What are scrotal pearls and how are they treated in middle-aged to elderly men?

Scrotal Pearls (Scrotoliths)

Definition and Clinical Significance

Scrotal pearls, also known as scrotoliths or scrotal calculi, are benign calcified fibrous bodies that form within the tunica vaginalis of the scrotum and are typically discovered incidentally during imaging or surgery. 1, 2

Pathophysiology and Formation

• These calcified loose bodies develop through several proposed mechanisms, including chronic inflammation from trauma, torsion and subsequent detachment of the appendix testis or epididymis, or sequelae to hematomas within the scrotum 1, 3
• Histologically, scrotoliths exhibit concentric collagen lamellae in their central portion that enclose calcified tissue debris, without evidence of vascular structures or parasitic larvae 1
• The prevalence is approximately 2.65% among patients undergoing scrotal ultrasound, with detection across a wide age range from 4 months to 65 years (mean age 28.3 years) 3

Clinical Presentation

• Scrotal pearls are typically asymptomatic and discovered incidentally during imaging for other scrotal conditions 1, 2
• When symptomatic, patients may present with painless scrotal swelling, often associated with hydrocele 2
• The calculi appear as free-floating, mobile bodies within the hydrocele sac, often described as "pearly white" on surgical exploration 2

Diagnostic Approach

• High-resolution ultrasonography is the diagnostic modality of choice, revealing free-floating echogenic lesions within the tunica vaginalis that may be isoechoic to surrounding tissue 1, 2
• Scrotal calculi can be solitary (48% of cases) or multiple (52% of cases), with mean size of 4.22 mm (range 2-10 mm) 3
• Associated findings on ultrasound may include hydrocele (13%), epididymal cysts (13%), varicocele (13%), or epididymitis (8.6%), though the majority of patients have no other abnormalities 3
• The key diagnostic challenge is distinguishing scrotal pearls from testicular tumors, though their location within the tunica vaginalis (not within testicular parenchyma) and mobility help differentiate them 1, 2

Management in Middle-Aged to Elderly Men

• Asymptomatic scrotal pearls require no treatment and can be managed with observation alone 3
• Surgical intervention is indicated only when patients are symptomatic (pain or significant swelling) or when associated with a large hydrocele requiring treatment 2
• The surgical approach involves hydrocelectomy with removal of the calculi, excision or eversion of the tunica vaginalis, and plication to prevent recurrence 2
• Prognosis after surgical removal is excellent with no significant complications reported 2

Important Clinical Pearls

• Scrotal pearls are entirely benign and have no malignant potential, distinguishing them from intratesticular calcifications which may warrant closer surveillance 1, 3
• No information is currently available about long-term complications from chronic irritation due to scrotal calculi, though they are generally considered harmless 3
• Athletes and individuals with repetitive scrotal trauma may be at higher risk, though further studies are needed to clarify prevalence in these populations 2
• Screening for calcium or phosphate metabolism disorders is not indicated, as these are typically negative 4