A case of giant hemorrhagic hydrocele testis

A 63-year-old man presented with a painless left scrotal swelling. Ultrasonography revealed intra-scrotal fluid retention and scrotal puncture collected 200ml of straw colored fluid, leading to a diagnosis of hydrocele testis. Three months later, he received next aspiration of 360 ml for scrotal re-swelling. He came back 4 months later with much larger scrotal swelling extending to left inguinal area. Two additional aspirations were performed one week apart to collect somehow hemorrhagic fluid of 700 ml and 850 ml, respectively. Each aspiration was incomplete due to catheter clogging with blood clot, leaving nearly half of the initial bulk in appearance. MRI revealed a giant cystic space spanning a diameter of 16cm that contained hemorrhagic fluid with linear septal structures and floating nodular structures suggestive of blood clots (Fig. 1). There was no structure like mural nodules alongside the scrotal wall. The left testis was flattened by this large cystic lesion. Although the patient had no history of testicular trauma or exposure of asbestos, the presence of septa and solid component as well as hemorrhage raised a possibility of malignancy such as mesothelioma of the tunica vaginalis. However, cytological examination of hydrocele fluid was negative. The hyaluronic acid level of hydrocele fluid was 25,600ng/ml, which was far below the proposed cut-off level of 100,000 ng/ml for pleural effusion of malignant mesothelioma. Collectively, we did not obtain data that is strongly suggestive of malignancy. Therefore, excision of the hydrocele sac was planned through scrotal approach. Intraoperative findings showed a well vascularized and thickened hydrocele sac, which was lined with denatured blood clots and filled with bloody fluid (Fig. 2). Left testis appeared normal. Intraoperative pathological diagnosis of the frozen section of tunica vaginalis was negative for malignancy and thus conventional hydrocelectomy was completed. The post-operative course was uneventful. The final histopathological diagnosis was chronic inflammation accompanied with hemorrhage, no evidence of malignancy (Fig. 3).