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Inflammatory communicating hydrocele
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CASE REPORTS
INFLAMMATORY
COMMUNICATING
HYDROCELE
LOUIS R. COS, M.D. CHARLES
A. LINKE,
M.D.
JOHN R. VALVO, M.D. From the Division of Urology, The University of Rochester School of Medicine and Dentistry, Rochester, New York
ABSTRACT - A case of acute scrotal swelling after appendectomy is described. nosis of an acute scrotal swelling is reoiewed.
Acute scrotal swelling is usually secondary to torsion of the spermatic cord or testicular appendages, or epididymo-orchitis. l-* Other less common possibilities should be included in the differential diagnosis. One of them is a patent processus vaginalis reflecting intraperitoneal pathology. Herein we report on a patient with inflammatory communicating hydrocele which occurred twenty-four hours after an appendectomy. Case Report A fourteen-year-old boy was hospitalized for right lower quadrant abdominal pain with guarding and rebound. Rectal temperature was 39” C. Results of admission laboratory studies were normal with the exception of a 21,10O/ml leukocytosis with shift to the left. Antimicrobial therapy with a single dose of gentamicin, cephaiothin (Keflin), and clindamycin was given preoperatively. Exploratory laparotomy disclosed an acutely was inflamed appendix, and appendectomy done. Although no perforation was found, culture of peritoneal fluid in the area was positive for Escherichia coli and Bacteroides fragilis. The following day fever persisted, and the patient noticed moderate left scrotal discomfort but did not report it. Because of persistence of fever, the same antibiotics were again given. On the second postoperative day, the left hemiscrotum became
528
Diferential
diag-
red, swollen, and exquisitely tender. The major portion of the swelling was of cystic character but did not transilluminate. The testicle and epididymis could not be palpated clearly within the enlarged hemiscrotum. The swelling and tenderness extended along the spermatic cord to the inguinal region. The right testicle and epididymis were normal. Urinalysis was normal. A technectium-99m pertechnetate testicular scan demonstrated increased perfusion to the left scrotal structures interpreted as consistent with orchio-epididymitis (Fig. 1A). A water bath ultrasonic scan of the scrotum* indicated an increased amount of fluid around the testicle and linear strands within the hydrocele fluid suggestive of an inflammatory collection of fluid. The echo “texture” of the testicular substance was normal (Fig. 1B). On the third postoperative day, the patient underwent left testicular exploration through an inguinoscrotal incision. The thickened tunica vaginalis was incised, and cloudy, odorless hydrocele fluid was found surrounding the testicle. There were strands of fibrin in the hydrocele fluid with prolongations covering epididymis and testicles. The testis and epididymis were both normal. The hydrocele sac was continuous with the abdominal cavity through an inguinal prolongation. The wound was irrigated and drained. The following *UI-Octoson,
UROLOGY
Ausonics, Australia.
/ NOVEMBER
1332
/ VOLUME
XX, NUMBER
5
FIGURE 1. (A) Immediate dynamic anteroposterior view of scrotum after injection of *“‘Tc pertechnetate shows increased uptake of radionuclide in left hemiscrotum; no “halo” is seen (LF = left femoral, RF = right femoral, LH = left hemiscrotum). (B) Water bath ultrasonic scan of left hemiscrotum (longitudinal view) shows hydrocele with linear echo patterns suggestive of inflammatory strands, and normal echo pattern of testicle (Ce = cephalad, Ca = caudad, T = testicle, S = strands, H = hydrocele).
day, the patient was afebrile; after an uneventful recovery, he was discharged on the sixth postoperative day. Cultures from the hydrocele fluid grew E. coli. Comment In spite of the relatively superficial location of the scrotal contents, differential diagnosis of scrotal lesions is often difficult. Physical examination findings may be augmented by nuclear medicine and ultrasound studies to aid in the differentiation of the multiple processes that may result in scrotal pathology. The ultrasound imaging was particularly accurate in identifying the nature of the pathologic process in our patient. Claudius Amyand, principal surgeon, St. George’s Hospital, London, performed the first recorded appendectomy, published in the Philosophical
Transactions of the Royal Society, 1736. ’ The patient, an eleven-year-old
October, boy, was hospitalized “for the cure of a Hernia Scrotalis and a fistula between the Scrotum and Thigh.” At operation, Amyand found a sliding inguinoscrotal hernia with the cecum in the scrotum, a perforated appendix, and a stercoral fistula. He performed an appendectomy, repair of the hernia, and drainage of the scrotum.’ The presence of a patent processus vaginalis may reflect in the scrotum intra-abdominal pathology. This “scrotal peritonitis” may be the result of acute appendicitis,4 perforated and
UROLOGY
/
NOVEMBER
1982
/
VOLUME
XX, NUMBER 5
non-perforated postappendectomy complications as in our patient, splenic rupture,5 meconium hydrocele with speckled calcifications as the result of prenatal perforation of the intestine,’ testicular strangulation in association with inguinal hernia compressing the testicular vessels,s the tip of a ventriculoperitoneal shunt for hydrocephalus lodged in the processus vaginalis,’ urine ascitis secondary to a pelvioperitoneal fistula,’ resuscitative measures, increasing intra-abdominal pressure and creating a scrotal pneumatocele,* and potentially any of the causes for acute symptoms of the abdomen. Urology, Box 656 University of Rochester Medical Center Rochester, New York 14642 (DR. COS) References 1. Creese PG: The Surgeon’s Library, The Book Shelf, The First Appendectomy, Surg Gynecol Obstet 97: 643 (1953). 2. Kaplan GW, and King LR: Acute scrotal swelling in children, J Urol 164: 219 (1970). 3. Wasuick RJ, Rohutsky KR, and Macchia RJ: Testicular torsion and usefulness of radionuclide scanning, Urology 15: 318 (1980). 4. Alveav DT, and Rayheld MM: Acute appendicitis presented as a scrotal mass, J Pediatr Surg 11: 91 (1976). 5. Henry HH II: Unusual presentation of splenic rupture, Sot Pediatr Urol Newsletter, Oct. 11, 1978. 6. Williams DI: Paediatric Urology, New York, AppletonCentury-Crofts, 1968, pp. 465-468. 7. Mani P: Unusual causes of acute scrotal swelling, Sot Pediatr Urol Newsletter, Nov. 29, 1978. 8. Gordon HL, and Walkup JL: Scrotal pneumatocele as an unusual sign of pneumoperitoneum: report of a case and review of literature, J Urol 194: 441 (1970).
529
,,_“,
“i.~-l
.-
_/,,
q,.irli-““-r(
CASE REPORTS
INFLAMMATORY
COMMUNICATING
HYDROCELE
LOUIS R. COS, M.D. CHARLES
A. LINKE,
M.D.
JOHN R. VALVO, M.D. From the Division of Urology, The University of Rochester School of Medicine and Dentistry, Rochester, New York
ABSTRACT - A case of acute scrotal swelling after appendectomy is described. nosis of an acute scrotal swelling is reoiewed.
Acute scrotal swelling is usually secondary to torsion of the spermatic cord or testicular appendages, or epididymo-orchitis. l-* Other less common possibilities should be included in the differential diagnosis. One of them is a patent processus vaginalis reflecting intraperitoneal pathology. Herein we report on a patient with inflammatory communicating hydrocele which occurred twenty-four hours after an appendectomy. Case Report A fourteen-year-old boy was hospitalized for right lower quadrant abdominal pain with guarding and rebound. Rectal temperature was 39” C. Results of admission laboratory studies were normal with the exception of a 21,10O/ml leukocytosis with shift to the left. Antimicrobial therapy with a single dose of gentamicin, cephaiothin (Keflin), and clindamycin was given preoperatively. Exploratory laparotomy disclosed an acutely was inflamed appendix, and appendectomy done. Although no perforation was found, culture of peritoneal fluid in the area was positive for Escherichia coli and Bacteroides fragilis. The following day fever persisted, and the patient noticed moderate left scrotal discomfort but did not report it. Because of persistence of fever, the same antibiotics were again given. On the second postoperative day, the left hemiscrotum became
528
Diferential
diag-
red, swollen, and exquisitely tender. The major portion of the swelling was of cystic character but did not transilluminate. The testicle and epididymis could not be palpated clearly within the enlarged hemiscrotum. The swelling and tenderness extended along the spermatic cord to the inguinal region. The right testicle and epididymis were normal. Urinalysis was normal. A technectium-99m pertechnetate testicular scan demonstrated increased perfusion to the left scrotal structures interpreted as consistent with orchio-epididymitis (Fig. 1A). A water bath ultrasonic scan of the scrotum* indicated an increased amount of fluid around the testicle and linear strands within the hydrocele fluid suggestive of an inflammatory collection of fluid. The echo “texture” of the testicular substance was normal (Fig. 1B). On the third postoperative day, the patient underwent left testicular exploration through an inguinoscrotal incision. The thickened tunica vaginalis was incised, and cloudy, odorless hydrocele fluid was found surrounding the testicle. There were strands of fibrin in the hydrocele fluid with prolongations covering epididymis and testicles. The testis and epididymis were both normal. The hydrocele sac was continuous with the abdominal cavity through an inguinal prolongation. The wound was irrigated and drained. The following *UI-Octoson,
UROLOGY
Ausonics, Australia.
/ NOVEMBER
1332
/ VOLUME
XX, NUMBER
5
FIGURE 1. (A) Immediate dynamic anteroposterior view of scrotum after injection of *“‘Tc pertechnetate shows increased uptake of radionuclide in left hemiscrotum; no “halo” is seen (LF = left femoral, RF = right femoral, LH = left hemiscrotum). (B) Water bath ultrasonic scan of left hemiscrotum (longitudinal view) shows hydrocele with linear echo patterns suggestive of inflammatory strands, and normal echo pattern of testicle (Ce = cephalad, Ca = caudad, T = testicle, S = strands, H = hydrocele).
day, the patient was afebrile; after an uneventful recovery, he was discharged on the sixth postoperative day. Cultures from the hydrocele fluid grew E. coli. Comment In spite of the relatively superficial location of the scrotal contents, differential diagnosis of scrotal lesions is often difficult. Physical examination findings may be augmented by nuclear medicine and ultrasound studies to aid in the differentiation of the multiple processes that may result in scrotal pathology. The ultrasound imaging was particularly accurate in identifying the nature of the pathologic process in our patient. Claudius Amyand, principal surgeon, St. George’s Hospital, London, performed the first recorded appendectomy, published in the Philosophical
Transactions of the Royal Society, 1736. ’ The patient, an eleven-year-old
October, boy, was hospitalized “for the cure of a Hernia Scrotalis and a fistula between the Scrotum and Thigh.” At operation, Amyand found a sliding inguinoscrotal hernia with the cecum in the scrotum, a perforated appendix, and a stercoral fistula. He performed an appendectomy, repair of the hernia, and drainage of the scrotum.’ The presence of a patent processus vaginalis may reflect in the scrotum intra-abdominal pathology. This “scrotal peritonitis” may be the result of acute appendicitis,4 perforated and
UROLOGY
/
NOVEMBER
1982
/
VOLUME
XX, NUMBER 5
non-perforated postappendectomy complications as in our patient, splenic rupture,5 meconium hydrocele with speckled calcifications as the result of prenatal perforation of the intestine,’ testicular strangulation in association with inguinal hernia compressing the testicular vessels,s the tip of a ventriculoperitoneal shunt for hydrocephalus lodged in the processus vaginalis,’ urine ascitis secondary to a pelvioperitoneal fistula,’ resuscitative measures, increasing intra-abdominal pressure and creating a scrotal pneumatocele,* and potentially any of the causes for acute symptoms of the abdomen. Urology, Box 656 University of Rochester Medical Center Rochester, New York 14642 (DR. COS) References 1. Creese PG: The Surgeon’s Library, The Book Shelf, The First Appendectomy, Surg Gynecol Obstet 97: 643 (1953). 2. Kaplan GW, and King LR: Acute scrotal swelling in children, J Urol 164: 219 (1970). 3. Wasuick RJ, Rohutsky KR, and Macchia RJ: Testicular torsion and usefulness of radionuclide scanning, Urology 15: 318 (1980). 4. Alveav DT, and Rayheld MM: Acute appendicitis presented as a scrotal mass, J Pediatr Surg 11: 91 (1976). 5. Henry HH II: Unusual presentation of splenic rupture, Sot Pediatr Urol Newsletter, Oct. 11, 1978. 6. Williams DI: Paediatric Urology, New York, AppletonCentury-Crofts, 1968, pp. 465-468. 7. Mani P: Unusual causes of acute scrotal swelling, Sot Pediatr Urol Newsletter, Nov. 29, 1978. 8. Gordon HL, and Walkup JL: Scrotal pneumatocele as an unusual sign of pneumoperitoneum: report of a case and review of literature, J Urol 194: 441 (1970).
529