Anoscrotal Median Raphe Sinus in a Child

INTRODUCTION

A sinus is an epithelium lined blind channel. It may occur anywhere, and can be a congenital or acquired condition. In the scrotum, it may be due to infection.[12] Congenital scrotal sinus like anoscrotal median raphe sinus is rare being an extremely rare entity, it is being presented with a brief review of the relevant literature.

CASE REPORT

A 4-year-old male child was referred with a complaint of intermittent discharge from the scrotum for last two years. The discharge disappeared on taking some medication, only to recur after variable time. He had no previous history of perianal infection or bladder or bowel complaints.

On examination, there was a small opening just left to the median raphe with pus discharge. The patient was put on antibiotic course for 1 week, to which he responded. Thereafter a sinogram was performed that revealed a sinus tract. After anesthetic fitness, the patient was operated upon under general anesthesia. The sinus opening was mobilized by an elliptical incision. When the tract was dissected, it reached deep into the scrotum without any internal connections. After ligating the base the tract was excised in toto [Figure 1].

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Figure 1

Left side showing an elliptical incision made around the sinus opening. A non-absorbable suture is passed in it. Right side showing the mobilised sinus just before ligation

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Postoperative period was uneventful, and the patient was discharged in satisfactory condition.

DISCUSSION

The exact etiolgy of this condition is not clear. It is believed to be a congenital condition, which arises from epithelial cells trapped after the incomplete closure of the urethral or genital folds.[3] The first description is believed to be given by Mermet.[4] However, his description was about cyst and not a sinus. However, having the same etiology, both can be taken together.

The presenting symptoms include recurring scrotal infections, perineal discharge and intermittent pain.[5] The diagnosis can be made on clinico-radiological basis. The treatment of this condition is surgical. Some have advocated laying open the tract with curettage and saucerization of the margins,[5] but complete excision of the tract, which we also performed, has been adopted by most surgeons.[346]

The clinical differential diagnosis can be hidradenitis suppurativa, tubercular or pyogenic epididymo-orchitis, or scrotal abscess.[27] Even incarcerated inguinal hernia may present as a scrotal sinus.[1] If not diagnosed and treated accordingly, it may lead to disseminated disease or septicemia. It may also persist as a smouldering infection. Treatment as per the diagnosis may cure the patient.

Till date, this condition has not been reported in such a young patient. Other reports have been described in adults.[3456] This condition, if not properly evaluated, may lead to suspicion of other conditions like anal fistulae or hydradenitis. It may be confused with infective lesions of the scrotum. Since it appears to be an infective condition of the skin, the patient may be referred to various clinicians, including dermatologists for treatment.

To conclude, congenital anoscrotal median raphe sinus is an extremely rare condition, which is curable. Proper evaluation and treatment gives excellent results.