Case of the Month: September 2012

Submitted by Blake Kightlinger, MD, and Thomas J. Learch, MD .

Patient JR is a 55-year-old white male who presents with hematospermia for 10 months. He was initially diagnosed with prostatitis and treated with ciprofloxacin without alleviation of symptoms. He denies recent STD, UTI, or hematuria. PMH includes hypogonadism and right testicular atrophy. PSH includes two bilateral inguinal hernia repairs. JR reports taking Androgel and Propecia medications daily. He drinks alcohol socially and denies tobacco and illicit drug use.

Vitals signs are stable and physical exam reveals a bulge in the left inguinal canal and small right testicle.

Labs show an INR = 1.1, WBC = 7, Hemoglobin = 18, and Platelet Count = 273. Urinalysis is negative for RBC, WBC, and proteins.

An MRI of the prostate was performed and revealed a heterogeneous, enhancing, elongated mass traversing from the left seminal vesicle to the left inguinal canal.

CT was also performed to evaluate further extent of disease but found no new additional findings.

Figure 1a.Transvere T2-Weighted MRI image of the pelvis reveals a heterogeneous mass bulging into the left inguinal canal.

For full-size image, please click MRI Pelvis 1 .

Figure 1b. Transverse T2-Weighted MRI image slightly cranial to image 1a, shows the elongated mass directly to the left of the urinary bladder and traversing to the region of the left seminal vesicle.

For a full-sized image, please click MRI Pelvis 2 .

Figure 2. Transverse CT image confirms findings on the MRI study with a mass originating from the left seminal vesicle region bulging into the left inguinal canal.

For full-size image, please click MRI pelvis 3 .

Question 1.Based on the history and physical along with the imaging findings, what is the most likely etiology of the mass?

A. Spermatic cord hematoma
B. Polyorchidism
C. Sarcoma
D. Persistent Mullerian Duct Syndrome
E. Lipomatous infiltration of spermatic cord
F. Inflammation secondary to epididymitis

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