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Asian Journal of Medical and Clinical Sciences
Case Report
Scrotal lymphocele (milky hydrocele)
Bipin Kumar1, Meenu Agarwal2
1
Department of Pathology,Indira Gandhi Medical College & Research Institute,Puducherry,India.
BP Koirala Institute of Health Sciences, Dharan, Nepal.
2
Abstract
We report a case of scrotal lymphocele diagnosed by fine needle aspiration cytology in a 22-year old male, who, came to the hospital with complaints of
pain and progressive enlargement of right side scrotum and clinico-radiologically diagnosed as hydrocele. No any history of abdominal or inguinal
surgical procedures or renal transplant had been found and probable etiology of filarial origin was considered excluding other obstructive lesion in
inguinal or retroperitoneal region.
Key Words: lymphocele, milky hydrocele, chylocele, fine needle aspiration cytology.
Received : 10Jun 2012
Accepted : 15 Jul 2012
INTRODUCTION
L
[1]
ymphocele is an accumulation of lymph fluid .
Scrotal lymphocele is uncommon occurrence and
only few of it in studies of filariasis or renal transplant is recorded
in English literature [2-9]. We report a case of scrotal lymphocele
(milky hydrocele or chylocele) diagnosed by fine needle
aspiration cytology (FNAC) in a 22-year male who was
presented to our hospital as a case hydrocele without any history
of abdominal or inguinal surgical procedures or renal transplant.
Published: 10 Sep 2012
cycling in hilly area was found. Repeat ultrasonogram didnot
reveal any communication between scrotum and peritoneal
cavity. CT and MRI didnot show any retroperitoneal
lymphadenopathy, mass or tumor compressing the intraabdominal course of lymphatic vessel. No any form of filaria was
found even in the repeat aspirate and peripheral smear made by
night blood collection. No eosinophilia was found in the
differential leucocyte count.
CASE PRESENTATION
A 22-year male student of hilly area of eastern Nepal came
to surgical outpatient department with complaints of pain and
progressively enlarging swelling of right side of scrotum for one
year. Ultrasonography showed right sided hydrocele (Figure 1)
and well-defined anechoic multisepted cystic lesion in right
epididymis, involving head and body region (Figure 2). The
largest cyst measured 7.2 mm in diameter in head region. The
heterogeneous thickening of right epididymis in head, body and
tail region with foci of calcification was also noted. With the
clinico-radiological diagnosis of right sided hydrocele with
epididymal cyst, the case was subjected for FNAC.
Figure 1: USG showing right sided hydrocele.
Cytological findings
Ultrasound guided FNA from the cystic swelling of the
epididymis and fluid collected in tunica vaginalis attempted
subsequently yielded milky material. Smear on microscopy
showed mature lymphocytes against lipo-proteinaceous
background (Figure 3). The aspirated material showed sodium,
potassium and creatinine level similar to extra-cellular fluid.
Based on these findings the case was diagnosed as lymphocele.
After the diagnosis made, the other relevant clinical
history was searched for. No any relevant history except vigorous
Address for correspondence*
Bipin Kumar
Department of Pathology,Indira Gandhi Medical College &
Research Institute,Puducherry,India.
Email:[email protected]
43
Figure 2: USG showing multi-septed cystic lesion in right
DISCUSSION
Lymphocele is an accumulation of lymph fluid [1].
Lymphocele can be primary (congenital lymphedema) or acquired
(eg. eg postoperative or as a result of complicated genital
lymphatic filariasis) [1, 2]. Scrotal lymphocele is also called milky
hydrocele [3]. Hydrocele is collection of fluid in the tunica
vaginalis [4]. Chylocele (collection of chyle), hematocele
(collection of blood), and pyocele (collection of pus) are the
Asian J Med Cli Sci |May -Aug 2012 |Vol-1 | Issue- 2
epididymis which may occurs in the case of filariasis. Apart from
it, epididymal thickening, epididymal cyst and calcification all are
considered as chronic form of genital filariasis, because the
patient belongs to the high prevalent area of filariasis.
Current treatment modalities include per-cutaneous
aspiration with or without drain, sclerotheraphy with various
agents, open surgical and laparoscopic marsuplization or excision
of the sac [10]. Our patient is treated by percutaneous aspiration and
is under follow-up.
Recurrence and increase in episodes of infection are two
common complications [10].
CONCLUSION
Figure 3: Microscopy showing many mature lymphocytes
in lipo-proteinaceous background (MGG; X100).
complications of it [4]. Filarial hydroceles and chyloceles account
for up to 80% of hydrocele in tropical countries where the
parasite is endemic [5]. Filarial hydroceles follow repeated attacks
of filarial epididymo-orchitis [5]. They vary in size and may
develop slowly or very rapidly [5]. Occasionally the fluid contains
liquid fat, which is rich in cholesterol [5]. This is due to rupture of a
lymphatic varix with discharge of chyle into the hydrocele [5].
Apart from these, filarial scrotum, abscess of scrotum, filarial
penis, elephantiasis of the female genitalia (due to lymphedema
involving the subcutaneous tissues), varicocele, Lymph varix
(dilatation and tortuosity of the lymphatics of the spermatic
cord), lymph-vesicles bursting on scrotum and abdomen,
chyluria, hematuria, hematochyluria (due to rupture of the
retroperitoneal lymphatics into the renal collecting system),
anemia, and Lymph scrotum (dilatation of the lymphatics of the
scrotal skin, which then rupture on the surface, oozing lymphatic
fluid) are other forms of genital lymphatic filariasis [3-6].
Occurrence of epididymal thickening and epididymal cyst are
also observed in filariasis [7]. Scrotal lymphocele secondary to
renal transplantation are also documented [8, 9]. It is the result of
lymphatic dissection with perirenal lymphocele tracking down
the scrotum [8].
Ultrasound is the most valuable diagnostic approach for
lymphocele [1]. Sonographically, the fluid is anechoic, shows
posterior acoustic enhancement, and surrounds the testis same to
the findings seen in hydrocele; although lymphocele contain
more septations [1, 8]. In our case the ultrsonographic findings
show multiple septations around the epididymis and fluid
collected around the testis show similar features of hydrocele. In
the present case, the history of cycling with progressive enlarging
mass and occasional pain along with the presence of anechoic
cystic lesion noted in right epididymis suggest the pathogenic
mechanism of lymphocele of the scrotum due to trauma of
lymphatic channel of epididymis possibly caused by vigorous
cycling in hilly region.
Lymphocele usually present as hydrocele on clinical and
radiological examination, but its mode of treatment is completely
different. The diagnosis can be easily and conveniently diagnosed
by FNAC without any complicated investigative procedures. The
etiologic factors in endemic area should be considered always as
filariasis after excluding any obstructive pathology, surgical
procedure and history of renal transplantatioin; inspite of absence
of any form of filaria or eosinophilia.
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In the present case no any history of abdominal injury or
surgery was found. Inspite, peripheral smear made from night
collected blood sample and aspirated fluid didnot reveal any
form of filaria and eosinophilia; we suggest that the accumulated
fluid may be due to reflux from the traumatized lymphatics of
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