Open Access

Case report
Giant abdomino scrotal hydrocele: a case report with literature review

Abdelfattah Latabi1,&, Mohammed Amine Lakmichi1, Zakaria Dahami1, Mohammed Said Moudouni1, Ismail Sarf1

1
University Hospital of Marrakesh, Marrakesh, Morocco

&
Corresponding author: Abdelfattah Latabi, University Hospital of Marrakesh, Marrakesh, Morocco

Key words: Abdominal scrotal hydrocele, urinary symptoms, scrotal approach

Received: 25/11/2017 - Accepted: 24/03/2018 - Published: 28/11/2018

Abstract
Abdomino scrotal hydrocele (ASH) is a condition in which the hydrocele sac is extended beyond the scrotum to the abdomen via the inguinal canal.
The treatment is ordinarily surgical. Different approaches have been described like paramedian laparotomy, an inguinal or inguino scrotal approach.
We report a case of giant unilateral hydrocele in an 18 year old male, occupying a large part of the abdomen with urinary symptoms. Ultrasonography
and CT showed typical cystic mass in hourglass shape that we have approached surgically by scrotal incision and we removed all the cyst. Pathological
examination found a hydrocele with no signs of malignancy. Urinary symptoms disappeared postoperatively. This is a rare entity that evolves often
painless and little reported in the literature. The etiology and pathogenesis of this disease is discussed.

Pan African Medical Journal. 2018;31:213. doi:10.11604/pamj.2018.31.213.14470

This article is available online at: http://www.panafrican-med-journal.com/content/article/31/213/full/

© Abdelfattah Latabi et al. The Pan African Medical Journal - ISSN 1937-8688. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original
work is properly cited.

Pan African Medical Journal – ISSN: 1937- 8688 (www.panafrican-med-journal.com)

Published in partnership with the African Field Epidemiology Network (AFENET). (www.afenet.net)

Page number not for citation purposes 1

Introduction (Figure 4). The post-operative course was uneventful. Histological
examination of the specimen confirmed the diagnosis of hydrocele
with no signs of malignancy, and after surgery we noted a
The hydrocele is a collection of fluid between the two layers of the
disappearance of urinary symptoms.
tunica vaginalis that surrounds the testicle. The hydrocele swells the
scrotum but the testicle remains normal. Rarely, scrotal hydrocele may
extend into the abdominal cavity through the inguinal canal, defining
the abdomino scrotal hydrocele (ASH), this condition is originally
Discussion
described by Dupuytren in 1834 [1]. We report a case of ASH that was
special by huge dimensions, urinary symptoms and scrotal incision We found more than 100 cases described in the literature. Unilateral
extended slightly to the inguinal level and was able removed the cyst ASH was found in 59% of cases with almost even distribution between
completely. left and right-sided hydroceles. Ipsilateral undescended testicle,
testicular dysmorphism, contralateral pathology (inguinal hernia) and
adjacent organs compression often accompanied ASH [2].

Patient and observation Dharamveer Singh et al. have described a case of HSA which
compresses the right urinary tract, this one has been solved after
surgery [3]. 11-month-old patient with a right ASH and undescended
An 18 year old male was referred to our Institution with a history of
testis are reported by Kara T1 [4]. The etiology of ASH is unknown;
an asymptomatic palpable mass in the left testis growing into the
however, different theories have been described in literature to
lower abdomen for 1 year. The patient complained of bladder
explain the pathogenesis such as, valve theory [3, 5], diverticulum
symptoms. Physical examination revealed a healthy adolescent
theory [5], displacement as per Laplace's law [6] and increased
presented left painless scrotal mass with ipsilateral palpable
production or decreased resorption of fluid [7]. However, the most
abdominal mass, there was non-transilluminant. An abdomino scrotal
accepted theory is the one by Dupuytren which suggests that
ultrasound performed in another hospital demonstrated left fluid
excessive intracystic pressure causes cephalad extension of scrotal
scrotal mass, measuring large diameter 8 centimeters (cm) above a
swelling through the deep inguinal ring [5]. Brodman described it to
testicle, which measuring large diameter 6 cm with a suprapubic mass
be because of high obliteration of processes vaginalis above the deep
hypoechogenic intra-abdominal measuring large diameter 11.5 cm.
inguinal ring, leaving a high infantile hydrocele [5]. Diagnosis of ASH
The bladder was displaced by the mass to the right (Figure 1, Figure
is done by clinical examination aided by imaging techniques. Positive
2). The right testis was normal except a simple hydrocele in the
transillumination test and cross-fluctuation between the abdominal
ipsilateral scrotal bursa with epididymal cyst measuring 6.5 millimeters
and the scrotal collections are the clinical hallmarks of ASH diagnosis.
(mm). Testicular tumour markers were unremarkable: alpha-
Ultrasound is the first choice to demonstrate the communication
fetoprotein (AFP), beta human chorionic gonadotropin (hCG), and
between two components however in selected cases ultrasonography
lactate dehydrogenase (LDH). To better characterize the lesion
may be inadequate and in these contrast enhanced computed
computed tomography (CT) scan before and after contrast agent
tomography or magnetic resonance imaging could be used to
enhancement was performed. It showed a cystic mass in hourglass
demonstrate extension of the hydrocele through the inguinal canal
shape in the left scrotum, extending towards the abdomen through
into the abdominal cavity [3, 6]. In our case, a contrast enhanced
the inguinal canal ipsilateral. This mass displaces the ipsilateral testis
computed tomography gave us a complete diagnosis. Axial MRI along
to down and back. It was a mass of fluid density, thin and regular
with MR angiography is useful in detecting vascular complications like
walled. It measures 23 cm in length and compressed the bladder
deep vein thrombosis [8]. The differential diagnoses include spermatic
(Figure 3). These findings were compatible with abdominal-scrotal
cord lymphangioma, giant hydronephrosis extending into the true
hydrocele. The patient was scheduled for inguino scrotal approach
pelvis, bladder diverticulum and pelvic neuroblastoma [3]. Sometimes
surgery. An incision was made in the left scrotal extended slightly on
ASH may be confused with large, complete, indirect inguinal hernia
groin. A large bilocular hydrocele was found. The smaller loculus in
[6]. Ordinarily, the reported management is by surgical excision.
the scrotum and the larger in the abdomen, both linked through the
Khorasani M et al. described in their series including 29 cases of ASH,
inguinal canal. It contained more than one liter of clear straw coloured
twenty out of 29 patients (70%) were initially managed expectantly.
fluid. The surrounding peritoneal layer was dissected from the cyst
Sixteen (80%) had resolution of their abdominal component, twelve
and complete excision of the abdominal and scrotal sac was performed

Page number not for citation purposes 2

(60%) of which went on to have full resolution, so they recommend References
observation as the first step in the management of uncomplicated
ASH [9]. Different approaches have been described like paramedian
1. Lyman RB, Feldtman RW. Abdominoscrotal hydrocoele: Youngest
laparotomy, an inguinal or inguinoscrotal approach [5]. In difficult
case report and review of the literature. J Urol. 1981 Dec; 126(6):
cases preperitoneal approach had been described which facilitates
847-8. PubMed | Google Scholar
complete removal of abdominal component. In our case, we have also
followed the preperitoneal approach by enlargement of the scrotal
2. Doudt AD, Kehoe JE, Ignacio RC, Christman MS. Abdominoscrotal
incision to the inguinal area to excise both the component in total.
hydrocele: a systematic review. J Pediatr Surg. 2016 Sep; 51(9):
1561-4. PubMed | Google Scholar

Conclusion 3. Dharamveer Singh, Pallavi Aga, Apul Goel. Giant unilateral

hydrocele "en-bisac" with right hydronephrosis in an adult: a rare
ASH is a very rare form of hydrocele. The diagnosis is evoked by entity. Uroradiology. 2011; 27(1): 142-143. PubMed | Google
clinical examination in front of a scrotal hydrocele associated with an Scholar
ipsilateral abdominal cystic mass. Ultrasound and CT scan show an
inguino-scrotal hourglass mass. The abdominal compartment of the 4. Kara T et al. Radiologic findings of a giant unilateral
ASH can cause loco-regional complications by compression. MRI can abdominoscrotal hydrocele associated with undescended testis.
be a valuable contribution to surgical curative treatment. J Med Ultrason (2001). 2013 Jan; 40(1): 65-
7. PubMed | Google Scholar

Competing interests 5. Garg P, Prasad D, Agrawal V, Bhatt S, Mohanty D, Dubey I.

Abdominoscrotal hydrocele: an insight into its origin. Hernia.
2011 Oct; 15(5): 587-9. PubMed | Google Scholar
The authors declare no conflict of interest.

6. Fenton L, McCabe K. Giant unilateral abdominoscrotal hydrocele.

Pediatr Radiol. 2002; 32(12): 882-884.PubMed | Google
Authors’ contributions Scholar

All the authors have read and agreed to the final manuscript. 7. Hisamatsu E, Takagi S, Nomi M, Sugita Y. A case of bilateral
abdominoscrotal hydroceles without communication with the
peritoneum. Indian J Urol. 2010; 26(1): 129-
130. PubMed | Google Scholar
Figures

8. Schlup S, Hanquinet S, Dumont M, Jequier S, Bugmann P. MRI &

Figure 1: ultrasonographic imaging of the abdomen and pelvis MRA of giant hydrocele in an infant. Pediatr Radiol. 2002; 32(12):
(coronal section): huge cystic lesion 885-887. PubMed | Google Scholar
Figure 2: ultrasonographic imaging of the abdomen and pelvis
(coronal section): intimate contact of the cyst with the bladder which 9. Khorasani M, Jamieson DH, Langer K1, Murphy JJ. The treatment
is compressed of abdominoscrotal hydrocele: is there a role for nonoperative
Figure 3: computed tomography scan imaging of the abdomen and management. J Pediatr Surg. 2016 May; 51(5): 815-
scrotum: fluid mass in hourglass typical of the abdominoscrotal 8. PubMed | Google Scholar
hydrocele
Figure 4: surgical specimen: abdominal and scrotal loculus

Page number not for citation purposes 3

Figure 1: ultrasonographic imaging of the abdomen and pelvis (coronal section): huge cystic lesion

Figure 2: ultrasonographic imaging of the abdomen and pelvis (coronal section): intimate contact of the cyst
with the bladder which is compressed

Page number not for citation purposes 4

Figure 3: computed tomography scan imaging of the abdomen and scrotum: fluid mass in
hourglass typical of the abdominoscrotal hydrocele

Page number not for citation purposes 5

Figure 4: surgical specimen: abdominal and scrotal loculus

Page number not for citation purposes 6