Projects

An 11-month-old boy presented with a painless right scrotal swelling that was gradually increasing in size since birth. On examination, the swelling was scrotal, cystic, and transilluminant (Figure 1). There was no change in size of swelling on crying. An ultrasound showed a cystic mass 10 × 8 cm with multiple septae and lobulations suggestive of a lymphangioma. On excision, the lymphangioma appeared to be associated with the gubernaculum of the right testis, although the body of the testis was characteristically uninvolved. For complete excision, the corpora and bulb of the penis had to be dissected out (Figure 2). Histopathologic examination revealed that macroscopically, the lymphangioma was well circumscribed with cysts of varying sizes containing clear fluid. Microscopically, it consisted of irregular dilated spaces lined with a single layer of endothelium. The intervening stroma contained lymphoid follicles and loose connective tissue. In children, cystic lymphangiomas predominantly occur in the head, neck, and axilla (95%). The scrotum is a rare site1 and is, hence, commonly misdiagnosed as hernia, hydrocele, torsion testis, or varicocele.2 In our case, the unusually large size of the swelling made us suspect that what we were not dealing with a hydrocele. Unusual features in purely scrotal swellings like skin changes, large dimensions, and lobulated appearance should prompt the pediatrician to get a Doppler ultrasonography that would suggest the diagnosis of lymphangioma.3 Suspicion of an extension beyond the scrotum warrants additional imaging in the form of a computed tomography/magnetic resonance imaging scan.

Scrotal lymphangiomas are benign and arise from inadequate drainage of lymph from sequestered lymphatic vessels. They are usually painless except when there is a hemorrhage into a cyst or during inflammation. A variety of treatment modalities have been tried including sclerosants and cryotherapy, however, the gold standard remains surgery.

The correct diagnosis is paramount for treatment. A herniotomy in the index patient would not have led to resolution of the scrotal swelling. Complete excision of the lymphangioma along with involved skin and tissues is important to prevent recurrence.