Abdominoscrotal Hydrocele Presenting as Abdominal Pain and Mass after Trans-Scrotal Hydrocelectomy
A
7-year-old boy presented to the emergency department with complaints of right lower quadrant pain. He had no symptoms to suggest gastrointestinal disease. His past surgical history was significant for a transscrotal right hydrocelectomy 5 years prior to presentation. He had no rebound tenderness or guarding. Examination of the scrotum showed normal testicles without hernia or hydrocele. Laboratory evaluation was unremarkable. Ultrasound of the abdomen revealed a cystic mass in the right lower quadrant that was interpreted as a possible appendiceal abscess. Because the usual signs of inflammation were absent and because the senior surgeon felt the exam was not consistent with appendicitis, the ultrasound result was questioned. A computerized tomography (CT) was obtained which confirmed the diagnosis of abdominoscrotal hydrocele (ASH) (Figure). Laparoscopic repair was attempted; however, inflammation made visibility difficult and the
procedure was converted to a mini-laparotomy with successful excision of the hydrocele and drainage of the inguinal portion. ASH is rarely encountered, comprising 0.17%-1.2% of all hydroceles in a pediatric population.1,2 Unlike a simple hydrocele, ASH extends from the scrotum through the inguinal canal and into the abdomen. First described in 1834, there have been fewer than 150 cases reported in the literature.2-4 Ultrasonography or CT may identify a cystic abdominal mass, which, when combined with physical exam findings, may suggest the diagnosis of ASH. It is unclear whether this case represents a recurrence of the hydrocele as an ASH, or whether this patient’s ASH went undiagnosed at the time of his prior procedure. Physicians must remain alert to the potential for an abdominal component to any hydrocele and must consider that with uncommon diagnoses, ultrasound may not provide the specificity required. Further imaging with CT can be useful. n Presented as a poster and abstract at the Hernia Repair Conference, Las Vegas, NV, March 12-15, 2014.
Tim Soeken, MSc Baylor College of Medicine Houston, Texas
Erica Hodgman, MD Steve Megison, MD Department of Surgery University of Texas Southwestern Medical School Children’s Medical Center Dallas, Texas
References
Figure. Coronal image of CT showing the abdominal and inguinal portions of the hydrocele.
J Pediatr 2015;166:1546. 0022-3476/$ - see front matter. Copyright ª 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpeds.2015.02.046
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1. Nagar H, Kessler A. Abdominoscrotal hydrocele in infancy: a study of 15 cases. Pediatr Surg Int 1998;13:189-90. 2. Avolio L, Chiari G, Caputo MA, Bragheri R. Abdominoscrotal Hydrocele in Childhood: Is it really a rare entity? J Urology 2000;56:1047-9. 3. Dupuytren G. Lecons Orales Clin Churgicale. Paris: Baliere; 1839, pp 705. 4. Syme J. Abdominoscrotal Hydrocele. Br Med J 1861;2:139.
A
7-year-old boy presented to the emergency department with complaints of right lower quadrant pain. He had no symptoms to suggest gastrointestinal disease. His past surgical history was significant for a transscrotal right hydrocelectomy 5 years prior to presentation. He had no rebound tenderness or guarding. Examination of the scrotum showed normal testicles without hernia or hydrocele. Laboratory evaluation was unremarkable. Ultrasound of the abdomen revealed a cystic mass in the right lower quadrant that was interpreted as a possible appendiceal abscess. Because the usual signs of inflammation were absent and because the senior surgeon felt the exam was not consistent with appendicitis, the ultrasound result was questioned. A computerized tomography (CT) was obtained which confirmed the diagnosis of abdominoscrotal hydrocele (ASH) (Figure). Laparoscopic repair was attempted; however, inflammation made visibility difficult and the
procedure was converted to a mini-laparotomy with successful excision of the hydrocele and drainage of the inguinal portion. ASH is rarely encountered, comprising 0.17%-1.2% of all hydroceles in a pediatric population.1,2 Unlike a simple hydrocele, ASH extends from the scrotum through the inguinal canal and into the abdomen. First described in 1834, there have been fewer than 150 cases reported in the literature.2-4 Ultrasonography or CT may identify a cystic abdominal mass, which, when combined with physical exam findings, may suggest the diagnosis of ASH. It is unclear whether this case represents a recurrence of the hydrocele as an ASH, or whether this patient’s ASH went undiagnosed at the time of his prior procedure. Physicians must remain alert to the potential for an abdominal component to any hydrocele and must consider that with uncommon diagnoses, ultrasound may not provide the specificity required. Further imaging with CT can be useful. n Presented as a poster and abstract at the Hernia Repair Conference, Las Vegas, NV, March 12-15, 2014.
Tim Soeken, MSc Baylor College of Medicine Houston, Texas
Erica Hodgman, MD Steve Megison, MD Department of Surgery University of Texas Southwestern Medical School Children’s Medical Center Dallas, Texas
References
Figure. Coronal image of CT showing the abdominal and inguinal portions of the hydrocele.
J Pediatr 2015;166:1546. 0022-3476/$ - see front matter. Copyright ª 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpeds.2015.02.046
1546
1. Nagar H, Kessler A. Abdominoscrotal hydrocele in infancy: a study of 15 cases. Pediatr Surg Int 1998;13:189-90. 2. Avolio L, Chiari G, Caputo MA, Bragheri R. Abdominoscrotal Hydrocele in Childhood: Is it really a rare entity? J Urology 2000;56:1047-9. 3. Dupuytren G. Lecons Orales Clin Churgicale. Paris: Baliere; 1839, pp 705. 4. Syme J. Abdominoscrotal Hydrocele. Br Med J 1861;2:139.
