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Year : 1999  |  Volume : 9  |  Issue : 1  |  Page : 17-18
Case report : Ultrasound demonstration of a scrotal calculus-an unusual complication of hydrocele


Department of Radiology, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi-110044, India

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Keywords: Scrotum, Hydrocele, Ultrasound, Scrotal Calculus

How to cite this article:
Vohra V, Goyal BR, Vohra S. Case report : Ultrasound demonstration of a scrotal calculus-an unusual complication of hydrocele. Indian J Radiol Imaging 1999;9:17-8

How to cite this URL:
Vohra V, Goyal BR, Vohra S. Case report : Ultrasound demonstration of a scrotal calculus-an unusual complication of hydrocele. Indian J Radiol Imaging [serial online] 1999 [cited 2019 Aug 21];9:17-8. Available from: http://www.ijri.org/text.asp?1999/9/1/17/28364
Scrotal calculi are benign entities believed to be freely mobile, calcified fibrinoid loose bodies, lying between the layers of the tunica vaginalis of the testes. They are an uncommon complication of long standing hydroceles and are considered to be of inflammatory origin [1],[2]. An appendix testis or appendix epididymis that has twisted and become detached has also been postulated to be a possible cause [2].

We present a case of scrotal calculus detected by US using a 7.5 MHz real time sector scanner. The pathogenesis of this uncommon benign process is discussed, along with a review of literature on the subject.


   Case Report Top


A sixty-five-years old man presented with a palpable lump in his right scrotum which had been slowly increasing in size over two years. There was no history of trauma or of any urinary problem. Physical examination revealed a 2.0cms firm, tender lump in the upper pole of the right testis. An ultrasound scan with a 7.5 MHz real-time sector scanner revealed a moderate right-sided hydrocele. Floating freely within this was a 1.2cms discrete focus of calcification with posterior acoustic shadowing [Figure - 1]. The US appearances of this mobile calcific nodule were typical of a scrotal calculus. No appendix testes or appendix epididymis was detected. The palpable mass identified clinically was a simple epididymal cyst [Figure - 2].


   Discussion Top


Scrotal calculi (also known as scrotal pearls or fibrinoid loose bodies) are benign entities only briefly mentioned in literature. They are an uncommon complication of particularly long standing hydroceles and can be associated with calcification of the tunica vaginalis [1],[3]. Kickham in 1934, presented the first case of "calcified hydrocele simulating tumor" at the American Urological Association [2]. In his case report, surgical exploration revealed about 15cc. of milky fluid between the layers of the tunica, with distinct, shining particles on the inner, calcified wall of the hydrocele sac. This unusual form of calcification had not been previously reported.

Scrotal calculi are believed to originate as a result of inflammation of the tunica vaginalis [2],[5] and are usually freely mobile within a co-existing hydrocele. Exfoliated epithelial cells from an inflamed endothelial lining on the tunica leave behind granulation tissue, which is prone to bleeding. The blood clots, fibrin debris and desquamated epithelial cells from the tunica form the nucleus for crystallization, leading to calculus formation. The associated hydrocele is an exudate that accumulates between the membranes of the tunica. It is usually an abundant, clear serous fluid with a high protein concentration in the majority of patients [5]. The cholesterol content of the hydrocele is variable and may be high in chronic cases. The source of cholesterol is thought to be obstruction of the lymphatics of the tunica as a result of a low-grade infection [1].

An appendix testis or appendix epididymis that has twisted and become free has also been postulated as a cause of scrotal calculus [2]. This is thought to be unlikely as, acute, severe, symptoms, commonly associated with infarction, are not described with a scrotal calculus and multiple scrotal calculi described in the literature cannot be explained on this basis [1],[6]. In our patient too there was no such history of severe, excruciating pain related to infarction. Scrotal calculi have also been reported secondary to a chronic fistulous connection between the urethra and the scrotum [6], thought to be the result of stagnant urine in the scrotum.

Scrotal calculi are as a rule, round, pearly white, rubbery, loose bodies, rich in water, fibrin or fibrinoid material (matrix) and contain a central nucleus of hydroxyapatite [3]. They typically have reversible hydration, which is the ability of desiccated calculi to regain their original size and consistency when exposed to water [5]. Cholesterol calculi rarely occur even though cholesterol is almost always present in the hydrocele fluid in variable concentration [1]. The presence of a hydrocele, which may preclude the detection of these concretions clinically, enhances the visualization on ultrasound, by serving as a water bath. Sonographically they appear as discrete, echogenic foci, freely moving within an associated hydrocele and casting sharply defined posterior acoustic shadows. US appearances are pathognomonic if all the criteria for diagnosis are satisfied as they were in our patient. Ultrasound is therefore the method of choice in identifying this unusual benign condition. Surgery is usually not contemplated unless the hydrocele becomes large and symptomatic.

 
   References Top

1.Chaterjee AC. A rare complication of hydrocele. Br J Surg 1975; 61:891-892.   Back to cited text no. 1    
2.Liukowski GD, Avellone A, Goodnig GAW. Scrotal calculi: Sonographic detection. Radiology 1985; 156: 484.   Back to cited text no. 2    
3.Illingworth C and Dick BM. A textbook of surgical pathology. 10th ed. London: Churchill Livingstone 1968; 651.   Back to cited text no. 3    
4.Kickham CTE. Calcified hydrocele of the tunica vaginalis testis: case report. New Engl J Med 1935; 212: 419.   Back to cited text no. 4    
5.Torok P, Perjes G, Rosdy E. Intrascrotal calcification. Int Urol Nephrol 1981; 13: 167-173.   Back to cited text no. 5  [PUBMED]  
6.Patel VG, Singleton JM, Draycott TJ. Scrotal bladder with scrotal calculi. Br J Urol 1992; 69: 320-321   Back to cited text no. 6  [PUBMED]  

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Correspondence Address:
Babu R Goyal
Department of Radiology, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi-110044
India
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Source of Support: None, Conflict of Interest: None


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[Figure - 1], [Figure - 2]

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