Unilateral undescended testicle with ipsilateral fixed-matted inguinal mass : A case report

We described a rare occurrence of unilateral undescended testis with an ipsilateral fixed matted inguinal mass in a 15 month old male with normal tumor markers. Doppler ultrasound showed calcified masses with no obvious color blood flow. We discussed considerations in the management of the case and reiterated the importance of basic thorough medical history taking and physical examination as a vital step to prevent unnecessary surgical procedures as well as arriving at a correct diagnosis.


Introduction
Undescended testis is one of the most common male pediatric disorders identified at birth [1].On the other hand, managing an inguinal mass should have several considerations to make, both benign and malignant lesions may come into the picture with significantly different management.
Algorithms and differential diagnosis for pediatric inguinal mass include inguinal hernia, lymphadenopathies and various benign and malignant conditions [2].To our knowledge, we report the first case of matted calcified mass in an ipsilateral undescended testis with normal tumor markers.We described the findings and management of our case and discussed considerations.

Case Report
A 15 month old male, born term to a 35year-old gravid 4 para 4 mother.He was

Discussion
Approximately 70% of undescended testes are palpable [1].For testes that are not palpable, approximately 30% will be found in the inguinal-scrotal area, 55% will be intra-abdominal, and 15% will be absent or vanishing [1].Spontaneous descent of undescended testes may occur in the first six months of life [1].However in patients with persistence of undescended testis after six months, location varies such as in the abdomen, the inguinal canal, the superficial inguinal pouch, the upper scrotum, or, may rarely be in an ectopic location (perineum, contralateral scrotum, or femoral) [1].
For an undescended testis, the ultrasound is non-contributory and is not recommended for routine use; however in the diagnostic approach for inguinal mass in children such as in our case, ultrasound with Doppler is the optimum diagnostic study [2].
Ultrasound can readily differentiate the features of hernias, hydroceles and undescended or ectopic testis, atypical masses of testis and reproductive organs [2]. In

DiscussionFig. 1 .
Fig. 1.Right inguinal mass on the arrow with inguinal hernia as noted in physical examination

Fig. 2 .
Fig. 2. Ultrasound Doppler of right inguinal mass showing Multiple nodular densities with calcifications in the right inguinal region most likely represent calcified inguinal nodes largest 1.2 x 0.7 x 1.0 cm.

Fig. 3 .
Fig. 3. BCG Vaccine scar right gluteus maximus At this point, the impression was BCG adenitis at right inguinal area with concomitant ipsilateral abdominal undescended testis versus a nubbin.Inguinal exploration was done on the right and noted an infracanalicular testis [Fig.4], orchidopexy done with herniotomy; inguinal lymph nodes were dissected [Fig.5] and sent for histopathology, which consequently confirmed the diagnosis of BCG adenitis [Fig.6,7].

However, testicular tumors may be considered .
The dilemma of our case was settled by thorough history taking and physical examination done in our institution, where a post BCG vaccine scar was noted on the ipsilateral gluteus maximus area and ultrasound findings suggestive of calcified lymph node with normal serum tumor markers.All of which were supportive of ruling out the presence of testicular malignancy.Development of pathological reactions at theInguinal hernia Inguinal lymphadenopathies/ granuloma inguinale Femoral hernia Appendicitis within the hernia sac/ Amyand hernia Benign/ malignant tumor* Hydrocoele of the spermatic cord Retractile testicles Undescended or ectopic testicle Traumatically dislocated testicle site of inoculation and in the regional nodes after BCG injection is expected [3].The finding of isolated enlarged axillary (rarely supraclavicular or cervical) lymph nodes ipsilateral to the site of BCG vaccination, with no other identifiable cause for adenitis, is usually sufficient for making the diagnosis [3].In our case, since the injection site is gluteus maximus, then ipsilateral inguinal lymph node was the site of lymphatic drainage.The original BCG vaccine is a liveattenuated form of Mycobacterium bovis.A series of 638 BCG-related lymphadenitis in infants was reported due to the change in the vaccine strain from Tokyo-172 to Pasteur-1173.The incidence of lymphadenitis was then declined after the Tokyo strain was reintroduced and awareness of this condition was commenced [4].Bacille Calmette-Guérin (BCG) lymphadenitis is the most common complication of BCG vaccination [3].There are two forms of this condition.Simple or non-suppurative lymphadenitis, which usually regresses spontaneously over a period of few weeks, and suppurative form, distinguished by the formation of swelling, with erythema and edema of overlying skin which frequently forms spontaneous perforation and sinus formation, followed by closure of the sinus by cicatrization [3].Non-suppurative BCG lymphadenitis is best managed with expectant follow ups only, because medical treatment with erythromycin or antituberculous drugs do not hasten the regression or prevent development of suppuration [3,4].Surgical excision is rarely needed and is meant for cases of failed needle aspiration or for draining BCG nodes.In our case, the surgical excision of the inguinal mass was done to only confirm diagnosis of BCG adenitis and rule out possible malignancy.A separate incision was made over the inguinal mass in order to avoid extention of BCG infection to the inguinal incision made for the orchidopexy.This is a rare occurrence of both undescended testis with an ipsilateral calcified inguinal lymph nodes which turned out to be a BCG adenitis.The importance of this report is to carefully take time to do history and physical examination in order not to miss a diagnosis of importance.Neglect of an important detail in the physical exam and history may lead to erroneous treatment.

Table 1 .
Differential diagnosis of inguinal swelling in children.
*Benign lesions of the inguinal canal can include, but are not limited to: lipomas, hematomas, mesothelial cyst, dermoid cysts.Soft tissue sarcomas comprise the most common malignant tumors of the groin.