The Scrotoschisis about a Case in the Pediatric Surgery Department of the Donka National Hospital

Introduction: Scrotoschisis is a very rare congenital defect of the scrotum characterized by the exteriorization of one or two testes. We report a case of right scrotoschisis in a newborn as well as a review of the literature for an approach of probable etiology. Patient and Observation: A newborn baby of 8 hours of life, weighing 3200 g was referred to our department for a right scrotal defect with exteriorization of the testis associated with fluid swelling of the left bursa. The 18-year-old mother, primiparous and primigeste followed all the prenatal consultations with eutocic delivery. After clinical investigation the diagnosis of right scrotosisis and left hydrocele was retained. Surgical treatment was carried out by primary closure after orchidopexy and exploration of the contralateral bursa, the content of which was calcified meconium bathed in a yellowish liquid. The post-operative consequences were simple. Conclusion: Scrotoschisis is an extremely rare birth defect whose etiology is poorly understood. However, it could be the cause of meconium peritonitis secondary to a scarred fatal intestinal perforation.


Introduction
Scrotoschisis is a congenital anomaly of the scrotum associated with the exteriorization of one or both testes. This very rare anomaly was first described by Von der Leyen in 1963 [1]. Only 10 cases were reported in the literature until 2016 [2]. All available information comes from clinical cases [3]. The exact me-  [1]. Several theories have been put forward to explain its occurrence, the most accepted nowadays is meconium peri orchitis. Late rupture of the scrotal skin secondary to an inflammatory reaction is caused by exposure to meconium through a permeable peritoneovaginal duct [4]. We report here a rare case of unilateral scrotoschisis in a newborn baby as well as a review of the literature on the probable etiology of this malformation.

Patient and Observation
A newborn, 8 hours old, weighing 3200 g was referred and admitted to our department for a right scrotal defect leading to exteriorization of the testicle. The anomaly was noticed by the midwife who delivered it to us immediately. The 18-year-old mother, primiparae and primigeste, followed all the antenatal consultations and the pregnancy had proceeded normally to term with a eutocic delivery. There was no blood relationship between the two parents.
The examination found a newborn baby awake, toned, feverish to the touch with a temperature of 39.6˚C, an oxygen saturation of 95%, a heart rate of 152 beats per minute, a respiratory rate of 36 cycles per minute, a good staining of the legs and conjunctiva.
The external genitalia were in place and male in appearance; exploration showed a defect in the upper part of the anteromedial aspect of the right he-scrotum.
The spermatic cord, epididymis and testis thickened and covered with fibrin deposits had eviscerated through this defect measuring 4 × 2 cm on its vertical and transverse axis, involving the scrotal structures. Over a distance of 2 cm surrounding the defect, the scrotal wall consisted of a thin membrane instead of skin. The testis was well vascularized and of normal size, shape and appearance.
The left bursa was swollen with fluid content (Figure 1). The examination extended to the other devices did not note any particularity.   Heyns ischemia, and iatrogenic scrotal laceration during cesarean section [5].
The meconium peri orchitis at the origin of Scrotoschisis suggested by Kajori and DeMaria is the most accepted theory today. The late rupture of the scrotal skin is thought to be secondary to an inflammatory reaction caused by the meconium released during intestinal perforation during fetal life. The passage of this meconium from the perforated intestine to the scrotum takes place through the peritoneo-vaginal canal [6]. VS is a rare entity associated with cured meconium peritonitis [7]. A case with an association between jejunal atresia and scrotoschisis has been reported, and the absence of intestinal abnormalities in most newborns can be explained by fetal scarring of the original intestinal lesion without sequelae, a recognized phenomenon [3]. Schaffer et al. [8] also opened the septum and explored the hydrocele and found lumps of meconium bathing in the liquid. The lumps corresponding to calcification of the meconium found in the vaginal area of the left bursa, the appearance of the exteriorized testicle, its normal size and consistency in our case could corroborate this hypothesis. The defect is always high on the anterior wall of the scrotum, close to the median raphe [9]. Wet, warm compresses should be applied to the testicles while awaiting surgery to prevent dehydration of the organ. The surgeon should avoid twisting the exteriorized testicle, as it is not attached to any anatomical structure except the cord.

Conclusion
Scrtoschisis, also called testicular exstrophy or extracorporeal ectopia, is a very rare congenital anomaly. The etiology is not well known, but it could be related to spontaneous fetal intestinal perforations healed with meconium peritonitis.
The result of the surgical treatment is good with normal growth of the testicles but the long-term follow-up data is not yet available.