paratesticular RMS presenting with an abdominoscrotal hydrocele.

[Traumatic Testicular Rupture Complicated with Hydrocele: A Case Report]

A 17-year-old man presented with right hydrocele because of an athletic injury. His scrotum was hit with a ball 2 months ago while playing baseball. He was diagnosed with post-traumatic hydrocele and underwent needle puncture at another hospital 1 month after the trauma. However, the hydrocele did not improve. Therefore, he was referred to our hospital for surgical treatment. For diagnosis of the traumatic hydrocele testis, a hydrocelectomy was scheduled. When we opened the tunica vaginalis, we realized that the tunica albuginea had been ruptured and the testicular parenchyma had gushed out. We tried to replace all the escaped testicular parenchyma into the tunica albuginea, but it was impossible. Therefore were moved some of the redundant testicular parenchyma, and replaced the remnants into the tunica albuginea. After the operation, right hydrocele and testicular atrophy did not occur. Traumatic testicular rupture complicated with hydrocele is rare.

Scrotal calculi in clinical practice and their role in scrotal pain: A prospective study

PURPOSE

Scrotal calculi are rare, and their clinical significance is uncertain. Scrotal pain is a frequent, hard-to-manage problem in urology clinics. Our purpose in this study was to determine the relationship between the presence of scrotal calculi and scrotal pain in a prospective manner.

METHODS

Sonography and color Doppler ultrasound of the scrotum were performed in 758 consecutive patients referred with scrotal pain. The pain was rated by using an 11-point numeric rating scale; scores were compared among patients with scrotal calculi with and without additional scrotal pathology.

RESULTS

Scrotal calculi were detected in 73 of the 758 patients (9.6%). Scrotal pain (n = 50 [61%]) and a palpable mass in the scrotum (n = 25 [30.5%]) were the most common complaints in patients with scrotal calculi. Hydrocele (n = 17 [29.8%]) and varicocele (n = 15 [26.3%]) were the most commonly associated abnormalities; there was a statistically significant association between the presence of scrotal calculi and hydrocele (p < 0.01). Scrotal pain was present in 61 (83.5%) patients with scrotal calculi, and this association was significant (p < 0.001). The presence of scrotal pain and the correlation between location of calculi and pain in patients without additional scrotal abnormalities were also significant (p = 0.04 and p < 0.004, respectively).

CONCLUSIONS

The prevalence of scrotal calculi was 9.6%, and hydrocele was found to be associated with scrotal calculi. We also found a significant relationship between the presence of calculi and scrotal pain. Because the etiology of scrotal pain is essential for appropriate treatment, scrotal calculi should be kept in mind when making a differential diagnosis of scrotal pain. © 2014 Wiley Periodicals, Inc. J Clin Ultrasound 43:406-411, 2015.

Hematocele secondary to rupture of an abdominoscrotal hydrocele

OBJECTIVE

To describe one case of hematocele secondary to rupture of an abdominoscrotal hydrocele in an adult patient.

METHODS AND RESULTS

We report a huge hematocele in a patient with this unusual type of hydrocele that suffered a minimal scrotal trauma. It was a hydrocele that extended through the inguinal canal to the retroperitoneal space.

CONCLUSIONS

Abdominoscrotal hydrocele is a rare condition in children and even rarer in adults. The presence of a hematocele requires early surgical treatment.

Bilateral polyorchidism with diffuse microlithiasis: a case report of an adolescent with 4 testes

Polyorchidism is a rare congenital anomaly, with only 140 pathologically proven cases reported. Bilateral polyorchidism is far less common than triorchidism. Most cases present as a painless scrotal mass or are found incidentally during evaluation of other inguinoscrotal pathologies. We report a case of bilateral polyorchidism with 4 testes, 2 in each hemiscrotum that presented as left-sided testicular pain and hydrocele.

Decision making in the management of hydroceles in infants and children

The aim of this article was to establish a ground for evidence-based decision making in dealing with hydroceles, according to the age of the child and the presenting signs and symptoms. This prospective cohort study was conducted at Al-Kademyia Teaching Hospital in Baghdad, Iraq, during the period from December 2001 to December 2005. There were two groups of patients: group 1 involved 121 patients that presented with hydroceles at less than 1 year of age that were followed up to their first birthday to monitor the fate of hydroceles. Group 2 involved 140 patients, 1-12 years of age, who presented with hydroceles and had surgery. Their age, the affected side, diurnal changes in size, and the findings at surgery were recorded. In group 1, 89% of patients with hydroceles had spontaneous resolution or showed marked improvement during the first year of life and only 11% required an operation. The indications for surgery were the presence of an associated inguinal hernia (7%) and development of a huge hydrocele (3%). In group 2, 83% of patients with hydroceles presented within the first 5 years of age. Diurnal changes in the size of hydroceles were encountered in 92% of cases.

CONCLUSION

89% of patients with infantile hydrocele will have a spontaneous resolution owing to the ongoing changes in the patent processus vaginalis. Surgical intervention in the first year of life is only required for those who have an associated inguinal hernia and for those with hydroceles that become huge in size.

[A case of liposarcoma of spermatic cord with a hydrocele]

A 59-year-old man was referred to our hospital with the chief complaint of painless left scrotal swelling. He was diagnosed with left hydrocele testis and underwent puncture of hydrocele. Radical hydrocelectomy was performed because of its frequent recurrence in a short period. A hard mass was found across the spermatic cord during the operation. The mass was removed, and histopathological examination revealed a well-differentiated liposarcoma. This was the 107th case of liposarcoma of the spermatic cord and the 3rd case with a hydrocele.

Marriage, sex, and hydrocele: an ethnographic study on the effect of filarial hydrocele on conjugal life and marriageability from Orissa, India

Background

Lymphatic filariasis (LF), a leading cause of permanent and long-term disability, affects 120 million people globally. Hydrocele, one of the chronic manifestations of LF among 27 million people worldwide, causes economic and psychological burdens on patients and their families. The present study explores and describes the impact of hydrocele on sexual and marital life as well as on marriageability of hydrocele patients from rural areas of Orissa, an eastern state of India.

Methodology/Principal Findings

This paper is based on ethnographic data collected through focus group discussions and in-depth interviews with hydrocele patients, wives of hydrocele patients, and other participants from the community. The most worrisome effect of hydrocele for patients and their wives was the inability to have a satisfactory sexual life. The majority of patients (94%) expressed their incapacity during sexual intercourse, and some (87%) reported pain in the scrotum during intercourse. A majority of hydrocele patients' wives (94%) reported dissatisfaction in their sexual life. As a result of sexual dissatisfaction and physical/economic burden, communication has deteriorated between the couples and they are not living happily. This study also highlights the impact on marriageability. The wives of hydrocele patients said that a hydrocele patient is the “last choice” and that girls show reluctance to marry hydrocele patients. In some cases, the patients were persuaded by their wives to remove hydrocele by surgery (hydrocelectomy).

Conclusions/Significance

The objective of the morbidity management arm of the Global Programme to Eliminate LF should be to increase access to hydrocelectomy, as hydrocelectomy is the recommended intervention. Though the study area is covered by the programme, like in other endemic areas, hydrocelectomy has not been emphasised by the national LF elimination programme. The policy makers and programme managers should be sensitised by utilising this type of research finding.

Lymphatic filariasis, the second leading cause of permanent and long-term disability, affects 120 million people globally. Hydrocele, an accumulation of fluid in the scrotum that causes it to swell, is one of the chronic manifestations of LF among men and there are about 27 million men with hydrocele worldwide. We conducted ethnographic interviews and discussions with patients, women whose husbands have hydrocele, and the general public in a rural community of eastern India. The study describes how hydrocele impacts patients' sexual and marital life. It reveals the most worrisome effect of hydrocele for patients and their wives due to the inability to have a satisfactory sexual life. Patients expressed their incapacity during sexual intercourse. A majority of hydrocele patients' wives reported that their married life became burdened and couples were not living happily. This study also highlights the impact on marriageability, and some women expressed that a hydrocele patient is the “last choice”. In some cases, the patients were persuaded by their wives to remove hydrocele by surgery (hydrocelectomy). Hence, access to hydrocelectomy has to be strengthened under the Global Programme to Eliminate Lymphatic Filariasis, which is operational in several endemic areas in the world. Also, this activity may be integrated with primary healthcare services and interventions of other neglected tropical diseases.

Giant hydrocele--an epitome of neglect

Hydrocele [Greek: water--sac] is abnormal fluid collection within the tunica vaginalis of the scrotum or a patent tunica vaginalis. It is a relatively common condition in surgical practice. However, a giant hydrocele, here defined for clinical purposes, as a hydrocele equal to or bigger than the patient's head, is rare as indicated by the limited number of reported cases in the literature. In this paper I am presenting three cases of giant hydroceles and highlighting how it affects the quality of patients' life by way of complications, infertility, sexual function and work capacity.

[Urethroplasty with tunica vaginalis flap for treating hypospadias with hydrocele: a report of 9 cases]

OBJECTIVE

To explore the treatment of hypospadias with hydrocele.

METHODS

Nine patients with hypospadias complicated by hydrocele underwent urethroplasty with tunica vaginalis flap.

RESULTS

Satisfactory results were achieved in 7 cases, all with a normal anatomic position of urethral meatus, perfect urination and no infection. Local infection and meatal stricture occurred in 1 case, which was restored to normal by urethral sounding. Scrotal urinary fistula developed in another.

CONCLUSION

With minimum surgical trauma, conveniently available material and fast tissue repair, urethroplasty with tunica vaginalis flap is a desirable method for the treatment of hypospadias with hydrocele.

Sclerotherapy of idiopathic hydroceles and epididymal cysts: a historical comparison trial of 5% phenol versus tetracycline

Operating time for idiopathic hydroceles and epididymal cysts is scarce as these conditions compete with an increasing caseload of more consequential surgical disease. Therapy is often relegated to repeated aspiration. Sclerotherapy appears to be effective in a majority of published trials, but comparative effectiveness, efficacy and safety of most agents, including phenol versus tetracycline, has not been established A deliberate strategy of re-treatment until cure is not universally practised, with surgery still being offered after single-treatment failures. Two trials, the first consisting of 53 scrotal cysts treated with 5% phenol-in-water and the second, 42 cysts treated with tetracycline, are compared for effectiveness, efficacy and safety of sclerotherapy per se and of re-treatment. Intention-to-treat analysis yields similar cure rates (no re-accumulation three months after last injection) for phenol and tetracycline (83% and 81% respectively, p = 0.8). Per-protocol analysis also yields similar cure rates (100% and 97% respectively, p = 0.26) and mean number of injections to cure (1.34 and 1.12 respectively, p = 0.069), with range 1-4 and 1-3 respectively. Severe pain following tetracycline injection required administration of pre-injection cord block. Other complications occurred equally (25% and 25.7% respectively, p = 0.94) and were trivial except for one case of chronic haematocele treated by orchiectomy in the tetracycline group. Phenol (5%) and tetracycline are equally efficacious sclerosants for idiopathic scrotal cysts, achieving almost 100% cure with re-treatment and matching the efficacy of surgery. Concern about post-treatment fertility applies equally to surgery and demands informed consent for both modalities.

Torsion of an indirect hernia sac within a hydrocele causing acute scrotum: case report and review of the literature

We report a case of acute scrotum in a 2-year-old child caused by torsion of an indirect hernia sac within a hydrocele. This is an extremely rare cause of acute scrotal swelling and pain in the pediatric population, with this case representing only the eighth instance reported in the literature. Despite the scarcity with which this diagnosis has been encountered, clinicians should include torsion of an indirect hernia sac on the differential diagnosis for acute scrotum in a child.

Mesothelioma of the tunica vaginalis testis: a rare malignancy mimicking more common inguino-scrotal masses

Malignant pleural mesotheliomas are rare malignancies associated with asbestos exposure and these tumors are infamous for their poor prognosis. Mesotheliomas in other body areas are much rarer. They may occur in the abdominal cavity and also in the inguinal region. In the latter area they are commonly confused with much commoner benign conditions. We present three cases of mesotheliomas in the tunica vaginalis testis.

Giant unilateral abdominoscrotal hydrocele in association with crossed testicular ectopia

Abdominoscrotal hydrocele and transverse testis ectopia are rare clinical conditions. This case report describes the combination of these two rare entities. An azoospermic and infertile adult man presented with left abdominoscrotal hydrocele and a right impalpable testis. He was treated with left orchiopexy, right orchiectomy, and excision of the abdominoscrotal hydrocele. We discuss the diagnosis and treatment of this combination, which has not been previously reported.

Bile causing an acute scrotum immediately after laparoscopic cholecystectomy

We report our experience with a patient that developed an acute right hemiscrotum immediately after undergoing an uncomplicated laparoscopic cholecystectomy for gallbladder dyskinesia. The etiology of the acute scrotal pain was due to bile which was spilled into the peritoneum after entry into the gallbladder during dissection. The bile obtained access to the right hemiscrotum via a communicating hydrocele. To the best of our knowledge this is the first report of bile causing an acute scrotum following laparoscopic surgery. A review of the current literature on the topic of the postoperative acute scrotum follows our case presentation.

Bilateral giant abdominoscrotal hydroceles complicated by appendicitis

Abdominoscrotal hydrocele is a rare entity, with fewer than 100 cases reported in children. Bilateral abdominoscrotal hydroceles are even less common, with 14 cases reported in children. Various complications of abdominoscrotal hydrocele have been reported in the literature. We present a 4-month-old boy with bilateral giant abdominoscrotal hydroceles who developed appendicitis apparently because of obstruction from the right hydrocele. We discuss the various imaging modalities used to establish the diagnosis and plan the operative approach.

Rhabdomyosarcoma of tunica vaginalis masquerading as hydrocele

Paratesticular rhabdomyosarcomas are rare tumors with aggressive growth patterns. Multimodal therapy with surgery, chemotherapy, and radiotherapy provides the patient with an excellent long-term prognosis. These tumors often present in the first two decades after birth. We report on the case of an 18-year-old man with a paratesticular rhabdomyosarcoma.

Concurrent male gynecomastia and testicular hydrocele after imatinib mesylate treatment of a gastrointestinal stromal tumor

We report a gastrointestinal stromal tumor (GIST) patient with male gynecomastia and testicular hydrocele after treatment with imatinib mesylate. A 42 yr-old male patient presented for management of hepatic masses. Two years earlier, he had undergone a small bowel resection to remove an intraabdominal mass later shown to be a GIST, followed by adjuvant radiation therapy. At presentation, CT scan revealed multiple hepatic masses, which were compatible with metastatic GIST, and he was prescribed imatinib 400 mg/day. During treatment, he experienced painful enlargement of the left breast and scrotal swelling. Three months after cessation of imatinib treatment, the tumors recurred, and, upon recommencing imatinib, he experienced painful enlargement of the right breast and scrotal swelling. He was diagnosed with male gynecomastia caused by decreased testosterone and noncommunicative testicular hydrocele. He was given androgen support and a hydrocelectomy, which improved his gynecomastia. The mechanism by which imatinib induces gynecomastia and hydrocele is thought to be associated with an inhibition of c-KIT and platelet-derive growth factor. This is the first report, to our knowledge, describing concurrent male gynecomastia and testicular hydrocele after imatinib treatment of a patient with GIST.

Could inguinal hernia be treated medically?

Inguinal hernia is the most common congenital anomaly requiring surgical correction. The cause of the hernia is, most commonly, persistence of the processus vaginalis. Study of testicular descent in rodents has revealed a role for the genitofemoral nerve and calcitonin gene-related peptide (CGRP). Since the testis cannot descend without the processus vaginalis, we wondered whether both descent and hernia closure might be regulated by the same mechanism. Therefore, we tested the idea that CGRP might be active in closure of the inguinal hernia. Using hernial sacs removed at herniotomy operation, fusion of the hernial surfaces was induced by CGRP, but not by CGRP 8-37, CGRP 27-37 or dihydrotestosterone. Hepatocyte growth factor also caused peritoneal obliteration in vitro. We propose that obliteration of the processus vaginalis is under the control of molecules released from the genitofemoral nerve, and that a chemical treatment of inguinal hernia is at least theoretically possible.

Early-onset Escherichia coli sepsis presenting as acute scrotum in preterm infant

Epididymitis, or epididymo-orchitis, and infected hydrocele are unusual in the neonatal period. It is critical to differentiate them rapidly from testicular torsion to salvage the affected testis and avoid unnecessary surgical exploration. Escherichia coli is an important gram-negative bacteria causing diverse neonatal infections and is also the common bacteria causing epididymo-orchitis from an ascending route. We report the case of a preterm infant affected with epididymo-orchitis and infected hydrocele caused by early-onset E. coli sepsis. We highlight the importance of sampling proper cultures and using suitable antibiotics after excluding testicular torsion in a neonate with an acute scrotum.

Torsion of the hernia sac within a hydrocele of the scrotum in a child

Torsion of the hernia sac is a rare disease that presents as acute scrotum in children. Including the present case, only six cases have been reported in the English literature. We report a 10-year-old boy who presented with pain and swelling of his right scrotum. Ultrasonography revealed a hypoechoic region adjacent to the normal right testis. The inflammatory changes of the right scrotum deteriorated. The patient underwent surgery and a necrotic cyst was recognized within a hydrocele of the scrotum. The cyst was not connected with the testis or epididymis and was twisted at an angle of 270 degrees. The cause of the necrotic cyst observed was anatomical and pathological torsion of the hernia sac.

[A case of mycotic spermatic cord abscess in a continuous ambulatory peritoneal dialysis patient]

A 66-year-old male patient has been on continuous ambulatory peritoneal dialysis (CAPD) since 1993, and was diagnosed with right hydrocele of the spermatic cord in 1998. He repeatedly developed CAPD-related bacterial peritonitis 3 times. In February 2001, hemodialysis was prescribed for treatment of mycotic peritonitis. A palpable mass was noted in the right inguinal region in October 2001 and a computed tomographic (CT) scan disclosed a 4 cm circular lesion with relatively low density and thick wall in the right inguinal region. Spermatic-orchiectomy was performed. Histological diagnosis was mycosis like Candida on the abscess wall. To our knowledge, this is the first case of spermatic cord abscess in a CAPD patient in the Japanese literature.

Primary testicular osteosarcoma with hydrocele

Primary testicular osteosarcoma is an extremely rare malignancy. To date, only two cases have been reported. Here, we report a third case of primary testicular osteosarcoma complicated with hydrocele. A 78-year-old man presented with right scrotal swelling. Ultrasonography revealed hydrocele and a testicular heterogeneous solid mass with focal calcification in the right testis. Right inguinal orchiectomy revealed a pure intratesticular osteosarcoma. Retroperitoneal lymph-node dissection revealed no metastasis. Thorough sampling of the tumor failed to show any additional histological components. It is unlikely that our case arose from teratoma or mixed sex-cord/stromal tumor, because no other neoplastic elements were identified in whole sampling of the tumor. He remained well without evidence of disease 44 months after operation. This case illustrates that primary pure testicular osteosarcoma may be associated with a favorable prognosis.

Infarto hemorrágico testicular en neonato: presentación de un caso

Hemorrhagic infarction of the testicle is an unusual occurrence in the newborn infant. It usually develops as a consequence of torsion of the spermatic cord. We report a case of global testicular infarction in a newborn associated with a tense hydrocele.

Diffuse fibrous pseudotumor of the testicular tunics associated with an inflamed hydrocele

Fibrous pseudotumors of the testicular tunics and paratesticular soft tissue are uncommon lesions. They typically arise as painless scrotal masses that may be associated with a hydrocele or history of trauma or infection. Although these lesions are clinically worrisome for a malignant neoplasm, they are thought to be reactive in nature, since they are composed of dense fibrous tissue with interspersed bland fibroblasts and myofibroblasts and mixed inflammatory cells. Once excised, these lesions behave in a benign fashion. Typically, these masses are multinodular, but in rare cases they are diffuse, bandlike myofibroblastic proliferations that encase the testis and are termed fibromatous periorchitis. Herein, we describe a 57-year-old man with a diffuse fibrous pseudotumor/fibromatous periorchitis that encased the left testis and adnexa and arose in close apposition to an inflamed hydrocele.

MRI and MRA of a giant hydrocoele in an infant

We present a 7-month-old boy with a giant abdominoscrotal hydrocoele associated with right leg oedema. US revealed an abdominoscrotal fluid-filled mass with a normal testis in the scrotum. MRI allowed precise delineation of the mass while MRA sequences showed extrinsic compression of the right iliac vein and its patency. Hydrocoelectomy and laparotomy were performed and confirmed the diagnosis. US followed by MRI are often necessary to diagnose and delineate giant hydrocoeles. MRA is a non-invasive elegant tool for the detection of vascular complications.

Malignant mesothelioma of testicular tunica vaginalis

We report here a case with malignant mesothelioma of testicular tunica vaginalis. An 81-year-old Japanese man with left hydrocele was referred for operation. When hydrocelectomy was performed, a thick wall of tunica vaginalis without malignancy was observed. Seven months after hydrocelectomy, a hard irregular mass was noticed in the left scrotum, therefore inguinal orchiectomy was performed. Pathologically, the mass showed severe atypia and mitosis. The diagnosis of malignant mesothelioma was made. He refused any adjuvant treatment and died 1 year later from multiple metastases to the paraaortic lymph nodes and lumbar supine.

[A rare retroperitoneal tumor: abdomino-scrotal hydrocele. Two case reports]

Abdominoscrotal hydrocele is a very rare condition, different from the majority of cases of hydroceles related to the persistence of the processus vaginalis. The anomaly consists of a large scrotal hydrocele which communicates in an hour-glass fashion with a large abdominal component through the inguinal canal. We report two cases observed in infants.

CASE REPORTS

1. A nine-month-old infant was referred because of a large bilateral hydrocele. On clinical examination on the right side in the lower quadrant of the abdomen was found a mass which communicated with the right scrotal pouch. Diagnosis of abdominoscrotal hydrocele was established by ultrasonography. During the surgical exploration the right testis was found to be dysmorphic, fusiform and ectopic in the inguinal canal. Surgical treatment comprised hydrocelectomy and right orchidectomy. 2. A six-month-old infant presented with a large right hydrocele in communication with an abdominal pouch located in the right lower quadrant, in association with a lymphoedema of the right limb. Diagnosis of abdominoscrotal hydrocele was confirmed by ultrasonography. During the surgical procedure the pouch was opened and everted. The testis was dysmorphic as in the first case, in normal scrotal position and was preserved.

COMMENTS

Abdominoscrotal hydrocele is a rare condition reported in adult population and also in the infant. The exact mechanism by which it develops is unknown. The diagnosis can be suspected on clinical examination if an abdominal mass in a lower quadrant is palpable just above the inguinoscrotal pouch. The diagnosis relies on ultrasonography. Complications sometimes occur due to the pressure on adjacent structures (ureters, iliac vessels). Testicular dysmorphism has been reported in some patients. In any case, as spontaneous resolution of abdominoscrotal hydrocele has never been reported, surgical treatment is indicated.

Malignant mesothelioma of tunica vaginalis testis associated with long-lasting hydrocele: could hydrocele be an etiological factor?

A case of malign mesothelioma of tunica vaginalis testis in a 67 year old man with a 30 year history of hydrocele was reported. The diagnosis was made with an excisional biopsy performed in scrotal exploration and revealed epithelial type mesothelioma. High orchiectomy with hemiscrotectomy was performed. The patient had a local recurrence at the end of two years. As there were no distant metastasis only local excision was performed. In his sixth month after the second surgery he is still tumor free. Related literature reviewed.

[Intra-scrotal lithiasis. Crystallographic analysis]

OBJECTIVE

To present two cases of intrascrotal lithiasis associated with hydrocele and the results of the crystallographic study.

METHODS

Three intrascrotal calculi in two patients aged 72 and 75 years that underwent surgery for hydrocele were analyzed. Two 2-mm. calculi were incidentally discovered during surgery for a right hydrocele in one patient. An ultrasound scan of the other patient showed a left hydrocele with a free-floating, round, hyperechoic, 6-mm. calculus, with posterior acoustic shadow. None of the patients had a previous history of trauma. The 3 calculi were white and smooth, but turned yellow and rough after removal. Scanning electron microscopy and x-ray dispersion studies were performed.

RESULTS

All 3 calculi had a center comprised of hydroxyapatite and white organic matter, and an exterior of yellow organic matter. The mineral portion of the center of the 6-mm. calculus and one of the 2-mm. calculi was composed of 33% phosphorus and 67% calcium, and the other 2-mm. calculus contained 32% phosphorus and 68% calcium by x-ray dispersion analysis.

CONCLUSIONS

Intrascrotal lithiasis is rare. In the two cases described herein, we observed abundant organic matter, particularly on the stone surface, and hydroxyapatite, particularly in the center. Among the possible etiologic causes, the deposit of organic matter in the presence of high oversaturation of calcium phosphates and absence of crystallization inhibitors, can initiate calcification and the subsequent collection of organic matter makes the process irreversible.