JAMA CLINICAL CHALLENGE

Lower Abdominal Swelling and Scrotal Enlargement

Figure 1. Right lower abdominal and right scrotal swelling (figure reprinted from Arch Surg. 2011;146[6]:757-7581).

Huan J. Chang, MD, MPH 24-YEAR OLD MAN REPORTS PROGRESSIVE, RIGHT LOWER ABDOMINAL SWELLing and right scrotal enlargement over 2 years. He denies any pain or sudden changes in the size of the swelling. There is no history of trauma or urinary symptoms. Physical examination reveals a smooth, fluctuant, right abdominal swelling extending from the level of the umbilicus to the inguinal ligament (FIGURE 1). There is also a smooth, cystic swelling causing marked enlargement of the right half of the scrotum. There is no local warmth or tenderness. The left testis is within the scrotum, but the right testis is not palpable. When the patient is asked to cough, there is a palpable thrill. Palpation of the abdominal and scrotal swellings simultaneously reveals cross-fluctuation. Both the swellings are transilluminant.

What Would You Do Next? A. Consult a surgeon for immediate removal of the mass B. Do nothing; the lesion is not causing any problems C. Order a CT scan of the involved area D. Perform a needle biopsy to see if this is fluid or a mass lesion See www.jama.com for online Clinical Challenge.

Author Affiliation: Dr Chang (tina.chang@jama-archives.org) is Contributing Editor, JAMA. JAMA Clinical Challenge Section Editor: Huan J. Chang, MD, Contributing Editor. We encourage authors to submit papers for consideration as a JAMA Clinical Challenge. Please contact Dr Chang at tina.chang@jama-archives.org.

2011 American Medical Association. All rights reserved.

JAMA, October 19, 2011Vol 306, No. 15 1709

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JAMA CLINICAL CHALLENGE

Diagnosis Abdominoscrotal hydrocele What to Do Next C. Order CT scan of the involved area The key clinical feature in this case is understanding the workup of an abdominoscrotal mass. Computed tomographic (CT) scan is the preferred course of action in this case. Needle biopsy should not be done in this patient. Comment Abdominoscrotal hydrocele is an uncommon congenital condition, more often seen in children than in adults. It is characterized by a large scrotal hydrocele that communicates in an hourglass fashion with an abdominal component through the inguinal canal. Abdominoscrotal hydrocele is thought to be caused by extension of a scrotal hydrocele through the inguinal canal and into the retroperitoneum due to increased intrascrotal pressure along with a closed processus vaginalis.2,3 Tense abdominoscrotal hydrocele in infants is associated with a high rate of testicular dysmorphism, which is often reversed by early intervention.4 Patients with abdominoscrotal hydrocele usually present with a painless, long-standing, abdominoscrotal mass. The differential diagnosis includes hydrocele, nonincarcerated inguinal hernia, varicocele, spermatocele, localized edema from insect bites, nephrotic syndrome, testicular torsion, and testicular cancer. An abdominoscrotal mass can undergo torsion and may present as an acute abdomen or may cause compression of locoregional structures leading to leg edema,

puted tomography showed a homogeneous intra-abdominal mass that continued into the scrotum (FIGURE 2). The mass caused displacement of the urinary bladder. The right testis was localized in the inguinal canal. The operation was performed through the inguinoscrotal route. The fluid was drained through the scrotal component, and the sac was completely dissected and excised. The right testis appeared normal and was brought down into the scrotum and fixed in the subdartos pouch. The patient recovered and was discharged from the hospital on the second day after surgery.
Figure 2. Computed tomographic scan (coronal section) shows the cystic abdominal swelling in continuity with the scrotal swelling (figure reprinted from Arch Surg. 2011;146[6]:757-7581).
Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. Additional Information: This JAMA Clinical Challenge is based on a previously published article ( Jindal T, Sharma N. Image of the month: abdominoscrotal hydrocele. Arch Surg. 2011;146[6]:757-758).

hydroureter, hydronephrosis, and testicular dysmorphism. Ultrasonography will usually show an encapsulated fluid collection extending from the abdomen to the scrotal cavity through the inguinal ring. A CT scan would provide more information about the abdominal component of the lesion. In an uncomplicated case, CT would show a hypodense collection, whereas magnetic resonance imaging would show a normal fluid signal within the hydrocele.5 Scrotal and testicular masses should be evaluated promptly. Surgical treatment is recommended.6-8 In an uncomplicated scrotal hydrocele, a transilluminating lesion is diagnostic and no further imaging would be required before proceeding to surgery. In this patient, ultrasonography revealed a large, cystic, abdominal mass and a right-sided hydrocele. The right testis could not be visualized. Com-

REFERENCES 1. Jindal T, Sharma N. Image of the month: abdominoscrotal hydrocele. Arch Surg. 2011;146(6):757758. 2. Cuervo JL, Ibarra H, Molina M. Abdominoscrotal hydrocele: its particular characteristics. J Pediatr Surg. 2009;44(9):1766-1770. 3. Bayne A, Paduch D, Skoog SJ. Pressure, fluid and anatomical characteristics of abdominoscrotal hydroceles in infants. J Urol. 2008;180(4)(suppl):17201723. 4. Cozzi DA, Mele E, Ceccanti S, Pepino D, dAmbrosio G, Cozzi F. Infantile abdominoscrotal hydrocele: a not so benign condition. J Urol. 2008;180(6):26112615. 5. Rasalkar DD, Chu WCW, Mudalgi B, Paunipagar BK. Abdominoscrotal hydrocele: an uncommon entity in adults presenting with lower abdominal and scrotal swelling. JHK Coll Radiol. 2009;12:76-78. 6. Klin B, Efrati Y, Mor A, Vinograd I. Unilateral hydroureteronephrosis caused by abdominoscrotal hydrocele. J Urol. 1992;148(2 pt 1):384-386. 7. Krasna IH, Solomon M, Mezrich R. Unilateral leg edema caused by abdominoscrotal hydrocele: elegant diagnosis by MRI. J Pediatr Surg. 1992;27 (10):1349-1351. 8. Nagar H, Kessler A. Abdominoscrotal hydrocele in infancy: a study of 15 cases. Pediatr Surg Int. 1998; 13(2-3):189-190.

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