What is a scrotal pearl in adult males?

What is a Scrotal Pearl?

A scrotal pearl (also called a scrotolith or scrotal calculus) is a benign, freely mobile calcified body that forms within the tunica vaginalis of the scrotum, typically discovered incidentally during ultrasound examination or surgery. 1, 2

Pathophysiology and Formation

Scrotal pearls develop through several proposed mechanisms:

• Chronic inflammation from minor trauma, with the central portion exhibiting concentric collagen lamellae that enclose calcified tissue debris 1
• Torsion and subsequent detachment of the appendix testis or epididymis, leading to infarction and calcification 1, 2
• Sequelae to hematomas or inflammatory changes within the scrotum 2
• Repetitive mechanical stress, particularly noted in athletes who experience chronic scrotal trauma 3

Histologically, these lesions show concentric collagen lamellae surrounding calcified tissue debris, without evidence of vascular structures or parasitic larvae 1

Clinical Characteristics

Scrotal pearls are typically asymptomatic and discovered incidentally:

• Prevalence of approximately 2.65% in ultrasound examinations 2
• Size range from 2-10 mm (mean 4.22 mm) 2
• Can be solitary or multiple, with approximately 48% presenting as solitary lesions and 52% as multiple 2
• Age distribution spans from 4 months to 65 years (mean age 28.3 years) 2

Associated Conditions

While generally benign, scrotal pearls may coexist with other scrotal pathology:

• Hydrocele in 13% of cases 2, 3
• Epididymal cysts in 13% of cases 2
• Varicocele in 13% of cases 2
• Epididymitis in 8.6% of cases 2
• Testicular microlithiasis in 4% of cases 2

Diagnostic Approach

High-resolution ultrasonography is the diagnostic modality of choice:

• Appears as freely mobile, echogenic foci with posterior acoustic shadowing within the tunica vaginalis 2
• Free-floating lesions that move with position changes 3
• May appear isoechoic to surrounding tissue in some cases 3
• Important to distinguish from intratesticular pathology, as extratesticular masses are predominantly benign 4

Critical Clinical Pitfall

The key diagnostic challenge is distinguishing scrotal pearls from testicular tumors:

• Scrotal pearls are extratesticular (within the tunica vaginalis) and freely mobile 1, 2
• Intratesticular masses require different management due to higher malignancy risk 4
• Ultrasound is nearly 98-100% accurate for delineating intratesticular versus extratesticular processes 5

Management

Scrotal pearls require no specific treatment when asymptomatic:

• Observation is appropriate for incidentally discovered, asymptomatic scrotal pearls 2
• Surgical removal is indicated only if symptomatic or when discovered during surgery for other conditions (e.g., hydrocelectomy) 3
• Prognosis is excellent, as these are benign lesions with no malignant potential 2, 3

Special Consideration

In pediatric patients, scrotal pearls on the median raphe may indicate anorectal malformation:

• Meconium pearls on the scrotal raphe can be a sign of anorectal malformation (ARM) 6
• However, median raphe cysts can present similarly without ARM, requiring careful clinical evaluation 6