A Male Patient with Left Inguinal Bulge and Left Scrotal Pain.

SECTION 2 – ANSWER

Case

A 57-year-old male presented with complaints of dull aching pain in the left scrotum and a bulge in the left inguinal region. There was no history of trauma or fever. Ultrasound (US) examination of the inguinoscrotal region was performed [Figures 1-3].

Figure 1

Grayscale ultrasonography image of the left scrotal sac shows free fluid and a hyperechoic structure with posterior acoustic shadowing

Figure 3

Grayscale ultrasonography image of the left inguinal region shows hyperechoic fat-containing omentum into the inguinal canal

Interpretation

US images of the left scrotal sac showed an incidental finding of a hyperechoic structure with posterior acoustic shadowing [Figure 1], which is consistent with a diagnosis of scrotolith. Other findings include an epididymal cyst [Figure 2] and an inguinal hernia with omentum as its contents [Figure 3].

Figure 2

Grayscale ultrasonography image of the left scrotal sac shows a well-defined anechoic structure of size 5.2 mm × 5.1 mm with posterior acoustic enhancement in the head of the epididymis

Scrotoliths (scrotal pearls) are extratesticular calcifications within the scrotum which occur due to microtrauma to the scrotum. They are found within the layers of tunica vaginalis. Their prevalence is estimated to be approximately 3%.[1] They are asymptomatic and are diagnosed as an incidental finding on US. Small calcifications can present without posterior acoustic shadowing. Repeated microtrauma to tunica vaginalis and scrotal wall leads to abnormal accumulation of cholesterol and calcium minerals which leads to the formation of stones. On US, they are seen as free-floating echogenic foci measuring <10 mm in size. They are more apparent in the presence of hydrocele.

Epididymal cysts are the most common intrascrotal cystic lesions. They are seen as well-defined anechoic structures with posterior acoustic enhancement at the upper pole of the testis. Large cysts can also present with internal septations and internal debris within.[2]

Inguinal hernias can present with bowel or omentum as its contents. Omentum is seen on ultrasonography as a hyperechoic well-defined lobulated structure.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the 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.