bilateral meconium hydrocele an uncommon case · bilateral meconium hydrocele an uncommon case...

Bilateral meconium hydroceleAn uncommon case

Didem Turcan1, Evrim Yılmaz1, Deniz Arık1, Baran Tokar2

1Department of Pathology, Faculty of Medicine, Eskisehir Osmangazi University, Eskisehir, TURKEY

2Department of Pediatric Surgery, Faculty of Medicine, Eskisehir Osmangazi University, Eskisehir, TURKEY

Introduction

• Meconium hydrocele is a rare benign reason of scrotal masses in new-borns caused by meconium leakage due to in utero intestinal perforation

• Inspissated meconium associated with cystic fibrosis, bowel atresia, volvulus, vascular insufficiency, imperforated anus, hyperplastic lymphoid tissue and colonic aganglionosis are accused of causing perforation, but sometimes perforation can be idiopathic

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Introduction

• In most cases, the intestinal perforation had healed without obvious sequelae before birth

• The scrotal mass consistency depends on the perforation time; it is soft if the perforation was occurred recently at birth but it is hard and calcified if the perforation was occurred earlier

• Herein, we present a bilateral meconium hydrocele in a new-born and its histopathological features

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Case

• A 4 days old full term male baby

• Restlessness and reluctance feeding

• Voiding and defecation were normal since birth

• Uneventful pregnancy

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Case

• Firm scrotum on palpation

• No signs of tenderness or erythema

• No other abnormality on physical examination

• Tumour markers were unremarkable

• Scrotal ultrasound demonstrated intrascrotal extratesticular anechoic mass including millimetric calcifications, measuring 2,5 cm in diameter on the posterior side of both testes

• Paratesticular masses

• Normal testes

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Case

• Vascular flow on Doppler

• Calcification was not detected on abdominal X-ray

• A fibrous pseudotumor was suspected on scrotal MRI

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Case

• Bilateral inguinoscrotal exploration was done when the patient was at the age of one month

• Hydrocele containing meconium inside and on the wall was found on the both sides

• He also had bilateral inguinal hernia having connection to the hydrocele

• Hernia sac also had meconium inside

• Both testes were intact

• Hydrocele wall excision, hernia repair and orchiopexy were performed on both sides

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Case

• Gross pathologic findings:

• Oval shaped lump with variable consistency from soft to firm

• Yellowish green cut surface

• 4x1.5x0.8 cm diameters, right side

• 2x1x1 cm diameters, left side

• Microscopic examination:

• Fibromyxoid connective tissue containing mucin lakes, dystrophic calcifications, scattered hemosiderin-laden macrophages, bile pigment, lanugo hair

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Case

• These histopathological findings were consistent with meconium hydrocele

• The patient is healty one year after surgery

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Discussion

• Fetal peristalsis and meconium

• Meconium is sterile, greenish, viscous intestinal product

• If meconium enters to the peritoneal cavity, it provokes a sterileinflammatory reaction with calcification and fibrosis meconium peritonitis

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Discussion

• Extravasated meconium patent processus vaginalis scrotum

scrotal mass foreign body reaction fibrosis and calcification soft hydrocele transforms into hard "tumour-like" lesion

• Testicular involvement of the affected side is rare

• Different terminologies are used for this disease:

Meconium hydrocele

Meconium periorchitis

Scrotal calcification due to meconium peritonitis

Meconium in the processus vaginalis

Meconium granulomas

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Discussion

• The diagnosis time varies from birth to 20 months of age, average time of diagnosis is 1 month

• In our case, bilateral hydrocele were identified at 4 days old baby

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Discussion

• Demonstration of scrotal and peritoneal calcifications caused by healed meconium peritonitis on radiologic studies are pathognomonic

• Blood flow is not observed on Doppler studies

• When the characteristic radiologic findings are seen and the clinical diagnosis can be made; surgery is not necessary mostly due to spontaneous regression of the mass

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Discussion

• If there is suspicion for other scrotal masses with calcifications, surgical exploration is mandatory to confirm the diagnosis

Testicular teratomas

Gonadoblastomas

Leydig cell tumors

Testicular microlithiasis

Fibrous pseudotumors with calcifications

Calcifying organized hematoma

Metabolic calcinosis

Metastatic neuroblastoma

Yolk sac tumors

• Unless the mass establishes malignant, the testes must be saved

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Discussion

• Multiple small nodules along the spermatic cord or bulky solitary paratesticular mass

• Fibrous capsule

• Yellowish green colour

• Cut surface is gelatinous and faintly lobulated

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Discussion

• Microscopic characteristics

Dystrophic calcifications, foreign body giant cells, phagocytic histiocytes in the loose fibromyxoid connective tissue

• Throughout the connective tissue fibroblasts, hemosiderin pigment and the remnants of meconium; lanugo hair, desquamated epithelial cells, bile salt and pigments are seen

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Conclusion

• When a scrotal mass is discovered in infants and young children, this rare benign entity should be considered to decide on the choice of treatment modalities

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References

1. Algaba, F., Mikuz, G., Boccon-Gibod, L., Trias, I., Arce, Y., Montironi, R., ... & Lopez-Beltran, A. (2007). Pseudoneoplasticlesions of the testis and paratesticular structures. Virchows Archiv, 451(6), 987-997.

2. Dehner, L. P., Scott, D., & Stocker, J. T. (1986). Meconium periorchitis: a clinicopathologic study of four cases with a review of the literature. Human pathology, 17(8), 807-812.

3. Ring, K. S., Axelrod, S. L., Burbige, K. A., & Hensle, T. W. (1989). Meconium hydrocele: an unusual etiology of a scrotal massin the newborn. The Journal of urology, 141(5), 1172-1173.

4. Srivastava, P., Gangopadhyay, A. N., Gupta, D. K., Kumar, V., Sharma, S. P., Upadhyaya, V. D., & Jaiman, R. (2011). Giantmeconium hydrocele: a rare presentation of antenatal gastrointestinal perforation. Journal of paediatrics and child health, 47(3), 153-153.

5. Olnick, H. M., & Hatcher, M. B. (1953). Meconium peritonitis. Journal of the American Medical Association, 152(7), 582-584.

6. Forouhar, F. (1982). Meconium peritonitis: pathology, evolution, and diagnosis. American journal of clinical pathology, 78(2), 208-213.

7. Herman, T. E., & Siegel, M. J. (2004). Meconium periorchitis. Journal of perinatology, 24(1), 53-53.

8. Rekhi, H. S., Mittal, S. K., Mannem, S. R., Arora, S., Seth, K., Pakkiri, S., ... & Mathur, M. (2016). An atypical case of meconium periorchitis as paratesticular mass in a neonate. Clinical case reports, 4(9), 866-869.

9. Kalra, P., & Radhakrishnan, J. (2006). Meconium periorchitis. Urology, 68(1), 202.

10. Brown-Harrison, M. C., Harrison, A. M., Reid, B. S., & Cartwright, P. C. (2000). Meconium Periorchitis A—Cause of ScrotalMass in the Newborn. Clinical pediatrics, 39(3), 179-182.

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