Presentation
This patient was referred with a 3 month history of scrotal swelling and anemia. Testicular cancer was suspected.
Patient Data
There is significant subcutaneous edema of the scrotum and penis. Both testes are within normal limits for size, echogenicity and vascularity. No testicular mass.
Both epididymides are normal in appearance. A few simple cysts identified bilaterally but no sinister features. No hydrocele or varicocele.
The working diagnosis following the US was "lymphedema of unknown cause'
There is marked edema of the skin of the penis and scrotum bilaterally with enlarged nodes in both the right and left groins. There is a large complex lobulated rim enhancing fluid collection in the left buttock, superficial to the gluteus maximus muscle. This tracks anteriorly in the perineum towards the scrotum. There are also multiple abnormal gas pockets surrounding the anal region suggestive of fistulae. There is also thickening of the levator muscles. No free fluid in the pelvis. The rectum and sigmoid appear normal, also the bladder. No intrapelvic mass. No abdominal adenopathy.
There is severe, extensive, abscess formation with associated soft tissue edema affecting the base of the penis and scrotum, perineum, subcutaneous tissues of the buttocks, ischioanal fossa and ischiorectal fossa. Multiple complex tracts are seen.
There is no evidence of any significant supra elevator origin of the sepsis. Some involvement of the intersphincteric plane is shown inferiorly. Low down in the anal canal a small tract crosses the external sphincter at 6 o'clock . The intersphincteric plane is also crossed slightly higher.
Persistent abscess formation, fistulation and lymphadenopathy as well as severe scrotal and perineal edema are present.
Case Discussion
The still quite dramatic changes at 1 year follow up illustrate the long term nature of this debilitating condition.