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Scrotal Hydrocele in Acute Pancreatitis
Accepted Manuscript
Scrotal Hydrocele in Acute Pancreatitis Justin Loloi , Joseph Y. Clark PII: DOI: Reference:
S0090-4295(19)30551-5 https://doi.org/10.1016/j.urology.2019.06.012 URL 21645
To appear in:
Urology
Received date: Accepted date:
12 April 2019 13 June 2019
Please cite this article as: Justin Loloi , Joseph Y. Clark , Scrotal Hydrocele in Acute Pancreatitis, Urology (2019), doi: https://doi.org/10.1016/j.urology.2019.06.012
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Scrotal Hydrocele in Acute Pancreatitis
Authors: Justin Loloi1, Joseph Y. Clark2
1
Penn State College of Medicine, Hershey, Pennsylvania
2
CR IP T
Author Affiliations:
Department of Surgery, Division of Urology, Penn State Milton S. Hershey Medical Center,
AN US
Hershey, PA 17033
Word Count: case report (99); discussion (200)
Key Words: Pancreatitis, abdominal, pseudocyst, enzymes, scrotal, hydrocele, imaging, pain Financial Disclosure: The authors declare that they have no relevant financial interests.
M
From the Department of Surgery, Division of Urology, Penn State Milton S. Hershey Medical Center, Hershey, PA 17033, United States
Joseph Y. Clark, MD
ED
Correspondence to:
PT
Associate Professor of Surgery
Department of Surgery, Division of Urology
CE
Penn State Milton S. Hershey Medical Center 500 University Drive, Hershey, PA 17033, United States
AC
[email protected] Telephone: +1-717-531-8848 Fax: +1-717-531-4475
1
ACCEPTED MANUSCRIPT
Abstract:
Acute pancreatitis a common diagnosis. Although extremely rare, extravasated pancreatic fluid has the potential to third-space into the peritoneal cavity or
CR IP T
retroperitoneal space. We report the case of a 33-year old male with idiopathic subacute pancreatitis who developed acute scrotal pain and swelling. Computer tomography (CT) of the abdomen/pelvis revealed tracking of peritoneal fluid into the scrotum consistent with a pancreatic hydrocele, confirmed by ultrasound. He was taken to the operating
AN US
room for exploration and evacuation of the scrotal hydrocele. This case highlights the importance of active surveillance for the potential development of a scrotal hydrocele in
AC
CE
PT
ED
M
acute pancreatitis.
2
ACCEPTED MANUSCRIPT
CASE REPORT
A patient presented with symptoms consistent with acute pancreatitis. Amylase
CR IP T
and lipase levels were 173 U/L and > 4000 U/L, respectively. He developed right lower quadrant pain radiating to his right scrotum. CT scan revealed edema of the right
hemiscrotum and inguinal canal and a right hydrocele (Fig. 1). Within two days, the swelling increased and there were skin changes (loss of rugae), with progressive
AN US
swelling, spreading to the contralateral hemiscrotum (Fig. 2). He did not have psoas spasm.
Intraoperatively, careful dissection around the spermatic cord was done. He had
M
thickened scrotal subcutaneous tissues and 100 mL of cloudy hydrocele fluid (Fig. 3) was evacuated, which had a lipase level > 4000 U/L. A 10-Fr drain was placed along
ED
the path of the spermatic cord and another to drain the interstitial tissues. Postoperatively, each drain put out approximately 50 mL/day and decreased steadily.
PT
The last drain was removed 11 days later. He had an uneventful postoperative course.
CE
Few cases have reported scrotal involvement from acute pancreatitis.1,2 Pancreatic enzyme-rich fluid has potential to track into the retroperitoneum and inguinal
AC
canal resulting in a hydrocele3,4,5. Urologists should consider in the differential diagnosis pancreatitis as the etiology of the scrotal pain and swelling.
3
ACCEPTED MANUSCRIPT
References:
1.
Lee AD, Abraham DT, Agarwal S, Perakath B. The scrotum in pancreatitis: A
2.
CR IP T
case report and literature review. J Pancreas. 2004;5(5):357-359.
Kim SB, Je BK, Lee SH, Cha SH. Scrotal swelling caused by acute necrotizing
pancreatitis: CT diagnosis. Abdom Imaging. 2011;36(2):218-221. doi:10.1007/s00261-
3.
AN US
010-9638-0
Choong KKL. Acute penoscrotal edema due to acute necrotizing pancreatitis. J
Ultrasound Med. 1996;15(3):247-248. doi:10.7863/jum.1996.15.3.247 Maringhini A, Ciambra M, Patti R, et al. Ascites, Pleural, and Pericardial
M
4.
Effusions in Acute Pancreatitis: A Prospective Study of Incidence, Natural History, and
Skouras C, Skouras T, Pai M, Zacharakis E, Spalding D. Inguinoscrotal
PT
5.
ED
Prognostic Role. Dig Dis Sci. 1996;41(5):848-852. doi:10.1007/BF02091521
CE
extension of a pancreatic collection: A rare complication of pancreatitis - Case report and review of the literature. Updates Surg. 2013;65(2):153-159. doi:10.1007/s13304-
AC
012-0138-3
4
ED
M
AN US
CR IP T
ACCEPTED MANUSCRIPT
Figure 1: (A) Coronal image from an IV contrast CT showing pericholecystic fluid in the
PT
right upper quadrant and right hydrocele (arrow) (B) Coronal CT image showing edema
CE
of the right inguinal canal with fluid tracking to the right scrotum (arrow) (C) Transverse
AC
ultrasound imaging demonstrating a right hydrocele
5
AN US
CR IP T
ACCEPTED MANUSCRIPT
Figure 2 (A) Initial right scrotal swelling (B) Progressive right scrotal swelling 24 hours
AC
CE
PT
ED
M
later
6
M
AN US
CR IP T
ACCEPTED MANUSCRIPT
ED
Figure 3 (A) Immediate preoperative photo (B) Intraoperative photo showing the right testicle (top white arrow) and hydrocele (bottom white arrow) (C) Cloudy hydrocele fluid
AC
CE
postoperatively
PT
(D) Immediate postoperative photo with drains in place (E) Healed scrotum 6 weeks
7
Scrotal Hydrocele in Acute Pancreatitis Justin Loloi , Joseph Y. Clark PII: DOI: Reference:
S0090-4295(19)30551-5 https://doi.org/10.1016/j.urology.2019.06.012 URL 21645
To appear in:
Urology
Received date: Accepted date:
12 April 2019 13 June 2019
Please cite this article as: Justin Loloi , Joseph Y. Clark , Scrotal Hydrocele in Acute Pancreatitis, Urology (2019), doi: https://doi.org/10.1016/j.urology.2019.06.012
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Scrotal Hydrocele in Acute Pancreatitis
Authors: Justin Loloi1, Joseph Y. Clark2
1
Penn State College of Medicine, Hershey, Pennsylvania
2
CR IP T
Author Affiliations:
Department of Surgery, Division of Urology, Penn State Milton S. Hershey Medical Center,
AN US
Hershey, PA 17033
Word Count: case report (99); discussion (200)
Key Words: Pancreatitis, abdominal, pseudocyst, enzymes, scrotal, hydrocele, imaging, pain Financial Disclosure: The authors declare that they have no relevant financial interests.
M
From the Department of Surgery, Division of Urology, Penn State Milton S. Hershey Medical Center, Hershey, PA 17033, United States
Joseph Y. Clark, MD
ED
Correspondence to:
PT
Associate Professor of Surgery
Department of Surgery, Division of Urology
CE
Penn State Milton S. Hershey Medical Center 500 University Drive, Hershey, PA 17033, United States
AC
[email protected] Telephone: +1-717-531-8848 Fax: +1-717-531-4475
1
ACCEPTED MANUSCRIPT
Abstract:
Acute pancreatitis a common diagnosis. Although extremely rare, extravasated pancreatic fluid has the potential to third-space into the peritoneal cavity or
CR IP T
retroperitoneal space. We report the case of a 33-year old male with idiopathic subacute pancreatitis who developed acute scrotal pain and swelling. Computer tomography (CT) of the abdomen/pelvis revealed tracking of peritoneal fluid into the scrotum consistent with a pancreatic hydrocele, confirmed by ultrasound. He was taken to the operating
AN US
room for exploration and evacuation of the scrotal hydrocele. This case highlights the importance of active surveillance for the potential development of a scrotal hydrocele in
AC
CE
PT
ED
M
acute pancreatitis.
2
ACCEPTED MANUSCRIPT
CASE REPORT
A patient presented with symptoms consistent with acute pancreatitis. Amylase
CR IP T
and lipase levels were 173 U/L and > 4000 U/L, respectively. He developed right lower quadrant pain radiating to his right scrotum. CT scan revealed edema of the right
hemiscrotum and inguinal canal and a right hydrocele (Fig. 1). Within two days, the swelling increased and there were skin changes (loss of rugae), with progressive
AN US
swelling, spreading to the contralateral hemiscrotum (Fig. 2). He did not have psoas spasm.
Intraoperatively, careful dissection around the spermatic cord was done. He had
M
thickened scrotal subcutaneous tissues and 100 mL of cloudy hydrocele fluid (Fig. 3) was evacuated, which had a lipase level > 4000 U/L. A 10-Fr drain was placed along
ED
the path of the spermatic cord and another to drain the interstitial tissues. Postoperatively, each drain put out approximately 50 mL/day and decreased steadily.
PT
The last drain was removed 11 days later. He had an uneventful postoperative course.
CE
Few cases have reported scrotal involvement from acute pancreatitis.1,2 Pancreatic enzyme-rich fluid has potential to track into the retroperitoneum and inguinal
AC
canal resulting in a hydrocele3,4,5. Urologists should consider in the differential diagnosis pancreatitis as the etiology of the scrotal pain and swelling.
3
ACCEPTED MANUSCRIPT
References:
1.
Lee AD, Abraham DT, Agarwal S, Perakath B. The scrotum in pancreatitis: A
2.
CR IP T
case report and literature review. J Pancreas. 2004;5(5):357-359.
Kim SB, Je BK, Lee SH, Cha SH. Scrotal swelling caused by acute necrotizing
pancreatitis: CT diagnosis. Abdom Imaging. 2011;36(2):218-221. doi:10.1007/s00261-
3.
AN US
010-9638-0
Choong KKL. Acute penoscrotal edema due to acute necrotizing pancreatitis. J
Ultrasound Med. 1996;15(3):247-248. doi:10.7863/jum.1996.15.3.247 Maringhini A, Ciambra M, Patti R, et al. Ascites, Pleural, and Pericardial
M
4.
Effusions in Acute Pancreatitis: A Prospective Study of Incidence, Natural History, and
Skouras C, Skouras T, Pai M, Zacharakis E, Spalding D. Inguinoscrotal
PT
5.
ED
Prognostic Role. Dig Dis Sci. 1996;41(5):848-852. doi:10.1007/BF02091521
CE
extension of a pancreatic collection: A rare complication of pancreatitis - Case report and review of the literature. Updates Surg. 2013;65(2):153-159. doi:10.1007/s13304-
AC
012-0138-3
4
ED
M
AN US
CR IP T
ACCEPTED MANUSCRIPT
Figure 1: (A) Coronal image from an IV contrast CT showing pericholecystic fluid in the
PT
right upper quadrant and right hydrocele (arrow) (B) Coronal CT image showing edema
CE
of the right inguinal canal with fluid tracking to the right scrotum (arrow) (C) Transverse
AC
ultrasound imaging demonstrating a right hydrocele
5
AN US
CR IP T
ACCEPTED MANUSCRIPT
Figure 2 (A) Initial right scrotal swelling (B) Progressive right scrotal swelling 24 hours
AC
CE
PT
ED
M
later
6
M
AN US
CR IP T
ACCEPTED MANUSCRIPT
ED
Figure 3 (A) Immediate preoperative photo (B) Intraoperative photo showing the right testicle (top white arrow) and hydrocele (bottom white arrow) (C) Cloudy hydrocele fluid
AC
CE
postoperatively
PT
(D) Immediate postoperative photo with drains in place (E) Healed scrotum 6 weeks
7