Angioembolization as the treatment for a misdiagnosed scrotal arteriovenous malformation: A case report and literature review

Abstract

Scrotal Arteriovenous malformation (AVM) is a rare congenital vascular anomaly which presents with swelling, heaviness, pain and bleeding in inguinal and scrotal area and in some cases it may result in azoospermia and infertility. Therefore, this can be misdiagnosed with other usual pathologies of scrotum such as hernia and varicocele. In this study, we present a case of a scrotal AVM which was misdiagnosed as varicocele followed by unnecessary varicocelectomy, after which diagnostic angiography was performed and showed presence of AVM. Accordingly, successful angioembolization was performed for the patient. At the 6-month follow-up, all the symptoms had relieved.

Highlights

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Rare scrotal AVM misdiagnosed and treated as varicocele initially.
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AVM diagnosis confirmed by angiography showing multiple feeder vessels.
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Angioembolization successfully resolved symptoms and scrotal swelling.
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Embolization materials carefully chosen to prevent glue reflux.

1 Introduction

Scrotal swelling is a common medical condition. This can present as a primary or secondary tumor or due to infectious etiology or vascular malformations. Among the vascular etiologies, varicocele is the most common event while arteriovenous malformation (AVM) is the least common one. AVM can occur as a congenital anomaly while it can also be resulted from post-surgical complication. It stems from an excessive number of arteriovenous connections, bypassing capillary beds, with vascular morphological changes that gradually increase in size as the child grows (see Table 1 ).

Table 1

Summary of case reports on scrotal arteriovenous malformations.

Author (Year)	Age (Years)	Presentation	Diagnostics	Final Diagnosis	Management	Follow-up	Outcome
Bezirdjian et al. (1989)	24	Enlarging, painless right scrotal mass with bluish discoloration and palpable thrill	Testicular ultrasound, Doppler scan, retrograde venogram, pelvic arteriogram	AVM of scrotal wall	Embolization with Ivalon particles	Immediate	Skin necrosis post-embolization resolved with debridement
Guz et al. (1989)	23	Asymptomatic left scrotal mass	Physical exam, routine lab tests, urinalysis, surgical exploration	AVM of spermatic cord	Left scrotal exploration and excisional biopsy	Not mentioned	No complications reported
Hamid et al. (1992)	55	Progressive right scrotal swelling with extreme pain and bleeding	Physical exam, Doppler, CT, arteriography	AVM of the scrotum	Embolization attempt; surgical excision of hemiscrotum	No specific long-term follow-up	Symptomatic relief
Sule et al. (1993)	17	Scrotal mass with bleeding	Physical exam, arteriography	Scrotal AVM	Angio-embolization, wide excision	2 years	No recurrence
Konus et al. (1999)	8	Progressive scrotal enlargement with bleeding	Physical exam, Doppler ultrasound, arteriography	Scrotal AVM	Embolization and surgical excision	1 year	No recurrence with mild post-procedural pain
Bandi et al. (2004)	67	Recurrent scrotal ulcer with intermittent bleeding, scrotal wall thickening	Physical exam (bruit/thrill), Doppler, arteriography	Recurrent scrotal AVM	Embolization and surgical excision	12 years; recurrence after 12 years	Disease-free initially; recurrence managed with excision
Kang et al. (2004)	20	Scrotal mass post-bicycle collision	Ultrasound, Doppler	Intrascrotal-extratesticular AVM	Surgical excision	Not specified	No complications
Agrawal et al. (2006)	25	4-month pain and swelling over the right testicle, initially diagnosed as lipoma	Ultrasound, Doppler, MRI, angiography	Scrotal AVM	Initial excision; ileo-femoral bypass for recurrence	Long-term	Symptom relief, improved erectile function
Monoski et al. (2006)	31	Virtual azoospermia with left scrotal swelling	Physical exam, scrotal ultrasound, arteriography	Left hemiscrotal AVM	Microsurgical varicocelectomies, embolization, surgical excision	Ongoing	Improved semen parameters; successful pregnancies
Sountoulides et al. (2007)	22	Recurrent acute scrotal pain mimicking testicular torsion due to spermatic cord AVM	Clinical examination, grey scale scrotal ultrasound, CDU, diagnostic scrotal exploration	Scrotal AVM	Diagnostic exploration; orchiectomy for intractable pain	2 years	Symptom-free with no recurrence
Ruiz-Casado et al. (2007)	69	Scrotal vascular lesion and extreme pain during chemoradiation	Physical exam, echography	Superficial thrombophlebitis of scrotal AVM	NSAIDs, LMWH, wide excision	Not specified	Moderate pain relief
Hatten et al. (2012)	34	Spontaneous bleeding from scrotum after trauma history	Physical exam, CT angiography	Post-traumatic scrotal AVM	Observation, ethanol and coil embolizations	6 months (lost to follow-up)	Recurrent bleeding, resolved spontaneously
Zachariah et al. (2012)	30	Progressive scrotal swelling with pain, failed prior surgical attempt	Duplex ultrasound, MRI	Scrotal AVM	Surgical excision without angioembolization	4 months	No recurrence
Key et al. (2013)	41	Scrotal swelling, ecchymosis, and pain after trauma	Scrotal ultrasound, angiography	Right-sided scrotal AVM	Microcoiling, Embospheres, Gelfoam, Onyx embolization	18 weeks	No bleeding or complications
So et al. (2014)	26	Scrotal pain and swelling	Ultrasound, aortogram, arteriograms	Scrotal AVM	Coil embolization and sclerotherapy	3 months	No recurrence
Jafarpishefard et al. (2016)	15	Scrotal trauma with incidental AVM discovery	Grey-scale and color Doppler ultrasound	Intratesticular AVM	No intervention due to asymptomatic nature	1 year	Asymptomatic with no progression
Mohammad et al. (2020)	19	Painless scrotal swelling, more advanced on the left side	Duplex ultrasound, CTA, DSA	Scrotal AVM	Angioembolization sessions and surgical resection	12 months	No recurrence over 12-month follow-up
Singh et al. (2020)	8	Scrotal and penile swelling with bleeding	Physical exam, Doppler ultrasound, CTA	Ulcerated bleeding scrotal AVM	Oral propranolol	11 months (lost to follow-up)	Swelling reduction, ulcer healing, no recurrence
Thakur et al. (2023)	35	Enlarging scrotal swelling with infertility	Scrotal Doppler, CT angiography	Bilateral scrotal AVMs	Planned embolization declined	Not applicable	Lost to follow-up
Alashaikh et al. (2023)	37	Testicular swelling, pain, warmth	Physical exam, CT	Recurrent scrotal AVM	Embolization, partial excision	2 months	Symptom-free with no recurrence
Edris et al. (2024)	24	Progressive scrotal swelling since childhood	Physical exam, Duplex ultrasound, multi-slice CT	Scrotal AVM	Surgical resection without angioembolization	1 year	Improved sperm count and no recurrence