|Year : 2014 | Volume
| Issue : 1 | Page : 20-21
Multiple scrotal epidermal cysts: A rare case report
Department of Pathology, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India
|Date of Web Publication||21-Jul-2014|
12 A, Type V Quarters, IAS Colony, Kasumpti, Shimla, Himachal Pradesh
Source of Support: None, Conflict of Interest: None
Multiple epidermal cysts over the scrotum is a rare condition and requires excision if infected or cosmetically unacceptable. Grossly enlarged or infected cysts require total excision of the scrotal wall followed by the coverage of bare testes. We are reporting a case of multiple epidermal cysts on the scrotum. Total excision of scrotal wall followed by the fascio cutaneous flap coverage was done in this case.
Keywords: Epidermal cysts, multiple, scrotum
|How to cite this article:|
Mardi K. Multiple scrotal epidermal cysts: A rare case report. J Clin Sci 2014;11:20-1
| Introduction|| |
Multiple epidermal cysts over the scrotum is a rare condition,  with only one case reported in the literature so far. We report an additional case of multiple epidermal cysts over scrotum of 27-year-old male who approached the surgeon for cosmetic purpose. We discuss the possible histogenesis, complications, and treatment of multiple epidermal cysts of scrotum.
| Case report|| |
A 27-year-old male came with the chief complaints of small multiple painless swellings all over the scrotum since last one and half years. On examination, multiple swellings were found arising from the scrotal skin, the largest measuring 1 cm. The swellings were pearly white in color and were firm in the consistency. Scrotal wall could be moved easily over the testicles and there was no collection in the tunica vaginal sac clinically. Ultrasonography of the local part revealed testes of normal consistency without free fluid in the tunica vaginal sac.
The patient was taken for surgery and scrotal wall containing cysts was excised [Figure 1]. Blood supply of the scrotal wall was compromised but active bleeding was present on the cut margins after total excision of the scrotal wall. Superficial pudendal artery (branch of Femoral Artery)-based pedicle flaps of quadrangular shape were raised from both the thighs and rotated over the bare testes and tied in the midline. The triangular areas left behind after the rotation of the flap on medial side of both the thighs was covered by the split thickness skin graft harvested from lower part of the right thigh. Corrugated drains were kept under both the flaps. Drains were removed after 48 hours and the patient was discharged after 8 days. Patient recovered well with a fine scar over the wound without any complications. On histological examination of excised scrotal skin, variably sized cysts lined by keratinized [Figure 2] squamous epithelium with laminated keratin materials in the lumen were observed. Some of the cysts were surrounded by foreign body giant cells. Thus, the histological features were diagnostic of epidermal cysts of the scrotum.
|Figure 2: Photomicrograph revealing two of the many epidermal cysts filled with keratin (H and E, ×10)|
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| Discussion|| |
Epidermal cysts are the most common benign epithelial cysts. They are well encapsulated cysts and histologically characterized by a cystic lining of stratified squamous epithelial cells and no cutaneous adnexal structures in the stromal tissue.  Extratesticular, scrotal epidermoid cysts are relatively rare in contrast to intratesticular ones, which are the most common benign testicular neoplasm comprising 1% of all testicular masses. 
The histogenesis of the epidermoid cyst is not precisely known, but there are different theories about the embryonic origin of this lesion: (i) They arise from ectopic cutaneous tissue due to dislocation of tissue into a neighboring area; (ii) they are end results of monolayer teratoma from germ cells; (iii) they occur due to traumatic implantation of epidermal tissue into the dermis and subcutis.  However, in the case of the extratesticular scrotal epidermoid cyst, they are believed to be an abnormal closure or associated degenerative process of the median raphe and urethral groove. ,
Scrotal ultrasonography is usually the first and the most important imaging modality to investigate scrotal and inguinal pathologic conditions, and it can reliably differentiate extratesticular from intratesticular ones, as well as cystic from solid ones, with very high accuracy. The sonographic appearance of an epidermal cyst varies from an anechoic lesion to a hyperechoic, solid appearing mass, depending on its content. Although there are no specific pathognomonic findings to diagnose the epidermoid cysts accurately, they have most often appeared with well-demarcated hypoechoic masses with multiple scattered reflectors from the keratinous debris and posterior sound enhancement without internal vascular signals on the color flow Doppler sonography. 
Multiple epidermal cysts over the scrotum are a rare condition and men use to ignore the lesions, as the condition is painless. But the cyst being in proximity with potentially infective area may catch infection from genitourinary tract. Cyst becomes painful if becomes infected and may burst to discharge pus. Single infected cyst can be drained without complications. Untreated, it may spread in surrounding cysts and finally scrotal wall. Once the scrotal skin is infected, the infected portion has to be widely excised to avoid necrotizing fascitis of the scrotum (Fournier's gangrene) and septicemia.
Cannistra et al.,  used the technique of pedicle inguinal flap for the reconstruction of the scrotum in cases of Fournier gangrene and allow cover of the scrotal region with relatively thick, sensitive tissue with limited scarring and functional sequel. We used fascio cutaneous flap from anterior aspect of both the thighs and sutured them in the midline over the bare testes. The triangular raw areas developed due to elevation and rotation of the flap should not be closed under tension as this not only compromises the viability of the flap but also hampers the ballooning effect of the neo-scrotum by stretching and flattening it. The reconstruction as described above is technically demanding but the thick fasciocutaneous flap is protective for testes from trauma as well as balloon-like appearance of neo-scrotum is cosmetically acceptable. Kochakarn et al.,  published a series of 12 cases that proposed implantation of the exposed testes in the upper thigh pouch and delayed reconstruction of the scrotum using thigh pedicle flaps with excellent results. Monteiro et al.,  describes about the technique of covering testes in Fournier's gangrene with inner thigh flap. Infection is the most common complication followed by the flap necrosis. Flap necrosis can be avoided by designing broad-based flaps.
In conclusion, multiple epidermal cysts over the scrotum is a rare condition, but should be promptly treated if infected to avoid fatal sequels such as Fournier's gangrene.
| References|| |
|1.||Lee SJ, Lee JH, Jeon SH, Kim MJ. Multiple epidermoid cysts arising from the extratesticular scrotal, spermatic cord and perineal area. Korean J Urol 2010;51:505-7. |
|2.||Langer JE, Ramchandani P, Siegelman ES, Banner MP. Epidermoid cysts of the testicle: Sonographic and MR imaging features. AJR Am J Roentgenol 1999;173:1295-9. |
|3.||Cho JH, Chang JC, Park BH, Lee JG, Son CH. Sonographic and MR imaging findings of testicular epidermoid cysts. AJR Am J Roentgenol 2002;178:743-8. |
|4.||Tanaka T, Yasumoto R, Kawano M. Epidermoid cyst arising from the spermatic cord area. Int J Urol 2000;7:277-9. |
|5.||Katergiannakis V, Lagoudianakis EE, Markogiannakis H, Manouras A. Huge epidermoid cyst of the spermatic cord in an adult patient. Int J Urol 2006;13:95-7. |
|6.||Picanço-Neto JM, Lipay MA, D'Avila CL, Verona CB, Zerati-Filho M. Intrascrotal epidermoid cyst with extension to the rectum wall: A case report. J Pediatr Surg 1997;32:766-7. |
|7.||Koenigsberg RA, Kelsey D, Friedman AC. Case report: Ultrasound and MRI findings in a scrotal epidermoid cyst. Clin Radiol 1995;50:576-8. |
[Figure 1], [Figure 2]