A 33-year-old male with acute gallstone pancreatitis complicated by pancreatic fluid collection formation developed intense right-sided scrotal pain and swelling one week into his hospitalization. Computed tomography revealed inflammatory stranding near the pancreatic head with adjacent compression onto the stomach and duodenum (Left), and new, marked edema of the right inguinal canal and hemiscrotum with inflammatory peripancreatic fluid visibly tracking down into the pelvis (Center and Right) (Figure 1). Immediate scrotal exploration by the urology service yielded several hundred milliliters of cloudy, lipase-rich fluid from the right hydrocele sac, confirming the inguinoscrotal inflammatory fluid to be of pancreatic origin. The right testicle appeared viable and preserved without signs of infection or necrosis, and local percutaneous drainage was achieved intra-operatively via placement of two small caliber drains into the right scrotum to ensure complete resolution. The drains were removed seven days after insertion when output ceased. The patient eventually required endoscopic transluminal drainage of the evolving pancreatic head fluid collection for persistent anorexia and abdominal pain.
Clinically significant inguinoscrotal swelling from a pancreatic hydrocele is a rare complication of severe acute pancreatitis [1]. The mechanism is felt to occur by tracking of pancreatic fluid through weak fascial planes in the retroperitoneum along the psoas muscle and into the scrotum via the inguinal canal [2]. Once in the scrotum, inflammatory pancreatic ascites can readily accumulate and organize to form a pseudocyst - like collection that can cause infection and testicular necrosis [3]. Scrotal involvement in acute pancreatitis can also be confused with testicular torsion and other potential medical emergencies including epididymitis and incarcerated ventral/inguinal hernia, so it is generally recommended that patients be imaged quickly to determine if prompt surgical exploration is necessary [4]. Conservative management without surgery may be possible if there is no sign of testicular compromise [5].
Figure 1: (a) Computed tomography views demonstrating inflammatory stranding near the pancreatic head with adjacent compression onto the stomach and duodenum (left), and marked edema of the right inguinal canal and hemiscrotum with inflammatory peripancreatic fluid visibly tracking down into the pelvis (arrows at center and right).