Lower Abdominal Swelling and Scrotal Enlargement FREE

A 24-year old man reports progressive, right lower abdominal swelling and right scrotal enlargement over 2 years. He denies any pain or sudden changes in the size of the swelling. There is no history of trauma or urinary symptoms. Physical examination reveals a smooth, fluctuant, right abdominal swelling extending from the level of the umbilicus to the inguinal ligament (Figure 1). There is also a smooth, cystic swelling causing marked enlargement of the right half of the scrotum. There is no local warmth or tenderness. The left testis is within the scrotum, but the right testis is not palpable. When the patient is asked to cough, there is a palpable thrill. Palpation of the abdominal and scrotal swellings simultaneously reveals cross-fluctuation. Both the swellings are transilluminant.

A . Consult a surgeon for immediate removal of the mass
B . Do nothing; the lesion is not causing any problems
C . Order a CT scan of the involved area
D. Perform a needle biopsy to see if this is fluid or a mass lesion

Abdominoscrotal hydrocele

C. Order CT scan of the involved area

The key clinical feature in this case is understanding the workup of an abdominoscrotal mass. Computed tomographic (CT) scan is the preferred course of action in this case. Needle biopsy should not be done in this patient.

Abdominoscrotal hydrocele is an uncommon congenital condition, more often seen in children than in adults. It is characterized by a large scrotal hydrocele that communicates in an hourglass fashion with an abdominal component through the inguinal canal. Abdominoscrotal hydrocele is thought to be caused by extension of a scrotal hydrocele through the inguinal canal and into the retroperitoneum due to increased intrascrotal pressure along with a closed processus vaginalis.^2- 3 Tense abdominoscrotal hydrocele in infants is associated with a high rate of testicular dysmorphism, which is often reversed by early intervention.⁴

Patients with abdominoscrotal hydrocele usually present with a painless, long-standing, abdominoscrotal mass. The differential diagnosis includes hydrocele, nonincarcerated inguinal hernia, varicocele, spermatocele, localized edema from insect bites, nephrotic syndrome, testicular torsion, and testicular cancer. An abdominoscrotal mass can undergo torsion and may present as an acute abdomen or may cause compression of locoregional structures leading to leg edema, hydroureter, hydronephrosis, and testicular dysmorphism.

Ultrasonography will usually show an encapsulated fluid collection extending from the abdomen to the scrotal cavity through the inguinal ring. A CT scan would provide more information about the abdominal component of the lesion. In an uncomplicated case, CT would show a hypodense collection, whereas magnetic resonance imaging would show a normal fluid signal within the hydrocele.⁵ Scrotal and testicular masses should be evaluated promptly. Surgical treatment is recommended.^6- 8 In an uncomplicated scrotal hydrocele, a transilluminating lesion is diagnostic and no further imaging would be required before proceeding to surgery.

In this patient, ultrasonography revealed a large, cystic, abdominal mass and a right-sided hydrocele. The right testis could not be visualized. Computed tomography showed a homogeneous intra-abdominal mass that continued into the scrotum (Figure 2). The mass caused displacement of the urinary bladder. The right testis was localized in the inguinal canal. The operation was performed through the inguinoscrotal route. The fluid was drained through the scrotal component, and the sac was completely dissected and excised. The right testis appeared normal and was brought down into the scrotum and fixed in the subdartos pouch. The patient recovered and was discharged from the hospital on the second day after surgery.