Scrotal calcinosis is a rare and benign pathology fall under the large group of idiopathic skin calcinosis [1]. It was first described in 1983 by Lewinsky [2]. It is characterized by the presence of multiple calcified nodules on the scrotal skin. It most commonly occurs with patients presenting no calcium and phosphorus metabolic disorders. The treatment requires surgical removal of scrotal nodules. We hereby report a case of massive scrotal calcinosis with a 57-years old patient.

Mr. D. C. aged 57 years old was admitted to intense care unit for complete urine retention. The oral questioning revealed an initial flare of small multiple pruritic scrotal swellings which gradually increased in sizes. When pressurized, they spurt out a whitish fluid crystallizing in few seconds. Physical examination carried out after urinary drainage revealed the presence of multiple whitish scrotal nodules of about 1 cm in diameter, hard, painless and movable in relation with muscle fascia (Figure 1).

Figure 1: Scrotal nodules.

Serum Calcium and phosphorus levels were normal: serum calcium=99 mg/L, serum phosphorus=36 mg/L and alkaline phosphatase=101 IU/L. Scrotal conventional x-ray showed the presence of numerous calcium opacities at the scrotal region (Figure 2).

Figure 2: Opacity of the scrotal region from pelvis conventional xray.

Scrotal ultrasound scan revealed regular testicles and no intra vaginal effusion. Following transurethral resection of the prostate, the patient later underwent, surgical excision of the nodules with scrotal plasty. Under spinal anesthesia, an elliptical incision in the scrotum was performed. It was centered on the median raphe while wiping out all nodular lesions. A dissection of the scrotal skin which is the seat of nodules was performed using diathermy knife (Figure 3).

Figure 3: Resected specimen.

The closure of the scrotum is carried out using an overedge stitches of 2/0 vicryl with no scrotal drainage. Histopathological examination of the surgical specimen revealed under scrotal acanthotis the presence of intradermal calcium dystrophic lesions of varying sizes lined with epithelial and connective tissues (Figure 4).

Figure 4: Intradermal calcification.

Post-op was ordinary with healing within seven days, the patient was aesthetically satisfied and there was no relapse a year later.

Scrotal calcinosis is relatively young adults pathology with an age of onset between 30 and 50 years in journals [3,4]. This is a rare disease and uncommon in Africa [4] and little known by medical practitioners. Most often, it is discovered during a consultation for aesthetic discomfort, fear of scrotal cancer, or other reasons [5]. In our case, the complete urine retention was conducted upon consultation. The timeline for consultation or discovery is often long because of the benign nature of the disease [4,5]. Symptoms are often poor as reported by Paquet [6]. Scrotal calcinosis etiopathology is unknown. More often, there is no calcium and phosphorus metabolic disorder as in our case. Several theories have been developed about the origin of scrotal calcinosis, but the most likely is described by Swine heart [7] who highlights calcification of epidermoid cysts. This theory was confirmed by others authors [8,9]. In our case, the blast of nodules spurting out a dull whitish fluid which crystallizes and the presence of epithelial tissue surrounding the calcifications confirmed this theory. In the case of our patient, we performed an excision of scrotal nodules wiping out all damaged skin without exceeding the dartos muscle. This technique allowed saving time and rapid healing with no relapse. Several techniques were described in the different studies including resection of all lesions in bloc with an elliptical excision centered on the median raphe inspired from scrotal lifting techniques described by Noel [10]. However, some authors recommend removing the nodules one after the other. This requires more time, exposes the patient to high risk of relapse [11] and unpleasant scars in case of multiple nodules. Most authors who carried out in bloc excision experienced no relapse [10,12].

Scrotal calcinosis is a rare and benign condition, whose most probable etiology is calcification of scrotal epidermoid cysts. Its treatment only meant for aesthetic purpose must be exclusively carried out by surgical excision limited to the skin, in bloc nodules.