Abdominoscrotal hydrocele: A rare cause of a cystic abdominal mass in children

Gurmeet Singh; Anand Pandey; Ajay Verma; Archika Gupta

doi:10.4103/fjs.fjs_110_17

CASE REPORT

Year : 2018 | Volume : 51 | Issue : 2 | Page : 88-90

Abdominoscrotal hydrocele: A rare cause of a cystic abdominal mass in children

Gurmeet Singh, Anand Pandey, Ajay Verma, Archika Gupta
Department of Pediatric Surgery, King George's Medical University, Lucknow, Uttar Pradesh, India

Date of Submission	01-Jul-2017
Date of Decision	30-Jul-2017
Date of Acceptance	13-Sep-2017
Date of Web Publication	24-Apr-2018

Correspondence Address:
Dr. Anand Pandey
Department of Pediatric Surgery, King George's Medical University, Lucknow - 226 003, Uttar Pradesh
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/fjs.fjs_110_17

Abstract

Abdominoscrotal hydrocele (ASH) is a rare cause of cystic abdominal and scrotal mass in children. A timely diagnosis is important because appropriate surgical treatment is important. We encountered a patient who presented with scrotal swelling and later turned out to be a patient of ASH. The case is being presented with review of relevant literature.

Keywords: Abdominoscrotal hydrocele, congenital hydrocele, inguinoscrotal hydrocele

How to cite this article:
Singh G, Pandey A, Verma A, Gupta A. Abdominoscrotal hydrocele: A rare cause of a cystic abdominal mass in children. Formos J Surg 2018;51:88-90

How to cite this URL:
Singh G, Pandey A, Verma A, Gupta A. Abdominoscrotal hydrocele: A rare cause of a cystic abdominal mass in children. Formos J Surg [serial online] 2018 [cited 2020 Nov 23];51:88-90. Available from: https://www.e-fjs.org/text.asp?2018/51/2/88/231138

Introduction

Abdominoscrotal hydrocele (ASH) is an uncommon clinical entity characterized by a dumbbell-shaped hydrocele that extends from the scrotum into the abdominal cavity and through the inguinal canal and internal inguinal ring.^[1] The reported incidence of this rare condition in children varies from 0.17% to 3.1% of all hydroceles. Dupuytren originally described the anomaly as a hydrocele variant, and later Bickle introduced it as ASH. The patients typically present with scrotal swelling and abdominal mass. Currently, physical examination and ultrasonography are practical diagnostic methods for ASH.^[2],[3]

We operated one such patient, who presented for the treatment of right scrotal swelling and later turned out to be having ASH.

Case Report

A 4-year-old boy presented to our department with a right scrotal swelling since birth. Clinically, he was diagnosed to be having right congenital hydrocele. The testis could not be felt separately from the swelling. However, on palpation of the abdomen, there was a lump in the right flank [Figure 1]a. There was the presence of cross-fluctuation in between the scrotal and the abdominal lump. Ultrasound (USG) of the abdomen suspected right retroperitoneal cystic lymphangioma. The patient underwent contrast-enhanced computed tomography scan of the abdomen. It revealed a large cystic mass with internal septations involving the mesentery and herniating into the right scrotal sac [Figure 2].

Figure 1: (a) Clinical picture of the patient showing bulge in the right inguinal region and fullness in the right flank. (b) Intraoperative picture of the patient showing the swelling communicating at the deep inguinal ring with the scrotal swelling

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Figure 2: Contrast-enhanced computed tomography abdomen and pelvis of the patient showing intra-abdominal cystic mass communicating with the scrotal swelling

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After anesthetic fitness, laparotomy was performed by right transverse infraumbilical incision. Intraoperatively, there was a large cystic mass in the abdomen, which was communicating with scrotum in hourglass manner at deep ring [Figure 1]b. The ureter and kidney were not compressed by the mass. The sac was carefully dissected off the mesentery, along with the cord structures. The sac was opened and fluid was aspirated. Excess sac tissue was trimmed. Since testis was present inside the sac, orchiopexy was also performed in the same setting. The procedure included extension of the incision medially and mobilization of the cord structures. A subdartos space was made and plane was created laterally to the urinary bladder from the scrotum. The testis was pulled through this space into the subdartos pouch and orchiopexy was performed.

Postoperative period was uneventful, and the patient was discharged in satisfactory condition on the 10^th postoperative period. The patient is on our follow-up for the past 4 months without any problem.

Discussion

ASH is not frequently included in the differential diagnosis for a cystic abdominal mass in a child. The differential diagnosis typically includes mesenteric and enteric duplication cysts, massive hydronephrosis extending into the pelvis, bladder diverticulum, and cystic neoplasm.

The exact etiology of ASH is unclear. Several theories have been proposed for its development. One of the more widely accepted theories describes upward extension of a scrotal hydrocele into the abdominal cavity due to excessive pressure from the scrotal component.^[4] Others have hypothesized that ASH results from downward extension or prolapse of abdominal fluid through the inguinal canal into the scrotum.^[5] Obliteration of the processus vaginalis at the level of the inguinal ring prenatally has been cited as a causative factor. Downward extension from the abdominal cavity by way of a flap-valve mechanism that allows fluid downward but not upward has also been described.^[6]

Accurate physical examination in patients presenting with hydrocele and an abdominal mass could be very suggestive of the diagnosis; compression of the lower abdominal mass will result in enlargement of the ipsilateral scrotal component and vice versa. This is one of the most common diagnostic features of ASH, named “springing back ball” sign.^[7] It was noticed in our patients also. In all patients with primary impression of hydrocele, abdominal palpation should be an integral part of physical examination for positive “springing back ball” sign. USG abdomen demonstrates encapsulated anechoic fluid collection extending from the abdomen to the scrotal cavity through an inguinal ring. However, there may be a possibility that the relationship between the abdomen and the scrotal sac cannot be clearly delineated on a USG. In such a situation, CT or magnetic resonance imaging through the multiplanar approach may help to delineate the full extent of the ASH. Since we were not sure about ASH on USG abdomen, CT scan was performed in our patient.^[8]

Because of the mass effect, complications such as leg edema or hydroureteronephrosis may occur in ASH.^[2] Besides this, cryptorchidism, inguinal hernia, and testicular dysmorphism may also occur with ASH.^[6.9] Hence, timely intervention may be needed. Although nonoperative measures have been attempted,^[10],[11] surgical treatment is still preferred by majority. The described surgical options are inguinal, combined inguinal + extraperitoneal, combined inguinal + laparoscopic, and scrotal.^[10] Since it is not a very common situation, the preferred treatment choice depends on the surgeon and the coexisting pathologies in the patient.^[12] It may be argued that a scrotal approach in patients of ASH with undescended testis obviates the need of a laparotomy;^[13] however, in the present report, the abdominal component was massive. We felt it was not possible to manage the patient by scrotal only approach. Besides this, the scrotal approach also has limitations in regard to the treatment of coexisting anomalies and readily abandons any attempt at high ligation of a patent processus vaginalis or excision of the abdominal component.^[12]

Conclusion

ASH needs a proper inclusion in diagnosis of a cystic abdominal mass. Besides, for any congenital hydrocele, the abdominal examination must be done properly to diagnose an unsuspected abdominal counterpart.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his consent for his images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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