Pediatric scrotal lymphatic malformation: a 15-case series and a proposed diagnostic and management algorithm

To investigate the clinical characteristics, risks of misdiagnosis, and diagnostic and management strategies for pediatric scrotal lymphatic malformation.

A retrospective analysis was conducted on clinical data (demographics, symptoms, diagnostic work-up, and treatment) of 15 pediatric cases with scrotal lymphatic malformation treated at our institution between 2012 and 2025. Additionally, a targeted literature review of previously reported cases with diagnostic challenges was performed.

All lesions showed a characteristic extratesticular distribution outside the tunica vaginalis. The overall accuracy rates of preoperative color Doppler ultrasound and clinical diagnosis were only 46.7% (7/15) and 40.0% (6/15), respectively. Furthermore, 26.7% (4/15) of cases had an indeterminate preoperative diagnosis, and 33.3% (5/15) were completely misdiagnosed. Surgical excision was performed in all patients, achieving complete resection in 10 cases and incomplete resection in 5 cases. Over a follow-up period ranging from 3 months to 6 years (mean, 22 months), 3 cases developed ipsilateral scrotal or inguinal recurrence, and 1 case presented with a gluteal lymphatic malformation one year postoperatively. A literature review identified an additional 12 reported cases with incorrect or indeterminate preoperative diagnoses. Indeterminate diagnosis was the largest category (41.7%), and among the definite misdiagnoses, hydrocele was the most common (25%), which closely mirrored the pattern observed in our series.

Pediatric scrotal lymphatic malformation is a rare entity that is highly prone to misdiagnosis and recurrence. Based on our 15-case series and reported cases, we propose a diagnostic and management algorithm integrating clinical evaluation, stepwise imaging, surgical excision, and selective sclerotherapy to improve diagnostic accuracy and optimize surgical outcomes.