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Incarcerated Scrotal Appendicitis
THE JOURNAL OF UROLOGY
Vol. 75, No. 5, May 1956
Printed in U.S.A.
INCARCERATED SCROTAL APPENDICITIS JOHN R. HERMAN
Scrotal appendicitis is a rare form of inflammation of the displaced vermiform appendix. It has been reported in the literature only four times. Numerous articles have described the abnormal position of the appendix and methods of locating it in the abdomen. Its position being so variable, one should not be surprised to find it present in hernias, scrotal or otherwise. A case will be presented illustrating incarcerated scrotal appendicitis. The vermiform appendix has been described in almost every place in the abdominal cavity and thorax; in the thigh in femoral hernias, in the right and left inguinal regions in hernias of those areas; and in the scrotum in scrotal hernias. Babcock1 portrayed the appendix as found frequently in hernia sacs. W atson2 reported the finding of the appendix alone in the hernial sac as fairly rare. His figure was 53 cases in more than 17,000 collected from the literature. Zambrana3 reported a case of scrotal appendicular abscess, and Keyes4 found both appendix and cecum in the scrotum. Reif5 described acute scrotal appendicitis in a male infant, and Mulholland et al. 6 gave a description of acute scrotal appendicitis in a 6-month-old boy who had bilateral inguinal hernias as well as an umbilical hernia. The anatomy of inguinal hernias extending into the scrotum has been well recounted. To quickly review, the pouch-like vaginal process of the peritoneum, which extends down into the scrotum preceding the testicle, may not complete the normal developmental plan of involution in the inguinal canal. If the processes vaginalis persists and remains open to the tunica vaginalis, it is a readymade hernia awaiting only the presence of an abdominal viscus. If it is still present, but partially or completely closed as in the hydrocele of the cord, the same herniating process is invited. Mulholland et al. 6 discussed the likelihood that the scrotal appendix, because of its exposed position, is more likely to inflammatory and traumatic changes than the normally located organ. Because of this exposed position, one would expect the diagnosis to be readily made. However, the acute local symptoms overshadow the abdominal. The actual herniation of the appendix is symptomatically unimportant. It is only when it becomes involved in inflammatory changes that these local changes make the patient aware that there is serious trouble. Then the painful, red, swollen scrotal mass becomes a very obvious source of complaint. The differential diagnosis rests between 1) acute hydrocele, 2) hematocele, 3) testicular torsion, 4) strangulated hernia, 5) hemorrhage into a testicular tumor or 6) virus or other types of orchitis or 7) acute scrotal trauma. Accepted for publication January 11, 1956. 1 Babcock, W.W.: Surg., Gynec. & Obst., 82: 414, 1946. 2 Watson, L. F.: Hernia. St. Louis: C. V. Mosby Co., 1924. 3 Zambrana C. L.: Rev. de med. y cir. Habana, 51: 1, 1946. 4 Keyes, E. F.: Am. J. Surg., 74: 833, 1947. 5 Reif, H. A.: J. Urol., 64: 783, 1950. 6 Mulholland, S. W., Madonna, H. M. and Cornely, D. A.: J. Urol., 69: 815, 1953. 811
812
JOHN R. HERMAN
In none of the cases reported was the diagnosis made preoperatively and it was not made preoperatively in the following case. CASE REPORT
r
r
Bronx Hospital No. 286724. This was the first admission of this 7-year-old Negro because of a painless swelling in the right scrotum. It was first noted about 2 weeks ago while his mother was drying him after a bath. It had been completely asymptomatic and neither he nor his mother could state when it had first appeared. He had no recollection of trauma or preceding febrile reaction or gastrointestinal upset. He had no symptoms referrable to the genitourinary or gastrointestinal tract. Physical examination revealed a well developed, well nourished Negro in no distress. His head, thorax and abdomen all were essentially normal. Temperature, pulse and respiration were also normal. There was a nontender, fusiform swelling in the right scrotal sac which was approximately 8 cm. long and 4 cm. wide. This was quite firm although somewhat cystic in consistency. The testicle and epididymis could not be differentiated from the mass. Examination of the mass revealed a small area at the upper pole that transilluminated clearly. The rest of the mass did not. There was no evidence of hernia on cough or straining and a finger could not be admitted into the external ring. There were slightly enlarged inguinal n:odes which interfered with palpation of the ring. The staff was divided on the diagnosis between traumatic hydrocele and hematocele. Blood count was 4,200,000 red blood cells, 6000 white blood cells, 84 per cent hemoglobin (12.2 gm.), 72 segs, 20 lymphs, and 6 monocytes. The urinalysis was negative, specific gravity 1.015. The scrotum was explored under general anesthesia and the operative report follows: A 4-inch incision was made from the upper portion of the scrotum parallel to the inguinal ligament and was carried down through the superficial fascial layers. After incising the last peritesticular layer, about 10 cc of straw colored fluid escaped. The tumor became slightly smaller. The testicle was identified and appeared normal in size, shape and consistency. The epididymis and spermatic cord were involved in a swelling which was 2 by 4 cm. in size. This mass was cartilaginous in consistency and was felt to be a neoplastic lesion. Grossly, the cut surface was mucinous with some grumous yellow fluid in one portion. The spermatic cord could not be identified as it lost itself in the mass. It was the consensus of opinion that orchiectomy should be done. What was thought to be the spermatic cord structures were freed of their surrounding tissues in the groin and ligated en masse, and divided. The vas deferens was isolated, clamped, divided and ligated. The mass and testicle were removed en bloc. A stab wound was made in a dependent portion of the scrotum for drainage and the scrotum was closed in layers. The postoperative diagnosis was supratesticular tumor, either granuloma or epididymal neoplasm. Grossly, the actual disease was not recognized by the surgeons at the
INCARCERATED SCROTAL APPENDICITIS
813
table, or by the pathologists in their gross examinations. It was the microscopic examination which revealed the true condition. The pathologist's report follows: The specimen consisted of a testicle measuring 15 by 15 mm. in size, and a supratesticular mass measuring 2 cm. by4 cm. The spermatic cord was not identified separately and the testicle appears to be slightly atrophic. The supra testicular mass was a firm, somewhat cystic structure which on cut section was composed of several fused, thin layers, the inner of which was dark blue. The entire supratesticular mass was matted and adherent to the testicle and epididymis. On cut section, two cord-like structures were identified. Microscopic section through the testis showed an irmnature appearance consistent with the patient's age. Section through the supratesticular mass revealed that the cystic structure had a thick fibrous appearance, its wall being composed of dense, partly hyalinized, collagenous bundles and numerous blood vessels. In the central portion of this cystic mass was a cross-section of an appendix essentially normal in appearance except for chronic inflammatory reaction and periappendiceal fibrosis. I'he peritoneum of the appendix was adherent to the thick fibrous wall of the cystic structure and in son1e places was absent. Adherent to, and encased. in the wall of this inflammatory mass, was the sperrnatic cord which was essentially normal. Diagnosis: Scrotal hernia with incarcerated appendix showing chronic appendicitis and peri-appendicitis. Normal testicle and cord. Figure l is a diagram based on the operative findings and pathologist's report . The pos1;operativc, cour:-,e was smooth and uneventful. There was no febrile
Frc;. 1
814
JOHN R. HERMAN
reaction; the drain was removed in 24 hours, and the boy was ready to go home in 6 days when the report of the pathologist was received. He was held in the hospital one week longer. He has been seen in the clinic and is doing very well. It is intended to readmit the patient to the hospital in 6 months, at which time he will be investigated with a view towards hernial repair and completing the appendectomy. COMMENT
Scrotal appendicitis, acute or chronic, should be added to the physician's differential diagnosis of scrotal masses. Undoubtedly, there must be more cases of this type that have not been reported. Perhaps a more careful inquiry into the history might reveal gastrointestinal disturbances that could hint towards diagnosis. An awareness of the possibility of this condition might save the physician and the patient from unneeded distress. SUMMARY
The four previously reported cases of scrotal appendicitis have been briefly reviewed and another case of chronic scrotal appendicitis added. Differential diagnosis has been discussed. Gratitude is extended to Dr. M. L. Gottlieb, chief of the urological service, and to Dr. Lycourgos Papapadakis, department of pathology.
111 E. 88th St., New York 28, N. Y.
Vol. 75, No. 5, May 1956
Printed in U.S.A.
INCARCERATED SCROTAL APPENDICITIS JOHN R. HERMAN
Scrotal appendicitis is a rare form of inflammation of the displaced vermiform appendix. It has been reported in the literature only four times. Numerous articles have described the abnormal position of the appendix and methods of locating it in the abdomen. Its position being so variable, one should not be surprised to find it present in hernias, scrotal or otherwise. A case will be presented illustrating incarcerated scrotal appendicitis. The vermiform appendix has been described in almost every place in the abdominal cavity and thorax; in the thigh in femoral hernias, in the right and left inguinal regions in hernias of those areas; and in the scrotum in scrotal hernias. Babcock1 portrayed the appendix as found frequently in hernia sacs. W atson2 reported the finding of the appendix alone in the hernial sac as fairly rare. His figure was 53 cases in more than 17,000 collected from the literature. Zambrana3 reported a case of scrotal appendicular abscess, and Keyes4 found both appendix and cecum in the scrotum. Reif5 described acute scrotal appendicitis in a male infant, and Mulholland et al. 6 gave a description of acute scrotal appendicitis in a 6-month-old boy who had bilateral inguinal hernias as well as an umbilical hernia. The anatomy of inguinal hernias extending into the scrotum has been well recounted. To quickly review, the pouch-like vaginal process of the peritoneum, which extends down into the scrotum preceding the testicle, may not complete the normal developmental plan of involution in the inguinal canal. If the processes vaginalis persists and remains open to the tunica vaginalis, it is a readymade hernia awaiting only the presence of an abdominal viscus. If it is still present, but partially or completely closed as in the hydrocele of the cord, the same herniating process is invited. Mulholland et al. 6 discussed the likelihood that the scrotal appendix, because of its exposed position, is more likely to inflammatory and traumatic changes than the normally located organ. Because of this exposed position, one would expect the diagnosis to be readily made. However, the acute local symptoms overshadow the abdominal. The actual herniation of the appendix is symptomatically unimportant. It is only when it becomes involved in inflammatory changes that these local changes make the patient aware that there is serious trouble. Then the painful, red, swollen scrotal mass becomes a very obvious source of complaint. The differential diagnosis rests between 1) acute hydrocele, 2) hematocele, 3) testicular torsion, 4) strangulated hernia, 5) hemorrhage into a testicular tumor or 6) virus or other types of orchitis or 7) acute scrotal trauma. Accepted for publication January 11, 1956. 1 Babcock, W.W.: Surg., Gynec. & Obst., 82: 414, 1946. 2 Watson, L. F.: Hernia. St. Louis: C. V. Mosby Co., 1924. 3 Zambrana C. L.: Rev. de med. y cir. Habana, 51: 1, 1946. 4 Keyes, E. F.: Am. J. Surg., 74: 833, 1947. 5 Reif, H. A.: J. Urol., 64: 783, 1950. 6 Mulholland, S. W., Madonna, H. M. and Cornely, D. A.: J. Urol., 69: 815, 1953. 811
812
JOHN R. HERMAN
In none of the cases reported was the diagnosis made preoperatively and it was not made preoperatively in the following case. CASE REPORT
r
r
Bronx Hospital No. 286724. This was the first admission of this 7-year-old Negro because of a painless swelling in the right scrotum. It was first noted about 2 weeks ago while his mother was drying him after a bath. It had been completely asymptomatic and neither he nor his mother could state when it had first appeared. He had no recollection of trauma or preceding febrile reaction or gastrointestinal upset. He had no symptoms referrable to the genitourinary or gastrointestinal tract. Physical examination revealed a well developed, well nourished Negro in no distress. His head, thorax and abdomen all were essentially normal. Temperature, pulse and respiration were also normal. There was a nontender, fusiform swelling in the right scrotal sac which was approximately 8 cm. long and 4 cm. wide. This was quite firm although somewhat cystic in consistency. The testicle and epididymis could not be differentiated from the mass. Examination of the mass revealed a small area at the upper pole that transilluminated clearly. The rest of the mass did not. There was no evidence of hernia on cough or straining and a finger could not be admitted into the external ring. There were slightly enlarged inguinal n:odes which interfered with palpation of the ring. The staff was divided on the diagnosis between traumatic hydrocele and hematocele. Blood count was 4,200,000 red blood cells, 6000 white blood cells, 84 per cent hemoglobin (12.2 gm.), 72 segs, 20 lymphs, and 6 monocytes. The urinalysis was negative, specific gravity 1.015. The scrotum was explored under general anesthesia and the operative report follows: A 4-inch incision was made from the upper portion of the scrotum parallel to the inguinal ligament and was carried down through the superficial fascial layers. After incising the last peritesticular layer, about 10 cc of straw colored fluid escaped. The tumor became slightly smaller. The testicle was identified and appeared normal in size, shape and consistency. The epididymis and spermatic cord were involved in a swelling which was 2 by 4 cm. in size. This mass was cartilaginous in consistency and was felt to be a neoplastic lesion. Grossly, the cut surface was mucinous with some grumous yellow fluid in one portion. The spermatic cord could not be identified as it lost itself in the mass. It was the consensus of opinion that orchiectomy should be done. What was thought to be the spermatic cord structures were freed of their surrounding tissues in the groin and ligated en masse, and divided. The vas deferens was isolated, clamped, divided and ligated. The mass and testicle were removed en bloc. A stab wound was made in a dependent portion of the scrotum for drainage and the scrotum was closed in layers. The postoperative diagnosis was supratesticular tumor, either granuloma or epididymal neoplasm. Grossly, the actual disease was not recognized by the surgeons at the
INCARCERATED SCROTAL APPENDICITIS
813
table, or by the pathologists in their gross examinations. It was the microscopic examination which revealed the true condition. The pathologist's report follows: The specimen consisted of a testicle measuring 15 by 15 mm. in size, and a supratesticular mass measuring 2 cm. by4 cm. The spermatic cord was not identified separately and the testicle appears to be slightly atrophic. The supra testicular mass was a firm, somewhat cystic structure which on cut section was composed of several fused, thin layers, the inner of which was dark blue. The entire supratesticular mass was matted and adherent to the testicle and epididymis. On cut section, two cord-like structures were identified. Microscopic section through the testis showed an irmnature appearance consistent with the patient's age. Section through the supratesticular mass revealed that the cystic structure had a thick fibrous appearance, its wall being composed of dense, partly hyalinized, collagenous bundles and numerous blood vessels. In the central portion of this cystic mass was a cross-section of an appendix essentially normal in appearance except for chronic inflammatory reaction and periappendiceal fibrosis. I'he peritoneum of the appendix was adherent to the thick fibrous wall of the cystic structure and in son1e places was absent. Adherent to, and encased. in the wall of this inflammatory mass, was the sperrnatic cord which was essentially normal. Diagnosis: Scrotal hernia with incarcerated appendix showing chronic appendicitis and peri-appendicitis. Normal testicle and cord. Figure l is a diagram based on the operative findings and pathologist's report . The pos1;operativc, cour:-,e was smooth and uneventful. There was no febrile
Frc;. 1
814
JOHN R. HERMAN
reaction; the drain was removed in 24 hours, and the boy was ready to go home in 6 days when the report of the pathologist was received. He was held in the hospital one week longer. He has been seen in the clinic and is doing very well. It is intended to readmit the patient to the hospital in 6 months, at which time he will be investigated with a view towards hernial repair and completing the appendectomy. COMMENT
Scrotal appendicitis, acute or chronic, should be added to the physician's differential diagnosis of scrotal masses. Undoubtedly, there must be more cases of this type that have not been reported. Perhaps a more careful inquiry into the history might reveal gastrointestinal disturbances that could hint towards diagnosis. An awareness of the possibility of this condition might save the physician and the patient from unneeded distress. SUMMARY
The four previously reported cases of scrotal appendicitis have been briefly reviewed and another case of chronic scrotal appendicitis added. Differential diagnosis has been discussed. Gratitude is extended to Dr. M. L. Gottlieb, chief of the urological service, and to Dr. Lycourgos Papapadakis, department of pathology.
111 E. 88th St., New York 28, N. Y.