British Journal of Urology (1998), 82, 765–767

CASE RE PORT

Meconium masquerading as a scrotal massK. HAN, J . MATA† and M.R. ZAONTZ*Robert Wood Johnson University, New Brunswick, and *Division of Pediatric Urology and †Pediatric Radiology, Cooper Hospital,Camden, New Jersey, USA

Case report

A 4-month-old boy presented with an enlarged, bluishright scrotum; he was born at full term after an uncom-plicated pregnancy. Voiding and bowel function hadbeen normal. On examination, the right hemiscrotumwas blue-tinged and swollen with a palpable mass, butwas otherwise unremarkable. A photograph taken atbirth showed an asymmetric enlarged right bluish hem-iscrotum (Fig. 1). Ultrasonography of the right scrotumrevealed densities of increased echogenicity, consistentwith calcifications anteromedial to the right testicle.Ultrasonography of the left scrotum revealed a hydrocelewith areas of increased echogenicity, again highlysuggestive of calcifications (Fig. 2). A plain film of theabdomen and pelvis showed no calcifications, but showedthe calcifications in the scrotum (Fig. 3). At explorationthrough a right inguinal incision, a meconium-stainedprocessus vaginalis and a paratesticular mass with calci-fications were encountered (Fig. 4). The testis was grossly Fig. 2. Ultrasonogram of the left scrotum showing the calcificationsnormal. A hernia repair was subsequently carried out. (arrow) and hydrocele.

Exploration of the left scrotum, also through an inguinalincision, revealed similar findings. The testis was againgrossly normal in appearance. Histology confirmed the

Fig. 3. Plain film of the scrotum, showing calcifications secondaryto meconium (arrow).

finding of fibrous giant-cell reaction with histiocytes,brown pigmentation and calcification, consistent withFig. 1. Photograph taken at birth showing the enlarged bluish

right hemiscrotum. meconium.

765© 1998 British Journal of Urology

766 CASE REPORTS

A radiological evaluation should include plain films ofthe abdomen and pelvis; they often detect intraperitonealcalcifications. Ultrasonography of the scrotum may alsoreveal hyperechogenic densities consistent with calcifi-cations. There are many diCerential diagnoses ofintrascrotal masses, as detailed by Dehner et al. [3].Therapy depends on the confidence level of the surgeonin establishing the diagnosis based on clinical evidenceand radiographic findings. Intraperitoneal and intrascro-tal calcifications on plain films, with increased areas ofechogenicity on scrotal ultrasonography, are highlysuggestive of meconium peritonitis causing meconiumto migrate into the scrotum [4,5]. The natural historyof meconium in the scrotum is that of spontaneousresolution [2,3]. Conversely, when the diagnosis remainsin doubt, especially in cases where tumour cannot beexcluded, surgical exploration is mandatory [4]. Dehneret al. [3] reviewed cases before 1986 and a further sixreports have been published, with a total of 26 patients.One case documented cystic fibrosis, while in seven itwas unclear whether cystic fibrosis was tested for as acause [2]. Cystic fibrosis is present in 4.5% of cases ofmeconium in the scrotum. In contrast, cystic fibrosisFig. 4. Intra-operative photograph of the right scrotum with testiclewas present in #20% of meconium peritonitis in theand meconium-stained paratesticular mass (arrow).

review by Tibboel et al. [1]. Four cases (#15%) haddocumented gastrointestinal atresia or obstruction; thisis less than the 30% found in meconium peritonitis. Two

Commentorchidectomies were performed [3] and three cases weretreated expectantly, with spontaneous resolution [1].Meconium peritonitis results from perforation of a seg-

ment of the alimentary tract, allowing extrusion of Resolution was documented both clinically and radio-graphically. The mean age at diagnosis was 4 monthsmeconium into the peritoneal cavity. A recent review of

1084 cases of meconium peritonitis concluded that half and 24 days, while the median age was 30 days. Inconclusion, there are many diCerential diagnoses ofthe cases had no aetiology for bowel perforation [1].

Pathological findings and experimental studies have sug- intrascrotal swelling; while meconium presenting in thescrotum is certainly a rare entity, it must be considered.gested that vascular insuBciency causing intestinal

ischaemia may lead to subsequent perforation. An esti- A clinical history of a soft hydrocele with transformationinto a firm tumour-like mass, with radiographic evidencemated 20% of cases of meconium peritonitis were attri-

buted to meconium inspissation secondary to cystic of intraperitoneal and intrascrotal calcifications, andultrasonographic hyperechogenicity within the scrotum,fibrosis [2]. The other 30% were probably the result of

intestinal atresia or obstruction (i.e. volvulus or intussus- are highly suggestive of meconium having spilled intothe scrotum from the peritoneum. Expectant manage-ception) [2]. Other rare causes include intestinal dupli-

cation, Meckel’s diverticulum, ulcers and hyperplastic ment is then an acceptable treatment. However, if atumour or any other diagnosis cannot be excluded,lymphoid hyperplasia [3]. Many patients with spillage of

meconium present with peritonitis requiring surgical surgical exploration is mandatory.intervention. However, in many patients the perforationresolves spontaneously, with no intestinal sequelae [4]. AcknowledgementsAs the processus vaginalis often remains patent late into

We thank Paul A. Rogers, CMI, and Joseph Rothrock,gestational life and even into birth, spilled meconiumfor their contributions to the illustrations.easily traverses the canal into the scrotum [1].

Immediately after birth, the fluid-like meconium mayresemble a hydrocele. Over the course of the next few Referencesweeks, a foreign-body reaction occurs, leading to 1 Tibboel D, Gaillard JL, Molenaar JC. The importance ofinflammation, fibrosis and calcification, transforming mesenteric vascular insuBciency in meconium peritonitis.

Hum Path 1986; 17: 411these soft hydroceles into tumour-like masses.

© 1998 British Journal of Urology 82, 765–767

CASE REPORTS 767

2 Berndon WE, Baker DH, Becker J, DeSanctis P. Scrotal hydrocele: an unusual hydrocele in the newborn. J Urol1985; 141: 1172masses in healed meconium peritonitis. New Engl J Med

1967; 277: 5853 Dehner LP, Scott D, Stocker JT. Meconium periorchitis: a

Authorsclinico-pathologic study of four cases with a review of theliterature. Hum Path 1986; 17: 807 K. Han, MD, Urology Resident.

M.R. Zaontz, MD, FACS, FAAP, Chief.4 Kizer JR, Bellah RD, Schnaufer L, Canning DA. Meconiumhydrocele in a female newborn: an unusual case of a labial J. Mata, MD, Pediatric Radiology.

Correspondence: Dr K. Han, 623 Waterford Drive, Edison, Newmass. J Urol 1995; 153: 1885 Ring KS, Axelrod SL, Burbige KA, Hensle TW. Meconium Jersey 08817, USA.

© 1998 British Journal of Urology 82, 765–767