An uncommon cause of massive scrotal enlargement

Abstract

A 48-year-old man with a history of decompensated alcoholic cirrhosis was evaluated for a progressive symptomatic scrotal enlargement over the last few months. Abdominal ascites was not clinically evident, but ultrasound showed perihepatic liquid accumulation (Fig. 1A, arrow). A local physical examination revealed a massive, tense but painless collection of liquid in the scrotum without palpable pathological masses or compromised scrotal skin integrity (Fig. 1B). A puncture of the scrotum was performed in the supine position until the liquid was completely aspirated. However, when the patient regained an upright position, the scrotum rapidly refilled. The analysis of the citrine clear liquid was compatible with the presence of ascitic fluid, indicating the existence of a communicating hydrocele. Despite surgical repair, the hydrocele relapsed a few months later. Ascites could not be mobilized with furosemide and spironolactone due to the development of diuretic-induced renal failure. The patient was subsequently listed for liver transplantation and the hydrocele was treated with regular scrotal punctures. Communicating hydrocele is usually associated with a patent processus vaginalis, allowing flow of peritoneal fluid into the scrotal sac. The diagnosis of hydrocele is based on clinical examination. Nevertheless, ultrasonography may be necessary for a better evaluation of the testicle. The differential diagnosis includes inguinal hernia, varicocele, epididymal cysts and testicular cancer. The last puncture was performed 6 months after liver transplantation (Fig. 1C) and later, the amount of peritesticular liquid progressively decreased (Fig. 1D, arrow).