An incidental finding of a testicular mass in young male population is always a case of great concern for the patient and controversy for the physician. Differential diagnosis ranges from acute scrotum (notably testicular torsion), to acute inflammation and infection, all the way to testicular tumors. We present a case of an incidental finding of a painless testicular solid mass in a 19-year-old male patient, with an end pathological result of paradidymis (organ of Giraldes) following orchiectomy. To the best of our knowledge, this is the first case of its kind to be reported in the literature.
A testicular appendage is a vestigial residual of the Wolffian (mesonephric) duct or the Mullerian (paramesonephric) duct. A Mullerian-inhibiting substance produced during fetal growth causes the degradation of the Mullerian duct, in a craniocaudal fashion [
Testicular appendages; VD: vas deferens; T: testicle; Ep: epididymis; Par: organ of Giraldes; EA: epididymal appendage; TA: testicular appendage;
We describe a case of a healthy 19-year-old male patient, presenting to the urology clinic for an incidental finding of a painless left scrotal mass. Clinical history goes back to a couple of days before, where the patient first noticed a mass while taking a shower. The patient denies recent scrotal trauma, unprotected sexual intercourse, penile discharge, urinary symptoms, fever, or chills. Physical exam revealed a 3-4 cm scrotal mass, attached to the left testicle at the level of the epididymis. The mass was painless to palpation and mobile with the testicle. No inguinal hernia or inguinal lymph nodes were detected during the physical exam. Both testicles were of normal size and position. Cremasteric reflex was present bilaterally. No signs of inflammation, edema, erythema, or infection were observed. Blood and urine exams were within normal ranges, including hemoglobin, Hb, hematocrit, Hct, white blood cells, WBC, C-reactive protein, CRP, negative red blood cells, RBC, and white blood cells, WBC, in urine and negative urine culture. Tumor markers (alpha fetoprotein, AFP,
The decision was made to treat the subclinical, ultrasound-evident epididymitis with a course of fluoroquinolones (ciprofloxacin). Two weeks later, physical exam showed similar findings to the one done two weeks ago, and testicular ultrasound showed a 3 cm testicular swelling, with similar Doppler findings.
This atypical presentation of a painless scrotal mass in a young male adult, with negative tumor markers and ultrasound suggestive of epididymitis in the absence of any inflammatory signs or symptoms, with no signs of improvement with a course of antibiotics, as well as the risk of malignant lesion, put a remarkable amount of stress on the patient and the treating team, resulting in a decision to go for surgical testicular exploration via an inguinal incision due to the risk of testicular malignancy. Metastatic workup was composed of fluorine-18-fluorodeoxyglucose positron emission tomography 18F-FDG PET-CT, showing a hypermetabolic lesion of the left testicle, with iliac and para-aortic lymphadenopathy.
During surgery, the left testicle was delivered via an inguinal incision. Dissection of the mass off the testicle was tried, but due to the adherent nature of the mass to the testicle itself, increasing the risk of malignancy, the final decision was made to undergo a total left radical orchiectomy. Patient was discharged the following day.
Pathology report showed a normal testicle (6.5 × 4 × 3.7 cm), spermatic cord, and an epididymis containing an indurated whitish lesion, measuring 3.5 × 2 × 1.6 cm. No histological anomalies of the testicle were noted. A significant inflammatory remnant of the epididymis was reported, with microabscess in vestigial remnants (Figures
Testicular parenchyma in the bottom, epididymis in the upper right, and inflammatory vestigial remnants in upper left.
Microabscess in vestigial remnants.
A cystic structure with no obvious continuity with the epididymis was also noted, bordered by a pseudostratified epithelium without tumoral cellular atypia, consistent with organ of Giraldes, with no sign of malignancy.
18F-FDG PET-CT was repeated 2 months after surgery and showed complete remission of the previously hypermetabolic picture that was reported in the previous imaging.
In a study by Sahni et al. [
There are no studies indicating risk of malignancy of these appendages, nor there were, to the best of our knowledge, any case reports of a painless scrotal mass, which was surgically explored, turning out to be an appendage.
Torsion of the appendages, mainly in adolescents, remains to be a risk to consider. Van Glabeke et al. described 543 cases of acute scrotum pain in boys aged between 1 and 16 years, resulting in surgical exploration [
Summary of studies describing testicular and epididymal appendages.
Study | Incidence of appendages | Incidence after surgical exploration (acute scrotum) |
---|---|---|
Sahni et al., 1996 [ |
20% | |
|
||
Favorito et al., 2004 [ |
14.5% in cryptorchidism |
|
|
||
Van Glabeke et al., 1999 [ |
46% torsion of appendages | |
|
||
Puri and Boyd, 1976 [ |
22 cases | |
|
||
Khairi et al., 2007 [ |
20.5% torsion of appendages | |
|
||
Çavuşoglu et al., 2005 [ |
32.3% torsion of appendages |
While the usage of 18F-FDG PET-CT is controversial in testicular cancer diagnosis according to the guidelines of the European Association of Urology, there are many studies in the literature favoring its usage. A meta-analysis done by Zhao et al. [
Even though surgical excision is theoretically not mandatory in case of testicular and epididymal appendages, due to the benign nature of these structures, with no signs of torsion, the burden of a solid scrotal mass in young males associated with the risk of testicular malignancy, even in the absence of elevated tumor markers or suspicious features of ultrasound, challenges both patient and urologist and drives management towards surgical exploration and excision.
In our opinion, the classic approach to scrotal masses in young male population, including physical exam, scrotal ultrasound, and tumor markers (AFP,
The authors confirm that they have given due consideration to the protection of intellectual property associated with this work and that there are no impediments to publication, including the timing of publication, with respect to intellectual property. In doing so the authors confirm that they have followed the regulations of their institutions concerning intellectual property.
The authors wish to confirm that there is no known conflict of interests associated with this work and there has been no significant financial support for this work that could have influenced its outcome.
The authors confirm that the paper has been read and approved by all named authors and that there are no other persons who satisfied the criteria for authorship but are not listed. The authors further confirm that the order of authors listed in the paper has been approved by all of them.