Scrotal Lesions Research Articles

Cystic lesions and scrotal fluid collections in adults: Ultrasound findings

The widespread use of scrotal ultrasonography (US) has led to increased detection of testicular and extratesticular pathologies. Cystic or encapsulated fluid collections are relatively common benign lesions that usually present as palpable testicular lumps. Most cysts arise in the epidydimis, but all anatomical structures of the scrotum can be the site of their origin. US may suggest a specific diagnosis for a wide variety of intrascrotal cystic and fluid lesions and appropriately guide therapeutic options. US should be used as an adjunctive diagnostic modality after clinical evaluation of a scrotal lesion associated or not with the presence of a lump.

Isolated Epidermolytic Acanthoma in a Renal Transplant Recipient

Dear Editor: Epidermolytic acanthoma (EA) was first reported in 1970 when six patients with solitary tumors clinically resembled warts were observed. Histologically these tumors showed epidermolytic hyperkeratosis (EH) without features of other epidermal tumors1. The exact etiology of EA remains unknown, but immunosuppression is thought to be associated with EA although case report is lacking. A 64-year-old man presented with a solitary papule on his scrotum. The lesion first appeared 7 years earlier and had gradually grown over time, but had not triggered symptoms such as itching or pain. This patient had no history of similar skin lesions. He had received a kidney transplant 7 years previously, and noted the scrotal lesion occurred immediately after starting an immunosuppressive regimen, consisted of tacrolimus (1 mg/day), azathioprine (50 mg/day), and deflazacort (6 mg/day). In addition, this patient also had type 2 diabetes and hypertension, both of which were controlled by medication. There was no family history of skin disease. Physical examination showed a solitary, brownish, verrucous, and keratotic papule, 1 cm in diameter, on the left side of the scrotum (Fig. 1). Histologic examination of a shave biopsy specimen of the lesion showed orthokeratotic hyperkeratosis, papillomatosis, and acanthosis. Hypergranulosis was also noted, and the cells of the granular and upper spinous layers contained numerous, large, clear, perinuclear space with basophilic keratohyaline granules and eosinophilic materials (Fig. 2). As a result of these clinical and histological findings, the patient was diagnosed with isolated EA. The scrotal lesion resolved after ablative CO2 laser treatment, with no evidence of recurrence during a 1-year follow-up period. Fig. 1 A solitary, brown papule, measured 1 cm in diameter, with a verrucous surface on the scrotum. Fig. 2 Histologic examination of the scrotal lesion showing epidermolytic hyperkeratosis: vacuolar degeneration, increased keratohyaline-like bodies, hypergranulosis and compact hyperkeratosis (A: H&E, ×40, B: H&E, ×400). EA is a solitary tumor that histologically shows EH without features of other epidermal tumors. EA is considered to be an acquired benign tumor, typically occurs in middle-aged adults. The lesions are characteristically brownish papules less than 1 cm in diameter with a verrucous surface. EA can be classified into solitary and disseminated subtypes, called isolated epidermolytic acanthoma (IEA) and disseminated epidermolytic acanthoma (DEA), respectively. Isolated lesions may occur anywhere on the body, but the disseminated subtype usually occurs on the back and the genitoscrotal area. EA is characterized histologically by EH, which consists of random-sized clear spaces around the nuclei in the stratum spinosum and granulosum, reticulated, lightly-staining material forming indistinct cellular boundaries, a markedly thickened granular zone containing an increased number of small and large, irregularly shaped basophilic keratohyaline-like bodies, and compact hyperkeratosis2. EH may be congenital or acquired. Congenital EH includes bullous congenital ichthyosiform erythroderma, systemized epidermal nevus, and hereditary palmoplantar keratosis, whereas acquired EH include IEA and DEA. The etiology of EA remains unknown and the differences between IEA and DEA in the pathogenesis are also unclear. Mutations in the keratin 1 and 10 genes have been observed in IEA3. EA may also be induced by exogenous factors, such as viruses or trauma. Human papillomavirus (HPV) was thought to be a cause of EA, because of the wart-like appearance, but these lesions have not been found to contain HPV DNA4. Immunosuppression has been known to be associated with the pathogenesis of DEA. Immunosuppression could inhibit immune surveillance, preventing abnormal keratinocyte clones from being recognized or removed. Alternatively, immunosuppression may allow latent abnormal keratinocyte clones to proliferate. To date, DEA with disseminated superficial porokeratosis and verruca vulgaris has been observed in a kidney transplant patient5, and DEA has also been observed after PUVA6. Although our patient had a solitary lesion and the possibility of coincidental occurrence of IEA may exist, this case suggests that IEA could be associated with immunosuppression, because the skin lesion had appeared immediately after commencing immunosuppressive treatment. Further case reports and studies are needed to elucidate the relationship between immunosuppression and EA.

Bleeding Scrotal Vascular Lesions: Interventional Management with Transcatheter Embolization

Vascular lesions of the scrotum are uncommon; the most common among them are varicocele lesions. The other vascular lesions that may involve the scrotum are hemangioma, lymphangioma, and arteriovenous malformations, which are exceedingly rare. The imaging modalities useful in the diagnosis and management of scrotal vascular lesions are grayscale sonography, color Doppler sonography, magnetic resonance imaging, magnetic resonance angiography, and digital subtraction angiography. We present two cases of scrotal vascular lesions involving the extratesticular scrotal soft tissues. Patients presented with bleeding and were treated by radiological interventional technique. We emphasize the importance of superselective catheterization and distal embolization.

Scleroderma and pyoderma gangrenosum

Pyoderma gangrenosum (PG) is an ulcerative disease of the skin with unknown origin. It may be associated with an underlying systemic disease like inflammatory bowel disease, lymphoproliferative disorders, sweet's syndrome and Behcet's disease. This case depicts a rare site of pyoderma gangronosum on scrotum. A 61-year-old man with scleroderma and pyoderma gangronosum on scrotum from two years ago. He had Skin thickening and hardening, hypertension, Raynaud's phenomenon, pulmonary hypertension, pulmonary fibrosis and multiple scrotal skin lesions.

Primary large-cell neuroendocrine carcinoma of the scrotum

Neuroendocrine tumors (NETs) mostly develop from the neural crest cells but a few arise from neuroectoderm. They are common in the lungs and gastrointestinal tract but rare in the genitourinary tract. A 78-year-old man with no family history of malignant or hereditary diseases presented with a 3-month history of a rapidly growing asymptomatic scrotal nodule and swelling in the groin. He had a negative history of sexually transmitted disease and of trauma, fungal infection or chronic irritation in the scrotal area; there was no history of radiotherapy or exposure to chemicals or arsenic. Both the scrotal and groin lesions were excised with a minimum of 1.2 cm of normal skin. Examination of the specimen revealed a confined poorly differentiated large-cell neuroendocrine carcinoma with a metastasis to the inguinal lymph nodes. Three months after the excision we found a local recurrence. The recurrent tumor revealed tumor tissue concurrent with the primary lesion. To the best of our knowledge, there have been no previously published case reports on neuroendocrine tumor of the scrotum.

Effects of ring castration with local anesthesia and analgesia in Holstein calves at 3 months of age on welfare indicators1

Forty-seven Holstein calves (130 +/- 3.43 kg of BW and 95 +/- 1.5 d of age) were randomly assigned to 2 treatments [intact (INT), n = 23; or castrated (CAS), n = 24] to evaluate the effect of ring castration at 3 mo of age on welfare indicators. Castration was performed with local anesthesia (2% lidocaine, 3 mL in each testis and 2 mL in the scrotum) and analgesia (flunixin meglumine, intramuscularly, 3 mg/kg of BW). No local anesthesia or analgesia was used with INT calves. Serum cortisol concentration was determined at -120, 0, 30, 60, 90, and 180 min with respect to castration. At d 0, 1, 3, 7, 14, 21, 28, 35, 42, and 49, serum haptoglobin concentration was determined, rectal body and scrotal temperatures were measured, lesions at the castration site were scored, and the activity and behavior of 18 calves (9 INT and 9 CAS) were recorded continuously for 24 h. Weekly BW and concentrate and straw DMI were recorded. To evaluate humoral immunity, at 14 d after castration, ovalbumin was injected subcutaneously and serum antibody titers against ovalbumin before the injection and at d 35 were determined. At d 49 after castration, calves were intravenously injected with ACTH, and at 0, 1, 2, and 4 h thereafter, serum cortisol and testosterone concentrations were determined. Average daily gain was greater (P < 0.001) in INT than CAS calves (1.36 vs. 1.16 +/- 0.038 kg/d, respectively). Area under the curve of cortisol at castration day was reduced (P < 0.05) in CAS calves compared with INT calves (18 vs. 33 +/- 5.2 nmol/L per hour, respectively). The main scrotal lesion score observed in CAS calves throughout the study was 0, corresponding to no visible swelling, inflammation, or infection. However, scrotal lesion scores classified as 1 (swelling) were greater (P < 0.01) at 21 and 28 d after castration than at 1, 3, 7, and 14 d. Abnormal standing occurred more frequently (P < 0.001) in CAS than INT calves (2.6 vs. 0.5 +/- 0.03%, respectively) from 3 to 14 d after castration. Head turning tended (P = 0.06) to be greater at d 14 of the study in CAS than INT calves (3.0 vs. 2.6 +/- 0.04%, respectively). At d 49, 100% of CAS calves had no testes and no serum testosterone was detected. In summary, ring castration of Holstein calves performed at 3 mo of age with local anesthesia and analgesia decreased ADG and affected some behavioral traits during the first 14 d after castration. However, intake, serum cortisol and haptoglobin concentrations, rectal temperature, and humoral immunity were not altered.

Long-term Follow-up of In situ Extramammary Paget’s Disease in Asian Skin Types IV/V Treated with Photodynamic Therapy

Photodynamic therapy is a potentially advantageous treatment for non-melanoma skin cancers. We evaluated the clinical response, recurrence and adverse events of photodynamic therapy for in situ extramammary Paget's disease in 14 male and 3 female Chinese patients with 21 lesions. Topical 20% 5-aminolevulinic acid was applied for 6 h. Each lesion was irradiated with 633 nm red light three times, 1 week apart, at a total dose of 339 J/cm2, followed by three assessments at 6, 12 and 24 months. Overall complete response (CR) rates were 52.4%, 42.9%, and 33.3% at 6, 12 and 24 months, respectively. The CR rate was significantly higher in scrotal lesions (66.6%) than in non-scrotal lesions (8.3%). The overall recurrence rate was 50%. The highest CR rate was for the lesions < 4 cm in diameter (62.5%), followed by those 4-8 cm (33.3%) and > 8 cm (0%). Most adverse events were well tolerated. In conclusion, photodynamic therapy for extramammary Paget's disease is not recommended as the first option except for scrotal cases or lesions < 4 cm in diameter.

Scrotal sonography revisited

Sonography is the imaging modality of choice for the scrotum because it is simple, relatively inexpensive, and quick. Recent technological advances and transducer improvements have led to exquisite high-resolution detail in gray-scale as well as Doppler imaging. The purposes of this pictorial essay are to review the anatomy and embryology of the scrotal contents and to review the various scrotal and extrascrotal pathologic conditions, including acute scrotum, pediatric and adult testicular and extratesticular scrotal neoplasms, traumatic lesions, and miscellaneous other scrotal lesions.

Bacillary Angiomatosis as an Initial Presentation in an HIV-Positive Man

0196-4399/00 (see frontmatter) © 2009 Elsevier Clinical Microbiology Newsletter 31:19,2009 Introduction A 26-year-old man presented with fever, malaise, scrotal skin lesions, and inguinal lymphadenopathy. An excisional biopsy specimen from an inguinal lymph node demonstrated a florid vascular proliferation. AWarthin-Starry stain, an immunoperoxidase stain, and PCR studies confirmed the presence of Bartonella henselae. The diagnosis of bacillary angiomatosis secondary to B. henselae infection was established. Bacillary angiomatosis is a vascular proliferative disease most often reported in patients with human immunodeficiency virus (HIV) infection (1) and less frequently in patients with other causes of immunosuppression. Because of the high correlation between HIV and Bartonella infection, we recommended that the patient be tested for HIV infection, whereupon he was found to be positive for HIV. We recommend that all patients with bacillary angiomatosis and unknown immune status undergo HIV studies.

Bleeding Scrotal Arteriovenous Malformation

Background: Arteriovenous malformation (AVM) of the scrotum has, to our knowledge, been reported fewer than 10 times in the medical literature. It may be of congenital or post-traumatic etiology and has been reported to present with spontaneous bleeding. Case Report: A case of a spontaneously bleeding scrotal AVM that developed after remote trauma is presented. The differential diagnosis of a scrotal vascular lesion includes varicocele, hemangioma, lymphangioma, and AVM. Although ultrasound and magnetic resonance imaging play an important role in the evaluation, angiography is essential to fully delineate the feeder vessels, vascular takeoffs, and draining veins. Conclusion: Scrotal AVMs are rare vascular scrotal lesions that may present with scrotal enlargement and a bruit. Definitive therapy should be planned in concert with Interventional Radiology and surgical consultants.

Unusual scrotal pathology: an overview

The diverse embryological origins of the contents of the scrotum create an environment that fosters a wide variety of unusual pathologies. Most scrotal pathologies are discovered by the patient and are initially evaluated by a thorough physical examination and scrotal ultrasonography. Scrotal lesions can be broadly grouped by the anatomical location in which they develop; the clinician must consider a wide differential diagnosis based on this location. Solid testicular masses are considered germ cell tumors until proven otherwise, but numerous other possible pathologies exist, including ectopic tissue, metastasis, and other neoplastic growths. Rete testis lesions are classified as developmental, benign or malignant. Cystic lesions of the epididymis are most commonly benign, but malignant neoplasms can also be present. The paratesticular region has the broadest differential diagnosis, as it contains numerous distinct structures and is a common location for ectopic tissue and metastatic disease; a narrower range of lesions develop in the scrotal wall because of its simpler anatomy. Treatment options range from conservative observation to wide surgical excision and should be considered carefully; the aim of therapy is to remove malignant or potentially malignant tissue while minimizing effects on fertility and function.

Role of color doppler in scrotal lesions

Color Doppler USG of the scrotum has been demonstrated to be useful in the diagnosis of scrotal lesions. Gray-scale USG characterizes the lesions as testicular or extratesticular and, with color Doppler and power Doppler, flow and perfusion can also be assessed. Color Doppler is particularly helpful in acute painful conditions, where it can differentiate testicular ischemia from inflammatory conditions and thus prevent unnecessary surgical explorations. With color Doppler, useful information can be gained about vascularity in testicular malignancies. Color Doppler also has high sensitivity and high specificity in the diagnosis of lesions like varicoceles.

Outcome of proximal hypospadias repair using three different techniques

To evaluate the outcome of proximal hypospadias repair using three different techniques. The study involved 194 boys with primary proximal hypospadias. The meatus was proximal penile, penoscrotal, scrotal and perineal in 98, 64, 30 and 2 patients, respectively. Tubularized incised plate (TIP) urethroplasty, onlay island flap (OIF) urethroplasty and two-stage repair were used in 96, 57 and 41 patients, respectively. Preoperative anatomical description and postoperative complications were recorded with evaluation of the final functional and cosmetic outcomes for each technique. Mean age at presentation was 14.43 months (range 6-31). Mean follow-up after second stage was 32.9 months (range 11-54). Complications were encountered in 27 cases (13.9%) with no statistically significant differences between techniques; however, a significantly higher complication rate was found among patients with scrotal and perineal hypospadias and in patients with associated scrotal lesions. Urethrocutaneous fistula was the most common complication, being encountered in 7.7% of patients with a significantly higher rate among patients with scrotal hypospadias (16.7%). Single-stage repair of proximal hypospadias can be successfully performed when plate preservation is possible, while two-stage repair is applicable when plate transection is necessary. Functional and cosmetic outcomes are satisfactory, with no statistically significant advantage with any technique.

Cutaneous genital complications of antiangiogenic agents

e14568 Background: Multikinase inhibitors targeting VEGFR, i.e. sorafenib and sunitinib are associated with various cutaneous side effects (1). Five cases of scrotal skin lesions were recently reported in male patients treated with sunitinib (2). Our observations of 8 patients presenting with genital inflammatory lesions during various anti-VEGFR therapies show that this side effect is linked to VEGFR blockade and not specifically to sunitinib and that it can also occur in women. Results: Six men and two women were seen for a genital eruption. They were treated with sorafenib (3 pts), sunitinib (5 pts), and a new pan-HER and VEGFR inhibitor (BMS 514, EVRI) (1 pt) for renal cell cancer (4 pts), hepatocellular carcinoma (2 pts), lung cancer (1 pt) and sarcoma (1 pt). Genital lesions occurred during the first six weeks of treatment. They appeared as a painful erythematous and squamous inguinal, intergluteal, and perianal rash rapidly involving all genital areas in 4 patients. Lesions became erosive in 3 cases. Four men presented more limited, pruriginous and lichenoid penile papules which were associated with a genital erythema for 3 of them. In one patient, penile inflammation resulted in a phimosis. One patient successively treated with sunitinib, sorafenib and once again with sunitinib experienced genital side effects with both agents. Patients taking sequential sunitinib treatment reported symptoms improvement during treatment interruptions and recurrences during the weeks on therapy. Microbiological samples were negative. Pathology of erythematous and squamous lesions showed a psoriasiform or a lichenoid aspect. Topical steroids were efficient for 5 patients but 3 patients had to interrupt anti-VEGF therapy because of their genital rash. Conclusions: Polymorphous genital inflammatory rash is a new skin side effect that can be associated with any cancer therapies targeting VEGFR in men and in women. Its frequency is unknown and probably underestimated because many patients might not report this side effect and its mechanism is still obscure. Physicians should be aware of this side effect and should inquire as to whether the patients have noticed such symptoms in order to avoid worsening thereof by symptomatic measures. No significant financial relationships to disclose.

Scrotal Dog Bite: Unusual Case and Review of Pediatric Literature

Animal bites to human external genitalia are rare. Only a few cases of scrotal dog bite in children have been reported. We present an additional specific case of a scrotal dog bite in a child because the lesion and its repair have not been previously reported in published pediatric studies. A traumatic resection of the right testicular vas deferens was repaired by microsurgical vasoepididymal anastomosis. A review of the published data was also performed to analyze the management of scrotal dog bite lesions.

ORIGINAL RESEARCH—WOMEN'S SEXUAL HEALTH: Ultrasonographic and Doppler Findings of Subclinical Clitoral Microtraumatisms in Mountain Bikers and Horseback Riders

Repeated microtraumas in horseback riders and mountain bikers are, in males, associated with perineal and scrotal lesions. No data are reported in the females. To report five cases of clitoral microcalcifications, diagnosed by ultrasonography, in six healthy, eumenorrheic athletes, and to verify the clinical and sexual impact of the ultrasonographic findings. Translabial ultrasonographic evaluation of the clitoris, Doppler analysis of dorsal clitoral arteries, and the two-factor Italian McCoy Female Sexuality Questionnaire (MFSQ) METHODS: The patients were assessed with a detailed history, and were submitted, in the periovulatory phase of the cycle (day 14), to clitoral ultrasonographic analysis and color Doppler evaluation of the dorsal clitoral arteries. The women were not sexually aroused. On the same day, in a separate room--and prior the ultrasound and Doppler examinations took place--the subjects completed the two-factor Italian MFSQ. All the patients were completely asymptomatic but reported a past history of intermittent perineal tenderness or discomfort. In five out of the six subjects, the ultrasonographic assessment of the clitoris evidenced a disseminated clitoral microlithiasis. Only the youngest (18 years old) biker showed a normal pattern of the clitoral structures. A normal clitoral body volume (0.68 +/- 0.21 mL) and a normal mean dorsal artery pulsatility index (PI) was found (PI = 1.75 +/- 0.32) in all the patients. The two-factor Italian MFSQ showed a mean value of 42 +/- 4 (range 37-45). The chronic traumatisms may be responsible, especially in well-trained riders, for microhematomas, inflammation, and/or degenerative processes at level of the clitoral structure. Further studies should be undertaken to determine the clinical significance of the described disseminated clitoral microlithiasis.

Scrotal metastases from colorectal carcinoma: a case report

A 72-year-old man presented with a two month history of rectal bleeding. Colonoscopy demonstrated synchronous lesions at 3 cm and 40 cm with histological analysis confirming synchronous adenocarcinomata. He developed bilobar hepatic metastases while undergoing neoadjuvant chemoradiotherapy. Treatment was complicated by Fournier's gangrene of the right hemiscrotum which required surgical debridement. Eight months later he re-presented with an ulcerating lesion on the right hemiscrotum. An en-bloc resection of the ulcerating scrotal lesion and underlying testis was performed. Immunohistological analysis revealed metastatic adenocarcinoma of large bowel origin. Colorectal metastasis to the urogenital tract is rare and here we report a case of rectal carcinoma metastasizing to scrotal skin.

A Soft Lesion on the Scrotum: A Quiz

An 18-month-old boy presented with an asymptomatic skin lesion of the scrotum that had been present since birth. Physical examination revealed a flesh-coloured, large, soft gyrate plaque with a few overlying scattered pores on the left side of the scrotum (Fig. 1A and B). There was no family history of a similar condition. In addition, the parents reported that the left testis was not palpable under the scrotal lesion. A skin biopsy specimen from the plaque, including a pore, showed epidermal papillomatosis as well as dermal deposition of mature adipocytes among collagen fibres (Fig. 2A and B). The pore lesion showed features of a comedone. On physical examination, the right testis moved spontaneously out of the scrotum, but could be returned to the scrotum with manipulation (retractile testis). What is your diagnosi’ See next page for answer.

Chronic Tuberculous Epididymo-orchitis Manifesting as a Non-Tender Scrotal Swelling: Magnetic Resonance Imaging–Histological Correlation

Clinically, chronic tuberculous epididymo-orchitis often is nonspecific and subsequently is indistinguishable from other various scrotal lesions. Gray-scale and color Doppler ultrasound is most commonly used for distinguishing these conditions. However, there are few reports on the magnetic resonance imaging (MRI) features of chronic tuberculous epididymo-orchitis. We describe MRI features of this lesion clinically manifesting as non-tender scrotal swelling with a correlation of the histological findings.

Lymphangioma Scroti

Lymphangiomas are congenital malformations of the lymphatic system. We report a 10-year-old boy with lymphatic malformation of the scrotum, which presented as a multiloculated scrotal mass associated with edema of the left thigh and left cryptorchidism. Histopathologic examination showed scrotal lymphangioma cavernosum. Ultrasonography was of major importance for the preoperative diagnosis and to determine the extent of the scrotal lesion. Scrotal lymphangiomas are very rare. It is important to consider them in boys with a cystic scrotal mass in order to avoid misdiagnosis, improper treatment and recurrences.