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Background
Median raphe cysts are a rare congenital condition and, although eminently amenable to surgical excision, can cause concern to the patient as well as to the attending physician due to their clinical presentation and differential diagnoses. First described by Mermet 1 , the condition has occasionally appeared in journals and paediatric reference texts but not in adult urology textbooks despite its potential extension into the scrotal area.
Case presentation
A 35-year-old man presented with a 12-month history of a non-visible, albeit palpable midline painless swelling from the bottom of his scrotum and extending down into the perineum ( figure 1 ). He had a normal voiding pattern and normal erections.
On examination, the penis and testicles were normal on palpation and there was no palpable inguinal lymphadenopathy. The patient had a mobile midline soft swelling that extended along the midline perineum and into the scrotal raphe.
Investigations
Ultrasonography demonstrated an isoechoic scrotal soft tissue mass with no internal vascularity on Doppler. A 3 T MRI (with gadolinium) of the pelvis was performed preoperatively to characterise the lesion ( figure 2 ). A 6.4 cmx2.5 cm long soft tissue lesion was identified in the midline from the scrotum into the perineum. It had a very low signal on T2-weighted imaging with no appreciable enhancement with contrast. It had a well-defined surrounding capsule and was discrete to the testicle although it abutted the tunica vaginalis.
Differential diagnosis
Owing to the rarity of the condition, other more common diagnoses were considered first. These included: Cowper gland cyst, steatocystoma, glomus tumour, dermoid cyst, urethral diverticulum, pilonidal disease, perianal polyp, haemorrhoids, sarcoma and other neoplastic conditions.
Treatment
The lesion was excised completely with a sheath of connective tissue around it through a midline incision...