Multiple Scrotal Swellings: Idiopathic Scrotal Calcinosis—A Case Series

Abstract

Idiopathic scrotal calcinosis is a rare, benign condition of uncertain etiology that typically begins in adolescence or early adulthood. Although often asymptomatic, patients usually seek medical attention for cosmetic concerns and may also report pruritus, soreness, or discharge of a white, chalky material from the nodules, occasionally accompanied by secondary infection. This condition occurs in the absence of calcium or phosphate metabolism abnormalities. We present a case series of patients with idiopathic scrotal calcinosis who underwent surgical excision of the involved scrotal skin or enucleation of individual cysts. In Case 1, resection of scrotal skin containing multiple nodules was followed by primary closure. Case 2, a 24-year-old male, underwent wide excision of scrotal skin with primary repair. In a 19-year old male (Case 3, a sleeve of scrotal skin containing a dominant nodule(s) was excised, while Case 4, an 18-year-old male, underwent enucleation of individual nodules. All patients showed good surgical & cosmetic outcomes during follow-up, with no postoperative complications and a high level of satisfaction with the results. Here we discuss the clinical features, pathogenesis and surgical management of this rare condition.

Introduction

Idiopathic scrotal calcinosis (ISC) is a rare, benign condition characterized by multiple intradermal nodules on the scrotum. It is not associated with any underlying metabolic or systemic disease.^1-3 It typically appears as white type nodules on the scrotal skin. Most patients present for cosmetic reasons, although some may report pruritus, erythema, or whitish discharge due to secondary infection. ⁴ The condition most commonly affects men aged 20 to 40 years. ⁵ The disorder often presents with single or multiple nodules on the scrotal skin which are painless. Differential diagnoses include sebaceous cysts, calcified steatocystoma, fibroma, atheroma, and xanthoma. The pathogenesis of ISC remains controversial. This case series presents 4 patients with ISC, with their clinical presentation, underlying pathophysiology, and current surgical management, with the aim of highlighting diverse surgical approaches and their postoperative outcomes.

Case Summary

Case 1

A 27-year-old male presented with multiple scrotal swellings that had gradually increased in size and number over 3 years, causing discomfort and interference with sexual activity. There were no other associated local or systemic complaints. He had no comorbidities and there was no contributory past or family history. Examination revealed multiple firm, non-tender, white-to-yellow nodules across the scrotum, the largest measuring approximately 2.5 cm. (Figure 1a) Testes and penis were normal. Laboratory investigations, including serum calcium, phosphate, vitamin D, and parathyroid hormone levels were within normal limits, ruling out secondary causes of calcium deposition. These investigations were performed to rule out systemic or metabolic causes of calcinosis, including parathyroid dysfunction, renal disease, and disorders affecting calcium or phosphate metabolism. Surgical excision of the affected scrotal skin (measuring 5 × 2.5 cm) with primary closure was performed (Figure 1b). Histopathological examination (HPE) revealed dystrophic calcium deposition within the dermis, characterized by basophilic amorphous material surrounded by a granulomatous inflammatory reaction, confirming the diagnosis of idiopathic scrotal calcinosis. The postoperative course was uneventful, discharged on day 2 and the patient remained asymptomatic during a 2-year follow-up period.

Figure 1.

Multiple scrotal cysts of Case 1. (a) Clinical picture. (b): A sleeve of involved scrotal skin was excised with primary closure of the defect.

Case 2

A 24-year male presented with complaint of multiple painless scrotal nodules. The lesions had been increasing in number and size over the past 5 years, occasionally discharging whitish material. The patient had no other significant history. Examination revealed multiple nodules similar to those in case 1, ranging from 0.5 to 3 cm in size (Figure 2). His laboratory parameters were within normal limits. During surgery, wide excision of the involved scrotal skin was performed which was followed by primary closure of the defect. The procedure yielded good result, and patient was discharged on day 3. The patient was doing well till 9 months, thereafter lost follow-up.

Figure 2.

Pre-operative image of multiple scrotal cysts of Case 2 where a sleeve of involved scrotal skin was performed followed by primary closure of the defect.

Case 3

A 19-year-old male presented with a few small, yellowish, painless scrotal nodules, the largest measuring 1 × 1 cm, from the last 3.5 years (Figure 3a). Laboratory parameters were normal. Diagnosis of scrotal calcinosis was made and the option of surgical excision was offered to the patient. Excision of a sleeve of scrotal skin containing the dominant nodule and smaller nodules was performed (Figure 3b). The patient had an uneventful postoperative course and was satisfied with the outcome.

Figure 3.

Surgical excision of Scrotal Calcinosis in Case 3. (a) Intra-operative view showing the excision of the involved scrotal skin. (b) Appearance after primary closure of the surgical defect.

Case 4

An 18-year-old male reported multiple scrotal nodules since childhood, which had gradually increased in number over a period. It caused significant distress to the patient because of poor cosmetic appearance, leading him to seek treatment. Patient was adequately counseled about his condition. Examination revealed multiple firm nodules in both hemi-scrotums, the largest measuring 2 × 2 cm (Figure 4a). His complete blood counts, renal profile, calcium, phosphate levels were within normal range. Enucleation of individual nodules followed by primary closure was performed under local anesthesia (Figure 4b). Histopathology confirmed scrotal calcinosis (Figures 5 and 6). Patient was discharged on day 3 and is doing good up to 8 months of follow up.

Figure 4.

(a) Preoperative photo of Case 4; (b) Excision of individual calcinosis lesions under local anesthesia.

Figure 5.

Photomicrograph shows tissue lined by squamous epithelium with sub epithelial zone showing basophilic amorphous deposits of calcium (H & E).

Figure 6.

Photomicrograph showing basophilic calcium deposits for case 4 (H & E, X100).

Discussion

Idiopathic scrotal calcinosis (ISC) is a rare benign condition characterized by the development of multiple nodules over the scrotal skin. It was first described by Lewinski in 1883 and later detailed by Shapiro et al. in 1970. ¹ The condition predominantly affects young men in their second and third decades of life, with a higher prevalence reported among individuals with darker skin tones. ² Contrary to earlier beliefs, patients typically have no abnormalities in calcium or phosphate metabolism. ³

Several studies have suggested that epidermal inclusion cysts undergoing dystrophic calcification may evolve into scrotal calcinosis.^{4, 5} Numerous theories regarding the etiology have been proposed, questioning whether ISC is truly idiopathic or represents dystrophic calcification of pre-existing epidermal inclusion cysts.^3,6 Another hypothesis proposes that these lesions arise de novo, without any underlying metabolic or triggering condition.^1,7 In some reports, no foreign-body reaction or history of trauma was identified. Earlier studies suggested that these lesions may originate from calcified steatocystomas, fibromas, atheromas, or xanthomas. ⁸ However, the most widely accepted pathogenesis is dystrophic calcification of pre-existing epidermal cysts, leading to scrotal calcinosis.^4,5

More recent studies have suggested that dartos muscle necrosis and degeneration may be the initiating pathological event, resulting in dystrophic calcification of the dartos muscle, in a manner analogous to calcification seen in uterine leiomyomas.^7,9 Parlaktaş and colleagues further suggested that minor trauma may play an important role as an initial triggering factor for dystrophic calcification. ¹⁰ Although the precise cause of ISC remains unknown, degenerative changes of the dartos muscle and dystrophic calcification of long-standing sebaceous or epidermoid cysts remain among the most accepted hypotheses.^3,11

Our findings, with all patients being young adults and demonstrating normal calcium metabolism, are consistent with the aforementioned theories. In addition, the different surgical methods employed in our series (wide excision and enucleation) reflect the range of treatment approaches described in the literature. Histologically, the presence of calcium deposits surrounded by a granulomatous reaction is a characteristic feature. Shapiro et al. found no evidence of epithelial lining, residual cysts, or microorganisms. Based on these findings, they concluded that the calcification was idiopathic in nature, leading to the term “idiopathic scrotal calcinosis,” which may present as a few isolated painless scrotal nodules or as extensive involvement of the entire scrotum. ¹

Clinically, ISC presents as gradually enlarging brownish intradermal nodules, often multiple, on the scrotal skin. These nodules tend to increase in both size and number over time and may exude a chalky white material.^6,9 Most cases are asymptomatic, although some patients report pruritus. Secondary infection has been reported in long-standing cases. Diagnosis is primarily clinical, with histopathological confirmation. ¹²

Surgical excision remains the treatment of choice and generally yields excellent results.^13,14,15 Due to the laxity of scrotal skin, good coverage and cosmetic outcomes can be achieved even after multiple elliptical excisions. Cosmetic concern is the main reason patients seek medical attention. A novel “pinch-punch” excision technique has been described for smaller lesions, involving pinching the scrotal skin and excising nodules using a disposable biopsy punch. ¹⁶

During surgical removal, the dartos layer is preserved and excision is limited to the dermis, as lesions are confined to this layer. The primary goal is complete excision of all nodules while preserving sufficient scrotal skin to allow primary closure or scrotoplasty using native scrotal tissue. Although multistaged excision has been described, it is time-consuming and costly.^15,18 Complete excision of all lesions, including smaller nodules, is essential to prevent recurrence and achieve optimal cosmetic results. Larger lesions may require wide excision and primary closure, whereas extensive involvement of the scrotum may necessitate subtotal scrotectomy with skin grafting.^13,17,18 The gold-standard surgical approach remains elliptical excision above the dartos fascia followed by primary closure.^12,15

This manuscript offers a comprehensive overview of pathophysiology and surgical management. Treatment involves excision of the affected scrotal skin, with primary closure often feasible due to the inherent laxity of the scrotal tissue. The approach should be individualized based on the location, number, and size of cysts. Management may range from simple enucleation of isolated cysts to excision of a sleeve of involved skin with primary closure. In cases with extensive involvement, complete excision of the affected scrotal tissue followed by scrotoplasty and skin reconstruction using local flaps may be necessary.

Conclusion

Idiopathic scrotal calcinosis is a rare benign condition, believed to arise either idiopathically or secondary to dystrophic calcification of sebaceous cysts. Most patients show no underlying metabolic abnormalities. The diagnosis is primarily clinical and confirmed histologically. Management should be individualized according to the number, size, and location of the lesions. Treatment options range from simple enucleation of isolated cysts to excision of the involved skin with primary closure, while extensive disease may require wide excision followed by scrotal reconstruction using local flaps. Even as a benign disorder, its recurrence after excision is not unheard of.