Clinico-radiological and pathological evaluation of extra testicular scrotal lesions

Abstract

Scrotal ultrasound, though reliable in distinguishing between intratesticular and extratesticular lesions and characterizing them as cystic and solid, cannot distinguish benign from malignant pathology. Although fine needle aspiration cytology (FNAC) has proved to be of great diagnostic importance in testicular lesions, its scope in extratesticular lesions is largely unexplored.
To evaluate extratesticular scrotal lesions cytologically and compare it with their clinical, radiological, and histological findings.
Sixty five patients with extratesticular scrotal lesions were assessed clinically, radiologically, and cytologically. Histopathology was done in 45 cases where surgical exploration was undertaken. All the data were then analyzed and correlated.
Extratesticular lesions accounted for 72.2% of the scrotal swellings. Of these, the epididymis is most commonly involved (61.5% cases) with the commonest type of lesion being cystic (49.3% cases). Ultrasonography preferably with color doppler is highly useful for the evaluation of the scrotum. Apart from distinguishing extratesticular from testicular and cystic from solid lesions, it has an important role in identifying individual lesions, thus reducing the list of differential diagnosis. Fine needle aspiration cytology contributed to a definitive diagnosis in 47.7% cases. It helps classify cystic masses on the basis of their contents and defines the etiology of chronic inflammatory lesions, apart from corroborating with the clinico-radiological diagnosis. Histological evaluation was possible only in cases where surgery was performed and helps further define the diagnosis.
Fine needle aspiration cytology is essentially non-traumatic and easy to carry out and should be a technique of choice for the study of scrotal pathology, main advantage being avoidance of delays in diagnosis.

Full text

27
Journal of Cytology / January 2013 / Volume 30 / Issue 1
suParna MuKherJee2, veena Maheshwari, roobina Khan, syed aMJad ali riZvi1, Kiran alaM, syed hasan harris1, raJeev sharMa3
Departments of Pathology and 1Surgery, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, 2Army College of
Medical Sciences, Delhi Cantt, New Delhi, 3Bishen Skin Centre, Aligarh, Uttar Pradesh, India
Address for correspondence: Dr. Roobina Khan, Hafeez Manzil, Marris Road, Aligarh ‑ 202 001, Uttar Pradesh, India.
E‑mail: roobinakhan123@rediffmail.com
Original Article
ABSTRACT
Background: Scrotal ultrasound, though reliable in distinguishing between intratesticular and extratesticular lesions and
characterizing them as cystic and solid, cannot distinguish benign from malignant pathology. Although ne needle aspiration
cytology (FNAC) has proved to be of great diagnostic importance in testicular lesions, its scope in extratesticular lesions is
largely unexplored.
Aim: To evaluate extratesticular scrotal lesions cytologically and compare it with their clinical, radiological, and histological ndings.
Materials and Methods: Sixty ve patients with extratesticular scrotal lesions were assessed clinically, radiologically, and
cytologically. Histopathology was done in 45 cases where surgical exploration was undertaken. All the data were then
analyzed and correlated.
Results: Extratesticular lesions accounted for 72.2% of the scrotal swellings. Of these, the epididymis is most commonly
involved (61.5% cases) with the commonest type of lesion being cystic (49.3% cases). Ultrasonography preferably with color
doppler is highly useful for the evaluation of the scrotum. Apart from distinguishing extratesticular from testicular and cystic
from solid lesions, it has an important role in identifying individual lesions, thus reducing the list of differential diagnosis. Fine
needle aspiration cytology contributed to a denitive diagnosis in 47.7% cases. It helps classify cystic masses on the basis of
their contents and denes the etiology of chronic inammatory lesions, apart from corroborating with the clinico‑radiological
diagnosis. Histological evaluation was possible only in cases where surgery was performed and helps further dene the diagnosis.
Conclusion: Fine needle aspiration cytology is essentially non‑traumatic and easy to carry out and should be a technique
of choice for the study of scrotal pathology, main advantage being avoidance of delays in diagnosis.
Key words: Cytology; epididymis; extratesticular; scrotum; ultrasound.
Introduction
The scrotum was earlier considered as an area of unaided
clinical expertise. Nevertheless, the nature of some of the
scrotal masses remains baffling.
Scrotal masses may be intratesticular or extratesticular,
either solid or cystic. Most of the intratesticular masses
should be considered malignant unless proved otherwise.
Extratesticular cystic masses are almost certainly benign,
whereas extratesticular solid masses have a malignant rate
of 16%, which though being much lower than intratesticular
masses, is high enough to be of concern.[1]
Scrotal ultrasonography (USG) has proved to be a highly
reliable method to distinguish between intratesticular and
extratesticular lesions and to characterize them as solid or
cystic. However, it cannot reliably differentiate benign from
malignant pathology.[2] The introduction of magnetic resonance
imaging (MRI) and correlation with histopathology have helped
to shorten the list of differential diagnoses and modify the
management of the patients with extratesticular scrotal masses.
Clinico‑radiological and pathological evaluation of extra
testicular scrotal lesions
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28
Mukherjee, et al.: Evaluation of extratesticular scrotal lesions
Journal of Cytology / January 2013 / Volume 30 / Issue 1
Although fine needle aspiration cytology (FNAC) has proved
to be of great diagnostic importance in testicular lesions, its
scope in extratesticular lesions is largely unexplored. The aim
of the present study is to evaluate the usefulness of FNAC as
a diagnostic tool in the management of scrotal swellings, as
well as to correlate the clinical, radiological, cytological and
histopathological findings in different types of extratesticular
scrotal lesions.
Materials and Methods
A total of 90 patients presented with scrotal swelling over a
period of 1½ years in outpatient and inpatient departments
of our hospital. Of these, 25 patients were excluded because
a testicular pathology was detected after ultrasonographic
evaluation. The remaining 65 cases (72.2%), comprising the
study group, were studied prospectively and assessed clinically,
radiologically, cytologically and histomorphologically. The
data collected were tabulated, analyzed and correlated.
Gray‑scale ultrasonography was done in all cases, accompanied
by color doppler in the suspected cases of epididymitis,
torsion and varicocele.
FNAC was done under sonographic guidance after confirmation
of the extratesticular nature of swelling by ultrasound, by
using a 23‑gauge needle and a 10‑mL disposable syringe.
Cytospin smears were prepared from the aspirated fluid.
After fixation, slides were stained with Papanicolaou or
hematoxylin and eosin stains.
In 47 cases where surgical exploration and excision was
undertaken, the histopathology was also done and the
findings were correlated.
Results
Out of 65 patients, the epididymis was found to be involved
in the maximum number of cases [40 cases (61.5%)], followed
by the tunica vaginalis [17 cases (26.1%)], the spermatic cord
and the scrotal wall [4 cases (6.2%) each].
The chief pathologies encountered were: Cystic lesions [32
cases (49.3%)], inflammatory lesions [28 cases (43.1%)] and
tumor and tumor‑like lesions [5 cases (7.6%)]. The sites of
origin and causes of the various lesions are summarized in
Table 1.
The age of the patients ranged from 12 to 75 years, with
the maximum number of patients [28 cases, (43.1%)] in the
age group 21‑30 years. The mean age at presentation was
32.1 years.
Scrotal pain or tenderness was the commonest symptom
[37 cases, (56.9%)]. Scrotal swelling was the only complaint
in 23 (35.4%) patients. In the remaining patients, there was a
wide spectrum of additional complaints such as fever, general
debility, urinary complaints, dragging sensation, trauma and
infertility.
Eleven (16.9%) patients presented with acute scrotum,
characterized by acute pain and swelling of scrotum with the
duration of symptoms varying from 1 day to 1 week. They
included 10 cases clinically diagnosed as acute epididymitis
with or without orchitis and one case of pyocele. One case
presenting as acute scrotum clinically but diagnosed as
testicular torsion radiologically was excluded from the study
group. The remaining 54 (83.1%) patients presented with
long‑standing symptoms, varying from weeks to months,
even years. The clinical diagnoses were made based on the
above symptoms, the commonest being chronic epididymitis
[Table 2].
The extratesticular swellings were predominantly unilateral,
while bilaterality was present in only 6 patients (9.2%).
Swellings showed no predilection for any hemiscrotum,
except for varicocele, where left‑sided lesions predominated.
Table 1: Distribution of cases of extratesticular swellings
Site of origin Pathology No. of
cases
Percentage
Tunica vaginalis Cystic
Hydrocele 12 18.4
Hematocele 2 3.1
Pyocele 2 3.1
Total 16 24.6
Neoplastic
Fibrous pseudotumor 1 1.5
Epididymitis Cystic
Epididymal cyst 7 10.8
Spermatocele 4 6.2
Late post‑vasectomy syndrome 1 1.5
Total 12 18.5
Inflammatory
Acute epididymitis 8 12.3
Acute epididymo‑orchitis 2 3.1
Chronic epididymitis 17 26.2
Elephantiasis 1 1.5
Total 28 43.1
Spermatic cord Cystic
Varicocele 4 6.2
Scrotum Neoplastic
Scrotal metastasis 1 1.5
Scrotal calcinosis 3 4.6
Tot al 46.1
Total 65 100
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Mukherjee, et al.: Evaluation of extratesticular scrotal lesions
Journal of Cytology / January 2013 / Volume 30 / Issue 1
All the 65 patients were scanned by USG and color doppler
wherever possible. In addition to confirming the clinical
diagnosis in all the other cases, USG evaluation led to a
different diagnosis in 2 (3.1%) of the cases. These were a case of
paratesticular neoplasm and a case of scrotal neoplasm, which
were clinically diagnosed as chronic epididymis and sebaceous
cyst, respectively. USG also provided additional information in
19 (29.2%) cases: 1 case diagnosed as acute epididymo‑orchitis
where inflammation was limited to the epididymis; 15 cases of
fluid accumulation which were grouped into two categories:
Simple fluid (hydrocele) with anechoic film in 12 cases and
complex fluid (hematocele/pyocele) with internal echoes
in 3 cases; 3 cases with the differential diagnosis of scrotal
calcinosis and sebaceous cyst where calcified scrotal masses
were seen, although a definitive diagnosis could not be made.
Cytological evaluation was attempted in all the patients with
extratesticular scrotal swelling. FNAC was not done in four
patients diagnosed to be varicocele, as clinical diagnosis
and imaging findings in varicocele are essentially diagnostic.
Cytological evaluation done in the 56 (86.1%) patients was
found to correlate with the clinico‑radiological diagnosis
[Table 3]. Cytology further added to the diagnosis in 31
cases (47.7%). For example, three cases diagnosed as
complex hydrocele radiologically were differentiated into
haematocele and pyocele. Cases of pyocele showed pus‑like
aspirate with predominant neutrophils. Cases of hematocele
yielded bloody aspirate with smears showing blood or altered
blood. FNAs from hydrocele yielded straw‑colored fluid and
scanty smears comprising squames, macrophages and mixed
inflammatory cells.
Twelve cases of cystic masses of epididymis were subclassified
into epididymal cysts and spermatoceles on the basis of
both the color of the fluid aspirated and the cell component.
Table 2: Clinical diagnosis
Clinical presentation Clinical diagnosis No. of cases Percentage
Acute 11 16.9
Pain, tenderness, fever, swelling of epididymis Epididymitis 7 10.8
Pain, tenderness, fever, swelling of testis and epididymis Epididymo‑orchitis 3 4.6
Pain, tenderness, fever, swelling in tunica vaginalis Pyocele 1 1.5
Chronic 54 83.1
Painless scrotal enlargement, transillumination+ Hydrocele 15 23.0
Painless scrotal mass separate from testis, transillumination+ Epididymal cyst/spermatocele 12 18.5
Mild pain, scrotal mass separate from testis Chronic epididymitis 18 27.7
Massive swelling of scrotum and penis, thickened skin Elephantiasis 1 1.5
Dragging pain, “bag of worms” on palpation, increases on valsalva, infertility Varicocele 4 6.2
Multinodular (eruptive) swellings on scrotal wall Scrotal calcinosis/sebaceous cyst 46.2
Table 3: Clinico‑radiological and pathological correlation of extratesticular swellings
Clinical diagnosis No. of
cases
Radiological diagnosis No. of
cases
Cytological
diagnosis
No. of
cases
Histopathological
diagnosis
No of
cases
Acute epididymitis 7 Acute epididymitis 8 Acute epididymitis 7 Acute epididymitis 1
Acute epididymo‑orchitis 3 Acute epididymo‑orchitis 2
Pyocele 1 Pyocele 1 Pyocele 2 Pyocele 2
Hydrocele/hematocele/pyocele/ 15 Complex hydrocele (hematocele/pyocele) 3 Hematocele 2
Hydrocele 12 Hydrocele 12 Hydrocele 12
Epididymal cyst/spermatocele 12 Epididymal cyst/spermatocele 12 Epididymal cyst 7 Epididymal cyst 7
Spermatocele 4 Spermatocele 3
Infected spermatocele 1 Infected spermatocele 1
Late post‑vasectomy
syndrome
1
Chronic epididymitis 18 Chronic epididymitis 17 TB epididymitis 14 TB epididymitis 12
Paratesticular neoplasm 1 Chronic nonspecific
epididymitis
3 Chronic nonspecific
epididymitis
2
Fibrous pseudotumour 1
Elephantiasis 1 Elephantiasis 1 Elephantiasis 1 Elephantiasis 1
Varicocele 4 Varicocele 4
Scrotal calcinosis/sebaceous cyst 4 Scrotal calcified mass 3 Scrotal calcified mass 3 Scrotal calcinosis 3
Scrotal neoplasm 1Scrotal metastasis 1
Tot al 65 65 56 47
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Mukherjee, et al.: Evaluation of extratesticular scrotal lesions
Journal of Cytology / January 2013 / Volume 30 / Issue 1
Epididymal cysts yielded clear, straw‑colored fluid which
comprised histiocytes, lymphocytes, neutrophils, at times
histiocytic giant cells and squames. In cases of spermatocele,
milky or turbid fluid was aspirated and showed numerous
sperms, other spermatogenic cells, sertoli cells and
histiocytes [Figure 1a and b].
Of the 17 cases of chronic epididymitis, tubercular etiology
was ascertained in 14 cases with smear showing either
epithelioid granulomas or caseous necrosis or both, in an
inflammatory background [Figure 1c]. Of the remaining three
cases, two were classified as chronic nonspecific epididymitis
as only mixed inflammatory infiltrate was seen and one
aspirate was inadequate for diagnosis.
Aspiration from the case of clinical elephantiasis yielded
milky fluid, which on light microcopy showed two intact
microfilariae along with histiocytes, other inflammatory cells
and cellular debris [Figure 1d].
Of the swelling in the scrotal wall, FNAC of the three
multinodular eruptive swellings diagnosed to be calcified masses
by USG showed calcific material with very scant cellularity
composed of necrotic and degenerating cells. A swelling
suspected radiologically to be scrotal neoplasm yielded a scanty
aspirate. Thus, FNAC did not add any further information to the
radiological impression of the lesions of the scrotal wall.
Histological follow‑up was available in 47 (72.3%) of the cases,
of which cytological correlation was seen in 44 cases. It was
helpful for the definitive diagnosis in 7 cases (10.8%) – one
case of tubercular epididymitis turned out to be nonspecific
epididymitis. One patient diagnosed as spermatocele on
cytology was found to be a case of post‑vasectomy syndrome
[Figure 2]. It was also helpful for the definitive diagnosis of a
case of inflammatory pseudotumor [Figure 3a and b], which
was diagnosed as paratesticular neoplasm radiologically and
as nonspecific epididymitis cytologically. Three cases showing
calcified scrotal mass were diagnosed as scrotal calcinosis
[Figure 4a, and c] and one case of scrotal neoplasm was found
to be scrotal metastasis from a testicular neoplasm.
Discussion
Studies dealing with intrascrotal pathology, especially those
attempting to find a correlation between clinical, radiological
and pathological data, are few and far between. Most of the
studies have evaluated the role of cytology in male sterility
or testicular lesions. There are only few studies based on the
role of cytology in epididymal nodule.[3,4]
In the present study, extra testicular pathology was found in
65 cases (72.2%) of the total scrotal lesions, as compared to
80% found in study by Rholl et al.[5]
Figure 1: (a) Epididymal cyst/spermatocele. Anechoic cyst in the head
of epididymis; (b) Spermatocele. Smear shows dense population of
dispersed sperm, other spermatogenic cells and hisocytes (H and E, ×500);
(c) Tuberculous epididymo‑orchis. Smear shows clusters of epithelioid
cells and lymphocytes in a background of neutrophils (H and E, ×500);
(d) Elephantiasis. Smear shows single intact microfilaria against a
background of inammatory cells and cellular debris (Pap, ×500)
d
c
b
a
Figure 2: Late post‑vasectomy syndrome. Smear shows sperm granuloma
around a tubule showing two mulnucleated giant cells, epithelioid cells,
inammatory cells and hisocytes (H and E, ×250)
Figure 3: (a) Fibrous pseudotumor (gross). Cut secon of tumor is pale
homogenous and aached to capsule of tess; (b) Fibrous pseudotumor
– Secon shows fascicles of spindle‑shaped cells with few inammatory
cells (H and E, ×250)
b
a
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31
Mukherjee, et al.: Evaluation of extratesticular scrotal lesions
Journal of Cytology / January 2013 / Volume 30 / Issue 1
Commonest site to be involved was the epididymis [40 cases
(61.5%)], comparable to the finding by Rholl et al.[5] This
was followed by the tunica vaginalis; [17 cases (26.1%)], the
spermatic cord and scrotal wall [2 cases (6.2%) each].
The most common category of lesions was cystic lesion [32
cases (49.3%)], with hydrocele being the most frequent. This
was followed by inflammatory lesions [28 cases (43.1%)] and
tumor and tumor‑like lesions [5 cases (7.6%)], similar to the
finding by Perez‑Guillero et al.[6] who, in their study of 89
palpable lesions of the scrotum, testicle and epididymis,
found cystic lesions (48.3%) and inflammatory pathology
(25.8%) to be the most frequent findings.
However, in a study by Handa et al.[7] on 137 cases of
non‑neoplastic testicular and scrotal lesions, inflammatory
lesions were found to be the commonest [52 cases (31.7%)],
followed by non‑inflammatory lesions [42 cases (25.6%)] and
infertility [43 cases (26.2%)].
Chronic inflammatory lesions (26.2%) were found to be
much common than acute inflammatory lesions (15.4%), as
opposed to the study results of Gerscovitch[8] where chronic
inflammatory lesions were less common. Tuberculosis was
the most frequent etiology of chronic epididymitis, followed
by chronic non‑specific epididymitis, and these findings were
similar to those of Woodward et al.[9] and Viswaroop et al.[10]
Scrotal swelling being the criterion for inclusion was found
in 100% cases, followed by scrotal pain and tenderness in
56.9% of the cases.
Acute scrotum, one of the main symptoms of the patients
presenting with scrotal pathology, was found in only 11 (16.9%)
of our cases, the reason being the most important cause of
acute scrotum, i.e., torsion of testis,[11] was excluded from
our study. Earlier studies have shown that the most frequent
cause of acute scrotum in adult is inflammatory disease, being
responsible for 75% of the cases,[12] though higher figure (90.9%)
was found in the present study probably because of complete
exclusion of cases of torsion, which, though rare, is found in
adults. According to Lyronis et al.,[13] the commonest cause of
acute scrotum in children was epididymo‑orchitis, followed by
torsion of appendages. In contrast, the most common cause in
boys of preschool age was spermatic cord torsion.
Clinically, chronic epididymitis poses a diagnostic problem,
as fever and pain are often absent and patient usually
presents with firm paratesticular mass.[9] Sonographically, the
enlarged and hyperechoic epididymis found in epididymitis is
indistinguishable from a tumor of the epididymis.[14] However,
in our study, the paratesticular location with separate
visualization of the epididymis as well as calcification led
to a suspicion of neoplasm radiologically. However, in
both these entities, pathological study was found to play
an important role. Cytological examination of the lesion
confirmed the chronic inflammatory nature of the swelling
and its categorization into tubercular and chronic nonspecific
type. Histopathological examination confirmed all the cases
diagnosed as tubercular on cytology and labeled another case
suspected as chronic epididymitis as tubercular.
Cystic masses of epididymis constituted 18.5% (12 cases) in
our study, with true epididymal cysts being more common.
However, in post‑vasectomy patients, spermatoceles were
common, which is similar to the report of Holden and List.[15]
Diagnostic confusion in cases of hydrocele did not arise since
in all the cases a fluctuant swelling was palpable separate
from the testis. The two entities – epididymal cyst and
spermatoceles – were, however, clinically and radiologically
indistinguishable and their cytology contributed in
differentiating the two, as the aspirated fluid in these entities
was different both macroscopically as well as microscopically.
But the clinical impact was not much as both conditions had
to be excised if large.
According to many studies, hydrocele and more complex
fluid collections are easily identified by ultrasonography.
However, it is not possible to differentiate hematocele from
Figure 4: (a) Scrotal calcinosis – Mulnodular, large, yellowish swellings on scrotum; (b) Scrotal calcinosis – Smear shows calcium deposits and few degenerang
cells (H and E, ×500); (c) Scrotal calcinosis – Secon shows intradermal basophilic calcic masses, with overlying epidermis (H and E, ×50)
c
b
a
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Mukherjee, et al.: Evaluation of extratesticular scrotal lesions
Journal of Cytology / January 2013 / Volume 30 / Issue 1
exudative hydrocele by ultrasound alone, and therefore
any fluid collection that entirely encircles the testis should
be explored and drained.[16] So, in the present study, after
categorization of fluid collection into simple and complex
hydrocele using ultrasonography, aspiration was done. This
led to further categorization of complex hydroceles into
hematoceles and pyocele.
The only true neoplasm detected in the present study was
metastasis to the scrotal wall from an ipsilateral testis having
embryonal carcinoma. An inflammatory pseudotumor of
the tunica was the only benign lesion which mimicked
a neoplasm. Each of these accounted for 1.5% of the
extratesticular lesions.
A study by Upton and Das[17] on solid intrascrotal masses,
both testicular and paratesticular, showed a higher incidence
of benign neoplasm in the paratesticular structures, with
adenomatoid tumor being the commonest and fibrous
pseudotumor being the second most common benign tumor
of testicular adnexa. A study of solid extratesticular masses
that underwent surgical resection by Beccia et al.[18] showed
an overall malignancy rate of 3%, in which the commonest
lesion was lipoma. Another study of 19 patients with
extratesticular masses using ultrasonography by Frates et
al.[1] gave a higher malignancy rate of 16%, the commonest
lesion being adenomatoid tumor. However, the number of
patients with neoplasms is too small in the present study to
be compared with any of the above.
Conclusion
Scrotal diseases, though previously considered to be a
forte of clinician, cannot be specifically diagnosed without
the help of ancillary techniques. The present study also
showed that ultrasound, though reliable in distinguishing
between intratesticular and extratesticular lesions and to
characterize them as cystic and solid, cannot distinguish
benign from malignant pathology. The advantage of FNAC
is that apart from being simple, safe, and cost‑effective, it
also helps to classify cystic masses of tunica vaginalis and of
the epididymis on the basis of the contents and defines the
etiology of the chronic inflammatory lesions. In corroboration
with clinico‑radiological diagnosis, FNAC also helps to
pinpoint a specific diagnosis, thereby influencing the clinical
management. It may at times have therapeutic implication,
e.g., in cases of hydroceles, which may either be completely
drained or sclerosants injected. Definitive diagnosis, however,
in many lesions is still possible only on histopathology.
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How to cite this article: Mukherjee S, Maheshwari V, Khan R, Rizvi SA,
Alam K, Harris SH, et al. Clinico‑radiological and pathological evaluation
of extra testicular scrotal lesions. J Cytol 2013;30:27‑32.
Source of Support: Nil, Conict of Interest: None declared.
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