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BMJ Case Reports 2011; doi:10.1136/bcr.05.2011.4170
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An epidermoid cyst presenting as testicular torsion in a patient with tri-orchidism

  1. Ted Mc Dermott
  1. Department of Urology, St. James’s Hospital, Dublin, Ireland
  1. Correspondence to Deirdre Mary Fanning, fanningdee{at}yahoo.co.uk

Description

A 38-year-old male presented to the emergency department with acute onset of scrotal pain. The pain was excruciating. A prior scrotal ultrasound was consistent with polyorchidism (figures 1 and 2). Clinical examination revealed a markedly distressed tearful man. Scrotal inspection showed three distinct scrotal masses, all of equivalent size, consistent with testes (figures 3 and 4). The reported third testis was located in the left hemiscrotum. It was exquisitely tender and lay high in the midscrotum. All three masses had similar consistencies. At emergency scrotal exploration, two masses were identified in the left hemiscrotum. There were no signs of testicular torsion. Incision of the third mass resulted in the expulsion of a copious quantity of thick brown material (figures 5 and 6). Pathology showed a saccular 6 × 3 × 2 cm epidermoid inclusion cyst, lined by keratinised squamous epithelium and filled with sterile brown caseous material. The patient made an excellent postoperative recovery. He had no recurrence of scrotal pain at 6 months follow-up. Epidermoid inclusion cysts (EICs) occurred after implantation of epidermal tissue into the dermis or subcutaneous tissues. In the scrotum they are usually secondary to trauma or abnormal embryologic closure of the median raphe or urethral groove.1 They have a stratified squamous epithelial wall and often contain a laminated cheesy material. They appear solid on all imaging modalities and may have an onion-skin appearance.2 Characteristically EICs lack internal and capsular flow on colour Doppler ultrasound. They may mimic rare malignant tumours such as liposarcoma, fibrosarcoma or metastatic disease. Surgical excision is recommended.

Figure 1

Preoperative scrotal ultrasound showing three structures of equivalent echogenicity.

Figure 2

Ultrasonic view of the middle scrotal structure. Dimensions: 6.81 × 3.46 × 8.19 cm. Tapered ends were seen. Poor colour flow Doppler was seen.

Figure 3

Three distinct scrotal masses.

Figure 4

Anterior hypospadias.

Figure 5

Incision of the middle scrotal structure.

Figure 6

Following resection of the middle scrotal structure, the proximal aspect appeared to represent a blind-ending duct.

Footnotes

  • Competing interests None.

  • Patient consent Obtained.

References

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