Isolated Epididymal Tuberculosis Presenting as a Chronic Hydrocele: A Rare Manifestation of Genitourinary TB

Isolated epididymal tuberculosis presenting as chronic hydrocele is exceptionally rare and poses significant diagnostic challenges. We report a healthy 35-year-old male who presented with 6-month progressive unilateral scrotal swelling clinically diagnosed as chronic hydrocele. During hydrocelectomy, intraoperative findings revealed approximately 150 mL of clear fluid with dense adhesions between testis and tunica vaginalis—an atypical finding that prompted epididymal biopsy. Histopathology demonstrated non-necrotizing granulomatous inflammation with epithelioid cells and multinucleated giant cells, suggestive of tuberculosis. Subsequent pulmonary evaluation confirmed active tuberculosis with positive sputum acid-fast bacilli (2+ on Ziehl-Neelsen stain), Mycobacterium tuberculosis detection by GeneXpert MTB/RIF, bilateral apical nodules with tree-in-bud opacities on chest CT, and 18 mm tuberculin skin test induration. The patient completed nine months of standard anti-tuberculosis therapy comprising intensive phase (rifampicin, isoniazid, pyrazinamide, ethambutol for two months) followed by continuation phase (rifampicin and isoniazid for seven months) with complete clinical and radiological resolution. This case highlights three critical diagnostic challenges: atypical presentation as isolated hydrocele without classic tuberculous features, non-necrotizing rather than typical caseating granulomas, and absence of systemic symptoms in an otherwise healthy patient. In tuberculosis-endemic regions, maintaining high clinical suspicion for tuberculosis even in routine scrotal pathology is essential. Epididymal tuberculosis should be considered in differential diagnosis of chronic hydrocele, particularly in endemic areas, and routine histopathological examination of all surgical specimens with multidisciplinary collaboration remains crucial for timely diagnosis and appropriate management.