Overview
Background
Scrotal abscess (see image below) is an abscess that can be either superficial or intrascrotal. The etiology of superficial scrotal abscess is infected hair follicles and infections of scrotal lacerations or minor scrotal surgeries. An intrascrotal abscess most commonly arises from bacterial epididymitis, but may also be related to tuberculous infection of the epididymis, a testicular abscess that ruptures through the tunica albuginea, or drainage of appendicitis into scrotum through a patent processus vaginalis. [1] Scrotal abscesses can also occur as a result of extravasation of infected urine from the urethra in patients with a urethral stricture and neurogenic bladder using an external collection device.
Fournier gangrene (necrotizing fasciitis) is a gangrenous process that involves the external genitalia. It often arises from an infection involving the urinary tract or from direct extension from a perirectal source. See image below.
Photomicrograph of Fournier gangrene (necrotizing fasciitis), oil immersion at 1000X magnification. Note the acute inflammatory cells in the necrotic tissue. Bacteria are located in the haziness of their cytoplasm. Courtesy of Billie Fife, MD, and Thomas A. Santora, MD.
Individuals presenting with a scrotal abscess may have symptoms related to the etiology of the abscess such as symptoms of a urinary tract infection or sexually transmitted disease, such as frequency, urgency, dysuria, penile discharge. The diagnosis of a scrotal abscess is often made by history and physical examination. The scrotum is often erythematous and edematous. Scrotal fluctuance may be palpable. Tenderness of the affected epididymis and/or testis may be present. If epididymitis is the source of the abscess, the scrotal wall may be fixed to the underlying epididymis. Scrotal ultrasound is helpful in diagnosing an intrascrotal abscess when an inflammatory mass is present. Scrotal ultrasound can localize the involvement of the abscess to the scrotal wall, epididymis, and/or testis. [2]
Indications
The management of an intrascrotal abscess, regardless of the cause, requires surgical drainage (see image below). The abscess cavities must be opened and drained, including the testis if it is involved. The cavity should be left open and packed. Fournier gangrene (necrotizing fasciitis) requires prompt resuscitation and surgical exploration and debridement as well as aggressive antibiotics. Superficial abscesses also require incision and drainage but may be treated in the emergency room/at the bedside depending on the size of the abscess.
The patient depicted in this image is a man with alcoholism and known cirrhosis who presented with exquisite pain limited to the scrotum. The scrotum has been opened along the median raphe, which liberated foul-smelling brown purulence and exposed necrotic tissue throughout the mid scrotum. The testicles were not involved. Courtesy of Thomas A. Santora, MD.
Contraindications
No contraindications to the drainage of an intrascrotal abscess exist, outside of the patient being too ill to withstand surgery. Patients with Fournier gangrene (necrotizing fasciitis) require aggressive resuscitation and institution of broad-spectrum antibiotics at the time of identification and prompt surgical intervention.
Preparation
Anesthesia
The incision and drainage of a superficial scrotal abscess can often be performed by infiltrating the area with an anesthetic and intravenous narcotic use. The surgical treatment of an intrascrotal abscess often requires general or spinal anesthesia. Patients with suspected Fournier gangrene (necrotizing fasciitis) are often explored under general anesthesia given the severity of the illness and the potential extent of the disease. These patients require aggressive resuscitation and institution of broad-spectrum antibiotics that cover both aerobic and anaerobic organisms.
Equipment
The instrumentation needed for the treatment of an intrascrotal abscess is that commonly used for any surgical exploration. The wound cavity should be left open and packed. In those individuals in whom Fournier gangrene (necrotizing fasciitis) is suspect, a more extensive set-up is needed due to the potential for widespread involvement of the disease. A cystoscope should be available to rule out urethral pathology as the source of the infection as well as instrumentation for sigmoidoscopy/anoscopy to rule out a anorectal source of the disease.
Positioning
In most cases, the patient positioning is in a supine position with the scrotum shaved and the genitalia prepped and draped. If Fournier gangrene (necrotizing fasciitis) is suspected, then a lithotomy position is more useful because it allows access to the lower abdominal wall, the genitalia, and the perianal region.
Complication prevention
Broad-spectrum antibiotics to cover skin and genitourinary flora are used, however, the treatment of an abscess remains primarily surgical. Incision, debridement, and packing are all key components of the treatment of an intrascrotal abscess, and failure to adequately treat may lead to the need for further debridement and drainage. Fournier gangrene (necrotizing fasciitis) is a surgical emergency and requires prompt hemodynamic resuscitation, broad spectrum antibiotics, and aggressive surgical intervention. It is not uncommon for the affected individual to require one or more “take backs” to the operating room for further debridement as the infection evolves. Even in the modern surgical era, the mortality rate for Fournier gangrene (necrotizing fasciitis) remains high, approaching 50%. [3]
Injury to intrascrotal contents may occur with exploration. In addition, severe epididymitis may lead to necrosis of the epididymis and loss of function and extension to the testis may lead to a testicular abscess and necrosis.
Technique
Overview
The scrotum is a continuation of the abdominal wall. The layers include the scrotal skin, the dartos layer (a continuation of Colles fascia), the external spermatic fascia (a continuation of the external oblique aponeurosis), the cremasteric muscle and fascia (a continuation of the internal oblique muscle), the internal spermatic fascia (a continuation of the transversalis fascia), and the tunica vaginalis. The scrotal contents consist of the testis, epididymis, and the spermatic cord structures. Thus, the location of the abscess, superficial versus intrascrotal, dictates the extent of the exploration. See images below.
Cross-section illustration of a testicle and epididymis. A: Caput or head of the epididymis. B: Corpus or body of the epididymis. C: Cauda or tail of the epididymis. D: Vas deferens. E: Testicle. Illustration by David Schumick, BS, CMI. Reprinted with the permission of the Cleveland Clinic Center for Medical Art and Photography © 2009. All Rights Reserved.
Superficial scrotal abscesses, those confined to the scrotal wall, can often be treated by infiltrating the skin around the abscess and then incising over the abscess with a knife until the cavity is opened and drained. The cavity is then packed to keep it open and drained.
The incision and drainage of an intrascrotal abscess is typically performed under general anesthesia. The skin, overlying the area of fluctuance/mass, is incised with a knife. The subcutaneous tissue (fascial planes) are dissected with electrocautery until the tunica vaginal is encountered. The tunica vaginalis is lifted from the underlying testis and epididymis and incised. Devitalized tissue, including the epididymis and/or testis, is debrided. The scrotal wound is left open and packed to prevent reoccurrence of the abscess.
Post-Procedure
After the initial surgical exploration, the scrotal wound packing is changed on a regular basis to prevent accumulation of purulent material and to debride devitalized tissue. Keeping the wound open allows it to granulate from the base, preventing a closed space from forming that may become secondarily infected.
Postoperative antibiotic therapy should be tailored to urine culture and wound culture sensitivities and should be continued until the infection is resolved.
Complications
Incomplete drainage or debridement of devitalized tissue may lead to persistence/extension of the abscess. Failure to identify the source of the infection, such as an underlying urethral stricture, may lead to recurrence.
Fournier gangrene (necrotizing fasciitis) may lead to significant tissue loss requiring subsequent skin grafting for scrotal, abdominal and perineal skin loss. Individuals may require placement of a suprapubic tube for urinary diversion as well as a diverting colostomy.
Despite aggressive resuscitation, broad-spectrum antibiotics, and aggressive surgical intervention, the mortality rate with Fournier gangrene remains high.
A study reported that temporarily relocating the testes in anteromedial thigh pouches facilitates scrotal wound closure in Fournier gangrene with extensive loss of scrotal skin and obviates the need for specialized reconstructive surgery. [4]
Long-term monitoring
Patients should be followed until full healing has occurred.
Devices, Tests, and Medications
Device Summary
No devices are associated with this surgery.
Diagnostic testing summary
Scrotal ultrasound (see images below) is a useful adjunct to the history and physical examination in the assessment of a scrotal abscess. [5] It allows for localization of the scrotal abscess as well as an evaluation of the vascularity of the epididymis and testis, which may be involved.
Color Doppler sonogram of the left epididymis in a patient with acute epididymitis. The image demonstrates increased blood flow in the epididymis resulting from the active inflammation.
Scrotal sonogram showing the testes adjacent to the inflamed epididymis with a reactive hydrocele.
Medication summary
The initial antibiotic therapy for a scrotal abscess is broad-spectrum until the urine and wound culture results and sensitivities are available. Patients with Fournier gangrene are treated with antibiotic regimens that cover both aerobic and anaerobic organisms.
In the setting of an epididymitis-associated scrotal abscess, the responsible organism often varies with the age and sexual activity of the male. In sexually active men, the predominant organisms are Chlamydia trachomatis and neisseria gonorrhea, with chlamydia being more common. In homosexual men younger than 35 year of age, coliform bacteria are more common. In older males who are typically less sexually active, urinary tract pathogens are the most common organisms, with Escherichia coli and pseudomonas being more common; however, sexually transmitted pathogens should also be considered.
Less common causes of epididymitis that can lead to abscess formation include candidal epididymitis in immunocompromised patients (AIDS) and epididymitis secondary to tuberculosis. In boys, epididymitis can also be secondary to a postinfectious inflammatory reaction to pathogens such as enterovirus and adenovirus.
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Scrotal abscess.
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Photomicrograph of Fournier gangrene (necrotizing fasciitis), oil immersion at 1000X magnification. Note the acute inflammatory cells in the necrotic tissue. Bacteria are located in the haziness of their cytoplasm. Courtesy of Billie Fife, MD, and Thomas A. Santora, MD.
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The patient depicted in this image is a man with alcoholism and known cirrhosis who presented with exquisite pain limited to the scrotum. The scrotum has been opened along the median raphe, which liberated foul-smelling brown purulence and exposed necrotic tissue throughout the mid scrotum. The testicles were not involved. Courtesy of Thomas A. Santora, MD.
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Cross-section illustration of a testicle and epididymis. A: Caput or head of the epididymis. B: Corpus or body of the epididymis. C: Cauda or tail of the epididymis. D: Vas deferens. E: Testicle. Illustration by David Schumick, BS, CMI. Reprinted with the permission of the Cleveland Clinic Center for Medical Art and Photography © 2009. All Rights Reserved.
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Color Doppler sonogram of the left epididymis in a patient with acute epididymitis. The image demonstrates increased blood flow in the epididymis resulting from the active inflammation.
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Scrotal sonogram showing the testes adjacent to the inflamed epididymis with a reactive hydrocele.
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Layers of the scrotum.
