Case Report Acute Idiopathic Scrotal Edema MILMED-D-13-00103

MILITARY MEDICINE, 178, 7:e890, 2013
A Case Report of Acute Idiopathic Scrotal Edema

CPT Michael M. Braun, MC USA*; MAJ Aaron J. Cronin, SP USA; LTC David G. Bell, MC USA
ABSTRACT Acute Idiopathic Scrotal Edema (AISE) is an uncommon cause of bilateral scrotal swelling encountered
in primary care. AISE is usually seen in children; however, several case reports have shown that AISE can occur in adult
males. We present an active duty adult male who presented with AISE while deployed in Afghanistan. The clinical
course of AISE is usually benign with labs and ultrasound being unremarkable. Besides swelling, the most common
symptom tends to be intense scrotal puritis. Treatment for AISE is watchful waiting and conservative therapy. Full
symptom resolution usually occurs within 24 hours.
INTRODUCTION
Acute Idiopathic Scrotal Edema (AISE) is an uncommon
cause of bilateral scrotal swelling found mainly in schoolaged boys. The disease process was first described by Qvist in
1956.1 An extensive literature search found only 10 other case
reports describing this rare disease in adult males over the past
25 years. Herein, we present another rare case of AISE in an
adult male while on deployment in western Afghanistan. The
purpose of this article is to bring awareness of this rare condition in adult males and provide treatment recommendations.
PRESENTATION
A 20-year-old, active duty Marine male presented to his aid
station while deployed in Afghanistan for acute onset of painless bilateral scrotal swelling. The patient awoke to intense
scrotal/penile pruritis when he discovered the scrotal swelling.
He recalls lifting heavy objects the day prior, but denied
any trauma, burns, or chemical substance spills. He routinely
shaved his scrotum and performed this act several days prior.
Review of systems revealed no fevers, chills, recent illnesses, nausea or vomiting, constipation, or diarrhea. He also
denied dysuria, penile discharge, painful erections, testicular
pain, rash, hematuria, back pain, and anal or perineal pain. He
denied abdominal and chest pain, as well as shortness of breath.
His past medical history included no chronic illnesses,
surgeries, history of sexually transmitted diseases, or drug
allergies. The patient was prescribed doxycycline 100 mg
daily for malaria prophylaxis which was initiated 3 months
prior, at the beginning of his deployment. His social history
did not include new sexual partners and he denied masturbatory activity. The patient had a history of tobacco use, smoking
half a pack of cigarettes daily. He denied any recent alcohol
consumption and exposure to irritants such as new detergents.
His family history was negative for testicular cancer.
*Madigan Army Medical Center, 9040 Fitzsimmons Drive, Joint Base

Lewis McChord, Tacoma, WA 98431.
Womack Army Medical Center, 2817 Reilly Road, Fort Bragg, NC 28307.
San Antonio Military Medical Center, 3623 George C. Beach Road,
Fort Sam Houston, TX 78235.
doi: 10.7205/MILMED-D-13-00103
e890
EXAMINATION
Physical examination was remarkable for bilateral scrotal
swelling with extension of edema to both inguinal canals and
the penile shaft (Figs. 1 and 2). The scrotum was erythematous
without signs of cellulitis or infection. Scrotal transillumination did not reveal any abnormal masses, but there was slight
discomfort with palpation. Palpation of the testes and epididymis was normal bilaterally without pain. No blue dot sign
was noted along the scrotum. Inguinal nodes were negative
for lymphadenopathy and canals were negative for hernias.
The patient had an intact cremasteric reflex bilaterally. Penile
examination revealed edema encompassing 90% to 95% of
the penile shaft. There was no urethral discharge. The perineal
and anal examinations were unremarkable. The vascular exam
revealed no dependent, distal edema. No rashes or skin lesions
were discovered. Vital signs were within normal limits.
STUDIES
Laboratory examination (BMP, CBC, UA, and LFTs) did not
reveal any abnormalities. (Of note, a urine culture was not
obtained on deployment because of the austere location.)
Scrotal ultrasound, performed by a Role II radiologist using
a Sonosite Titan with 10-5 MHz linear probe, showed diffuse
marked scrotal skin edema with normal testes (to include
Doppler blood flow). Ultrasound was negative for hydrocele,
hernia, hyperemia of the testicles, epididymitis, testicular
masses, and abscesses.
DISCUSSION
The differential diagnosis of scrotal edema or the acute scrotum consists of benign, as well as more concerning conditions. In general, the following conditions must be ruled
out through various radiological, laboratory, and physical
examination findings: testicular torsion, epididymitis, torsion
of the testicular appendages, hydrocele/varicocele, incarcerated hernia, malignancy, trauma, anasarca, and scrotal infection. A review of 40 acute patients hospitalized for acute
scrotum showed that the most common etiology of acute
scrotal edema was epididymitis (60%). This was followed
by testicular torsion, torsion of the appendages, and AISE in
27.5%, 10%, and 2.5%, respectively.2
MILITARY MEDICINE, Vol. 178, July 2013
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Case Report
FIGURE 1. Patient with marked swelling and erythema of the wrinklefree scrotum and penile shaft.
FIGURE 2.
AISE is an uncommon cause of scrotal swelling found

primarily in children; however, it can occasionally been seen
in adults. A retrospective study reviewed 38 patient cases
involving 44 episodes of AISE in children admitted to a
pediatric surgical ward and found an average affected age of
6.2 years.3 Another study evaluated 12 boys in an emergency
department and found an average affected age of 7.5 years.4
In adults, AISE is very rare and has only been documented
in a handful of case studies.
The etiology of AISE is not well understood. Several
reports believe that the condition is caused by an allergic
reaction rather than an infectious or traumatic etiology.5,6
These reports cite that routine lab tests (CBC, UA, CMP, urine
culture, etc.) are generally negative or normal. Lending credence to an allergic etiology is the sometimes raised eosinophil count seen in some studies. One study in particular showed
an elevated eosinophil count in 67% of the patients evaluated.3
Patients typically present with acute swelling and erythema that is often bilateral in nature, but occasionally can
be unilateral. In one case series, 12 patients were noted to
have AISE with only one patient presenting with unilateral
swelling. Another case series showed one out of six patients
with AISE had unilateral swelling.4,6 Patients are usually
pain free with the most common complaint being scrotal
pruritis. Sasso et al6 showed four out of six patients complained of intense scrotal pruritis without pain. Physical
examination usually reveals scrotal swelling with occasional

extension to the penile shaft and inguinal canals. The testes,
inguinal lymph nodes, and epididymis are normal in size
and free of pain with palpation.
Numerous radiological case studies have been performed
on patients with AISE. One study utilizing ultrasound in an
emergency department showed edematous scrotal wall thickening, easy compressibility, and enlargement/hypervascularity
of the ipsilateral lymph nodes in all patients.4 This study also
showed increased blood flow to the scrotal wall in over 90%
of the patients without testicular involvement. The edema
was confined only to the skin and Dartos Fascia while all
deeper structures remained unchanged. Other studies confirm
that scrotal wall thickening and hypervascularity seem to be
the most common ultrasound findings.7,8 One study evaluated
10 patients with AISE and found that the hypervascularity
resembled a fountain, coining the term fountain sign.7
A few case studies have documented this rare condition in
adults, but no randomized control studies have focused on its
treatment. Watchful waiting and reassurance seem to be the
best course of action in a patient who has had other disease
processes ruled out. In general, most symptoms resolve
within 24 to 48 hours after the onset of swelling with conservative therapy. Steroids, antihistamines, and antibiotics have
not proven effective in other studies.5,9 Furthermore, surgical
intervention is not warranted and should be avoided.
Lateral view of marked swelling of the scrotum and penile shaft.

e891
Case Report
SUMMARY
Our patient was a 20-year-old male who presented with
acute bilateral scrotal swelling. Numerous lab and radiological studies were negative for common causes of scrotal
edema. The patient was presumptively diagnosed with AISE
and placed on limited duty. Within 24 hours, the patients
scrotal swelling and pruritis had resolved. He returned to
full duty with the U.S. Marine Corps in support of Operation
New Dawn in Herat, Afghanistan.
AISE should be on the differential diagnosis in all male
soldiers with unexplained scrotal swelling after more serious
causes have been ruled out. Ultrasound proved to be the
decisive tool in the diagnosis of this patient. If available, and
utilized by a skilled operator at aid station level, ultrasound
could potentially decrease the need for unnecessary evacuations while maintaining operational strength on the ground.
As ultrasound devices become smaller and less expensive,
the military should consider ultrasound training for all
deploying physicians and mid-level providers.
e892
REFERENCES
1. Qvist O: Swelling of the scrotum in infants and children, and non-specific
epididymitis; a study of 158 cases. Acta Chir Scand 1956; 110: 41721.
2. Abul F, Al-Sayer H, Arun N: The acute scrotum: a review of 40 cases.
Med Princ Pract 2005; 14: 17781.
3. Klin B, Lotan G, Efrati Y, Zlotkevich L, Strauss S: Acute idiopathic
scrotal edema in childrenrevisited. J Pediatr Surg 2002; 37(8): 12002.
4. Lee A, Park SJ, Lee HK, Hong HS, Lee BH, Kim DH: Acute idiopathic
scrotal edema: ultrasonography findings at an emergency unit. Eur Radiol
2009; 19: 207580.
5. Ooi DG, Chua MT, Tan LG: A case of adult acute idiopathic scrotal
edema. Nat Rev Urol 2009; 6: 331 4.
6. Sasso F, Nucci G, Palmiotto F, Giustacchini M, Alcini E: Acute idiopathic scrotal oedema: rare disorder or difficult diagnosis? Inter Urol
Nephrol 1990; 22(5): 4758.
7. Geiger J, Epelman M, Darge K: The fountain sign: a novel color Doppler
sonographic finding for the diagnosis of acute idiopathic scrotal edema.
J Ultrasound Med 2010; 29: 12337.
8. Thomas AC, Cain MP, Casale AJ, Rink RC: Ultrasound findings of acute
idiopathic scrotal edema. ScientificWorldJournal. 2004; 4(Suppl 1): 910.
9. Brandes SB, Chelsky MJ, Hanno PM: Adult acute idiopathic scrotal
edema. Urology 1994; 44(4): 6025.


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MILITARY MEDICINE, 178, 7:e890, 2013

A Case Report of Acute Idiopathic Scrotal Edema

*Madigan Army Medical Center, 9040 Fitzsimmons Drive, Joint Base

AISE is an uncommon cause of scrotal swelling found

examination usually reveals scrotal swelling with occasional

Lateral view of marked swelling of the scrotum and penile shaft.

MILITARY MEDICINE, Vol. 178, July 2013

MILITARY MEDICINE, Vol. 178, July 2013

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