Annals of B Pod - Epididymitis to Pyocele

HISTORY OF PRESENT ILLNESS

A male in his 70s presents with eight days of worsening left-sided testicular pain and swelling. He states that the pain had been gradually worsening to the point that he is unable to sit upright. He denies fever, dysuria, hematuria, urinary frequency, penile discharge, or preceding trauma to the groin. He has no reported or documented history of genitourinary instrumentation. The patient is sexually active with one female partner and does not use barrier protection. Chart review reveals that the patient was evaluated in the emergency department eight days prior to symptom onset for similar complaints. His blood work at that time showed a leukocytosis of 24,000 and a urine sample during this visit revealed >100 white blood cells per high powered field on microscopy. Urine culture speciated Streptococcus agalactiae. The patient was diagnosed with epididymitis and was prescribed a course of Bactrim before being discharged back to his living facility. Discussion with the nursing facility revealed that the patient refused antibiotics upon his return for unknown reasons. 

Past Medical History: Benign prostatic hyperplasia, hypertension, schizophrenia

Past Surgical History: None  

Medications: Amlodipine, Atorvastatin, Benztropine, Lisinopril, Propranolol, Quetiapine, Tamsulosin

Allergies: No known allergies

Diagnostics

WBC: 11.2 Hgb: 14.7 Hct: 42.9 Plt: 176

Na: 135 K: 4 Cl: 109 HCO3: 19 BUN: 9 Cr: 1.1

Urinalysis: Trace urobilinogen

CT ABDomen and pelvis with IV contrast showing scrotal edema and left hydrocele exerting mass effect on the testicle, consistent with epididymo-orchitis and pyocele.

representative image of patient’s testicular ultrasound showing a large complex hydrocele consistent with a pyocele

Physical exam

Vitals: T 98.4 HR 65 BP 134/82 RR 24 SpO2 100% on RA

The patient was a well-appearing African American male lying in bed and in no acute distress.  His mucous membranes were moist.  He had an unremarkable cardiopulmonary exam.  Abdominal examination was notable for focal left lower quadrant tenderness without rigidity, rebound, or guarding.  The patient’s genitourinary exam revealed a swollen, warm, and diffusely tender left testicle that did not transilluminate.  He had a negative cremasteric reflex and a negative Prehn sign.  There was no evidence of tenderness, erythema, edema, or crepitus in the perineal region. 

Hospital Course

The patient was given morphine, ondansetron, and intravenous fluids shortly after arrival to the emergency department. The providers were concerned about the patient’s progression of symptoms, with differential to include Fournier’s gangrene, urinary tract infection, persistent epididymo-orchitis, testicular torsion, traumatic hematocele, incarcerated inguinal hernia, testicular cancer, and intra-abdominal infection with extension into the scrotum. Cross-sectional imaging and ultrasound was performed and demonstrated a heterogeneous fluid collection within the scrotal sac, consistent with a pyocele. Ceftriaxone was administered and urology was consulted. The patient was managed non-operatively, had improvement in his symptoms, and was discharged back to his skilled nursing facility with a two week course of ciprofloxacin.

Pyoceles

Pathophysiology and Epidemiology

Pyocele, an uncommon cause of testicular pain in the emergency department, is a purulent collection of fluid that forms between the parietal and visceral layers of the tunica vaginalis (see figure below). [1] Pyoceles most commonly occur as a complication of epididymitis or epididymo-orchitis, which develop from retrograde urinary tract infections. However, scrotal communication with the abdominal cavity can occur in the case of a patent processus vaginalis, and case reports exist of pyocele development as an extension of abdominal cavity infections, including perforated appendicitis and extension of spontaneous bacterial peritonitis. [2,3] It is important to note that patent processus vaginalis is more common in newborn males, estimated to be present in 80-95% of all newborn males and declining to 15-37% after the first 2 years of life. [4] In pyoceles secondary to epididymitis, the causative organisms vary with age. Neisseria gonorrhea and Chlamydia trachamotis are more common in men younger than 35 years old, and E. coli are more common in individuals greater than 35 years old. [5] Organisms in cases of trauma-related pyoceles typically result from seeding of dermatologic microbes into the scrotum from breakdown of the skin. These microbes can include Enterococci, Streptococcus, Staphylococcus, Klebsiella, and Pseudomonas species.

Testicular anatomy

Clinical Presentation and Diagnosis

Examination will often reveal a tense, warm, swollen testicle related to the complex collection of fluid in between the layers of the tunica vaginalis. [6] In cases related to epdidymitis, patients will often have an acute to subacute presentation marked by testicular pain (over the posterior aspect), swelling, penile discharge, and dysuria. An emergency provider should have a high index of suspicion for conditions that may mimic a pyocele, including testicular abscess, torsion, and incarcerated inguinal hernias. Fournier’s gangrene should also be considered if there are cutaneous manifestations or extensions beyond the scrotum. Ultrasound is the preferred mode of diagnosis. A hydro-cele appears as an anechoic collection in the tunica vaginalis on ultrasound examination. A pyocele appears as a complex fluid collection with septations, loculations, and air fluid levels on ultrasound examination. Doppler studies should also be obtained to rule out concerns for torsion. An increase in Doppler signal may additionally be indicative of infectious process, as in this case. When the diagnosis is questionable or there is concern for tissue tracking, CT of the abdomen and pelvis may be warranted.

Management

Pyoceles require urgent urologic consultation. Management requires broad spectrum antibiotics, with at least a third-generation cephalosporin and metronidazole to cover gram negative and anaerobic organisms. Patients may require surgical drainage and possible orchioectomy if there is evidence of infarction.

Complications

Testicular abscess

Untreated epididymitis or epididymo-orchitis can result in a testicular abscess. [5] This is an intratesticular lesion and is therefore contained within the tunica albuginea. Disruption of the tunica albuginea can lead to communication with the tunica vaginalis and resultant formation of a scrotal abscess or pyocele.

Testicular infarction

Testicular infarct is a complication from epididymitis and pyoceles, typically caused by mass effect upon the spermatic cord with resultant venous and arterial insufficiency. [7] An additional mechanism is thought to be related to arterial thrombosis from bacterial endotoxins leading to decreased blood flow. [8,9] Given that the testicle has little collateral flow, the testicle is susceptible to ischemia. Albeit rare, testicular rupture is an additional complication from unrecognized epididymo-orchitis and testicular infarct. [10]

Fournier’s Gangrene

Pelvic anatomy and fascial planes.

Fournier’s gangrene is a polymicrobial necrotizing fasciitis, with as many as 20-40% of cases attributable to genitourinary causes. [11,12] Fournier’s gangrene has a variety of presentations, all of which include an acute and progressive onset. Diabetics and immunocompromised individuals are at increased susceptibility.

Anatomy of the fascial planes is important to understanding progression of infection (see figure). Colles’ fascia attaches at the perineal body and is continuous with Buck’s fascia and Dartos’ fascia, allowing for spread of infections along the anterior abdominal wall. Anorectal sources spread outward from the anal ridge, whereas genitourinary sources will more likely spread along Buck’s and Dartos fascias. Ultrasound or CT examination may reveal the presence of subcutaneous emphysema in the perineum. This a true surgical emergency, requiring broad spectrum antibiotics and im mediate surgical consultation for debridement. A comparison of Fournier’s gangrene and pyocele is included in the table below.

Comparison of scrotal pyocele and fournier’s gangrene [3,4,7]

Summary

Scrotal pyoceles are rare but important considerations when presented with acute to subacute cases of scrotal pain. Management includes urologic evaluation, with antibiotics as a mainstay of therapy, although many progress to requiring surgical intervention. Ultrasound is helpful in confirming diagnosis and ruling out additional causes such as torsion, hematocele, and isolated abscesses. If the patient appears toxic, more advanced imaging such as CT scans may be needed to assess for Fournier’s gangrene.

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AUTHORED BY LAURA Frankenfeld, MD

Dr. Frankenfeld is a PGY-3 in Emergency Medicine at the University of Cincinnati

Editing by the Annals of B Pod Editors

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References

1. Adhikari, Srikar. “Small Parts-Testicular Ultrasound .” Testicular Ultrasound, 2008, www.acep.org/sonoguide/smparts_testicular.html.

2. Santucci, Richard A., et al. “Pyocele of the Scrotum: A Consequence of Spontaneous Bacterial Peritonitis.” The Journal of Urology, July 1994, www.auajournals.org/doi/full/10.1016/S0022-5347%2801%2967706-1.

3. Ramjit, Amit, et al. “Complete Testicular Infarction Secondary to Epididymoorchitis and Pyocele.” Radiology Case Reports, Else-vier, 12 Feb. 2020, www.sciencedirect.com/science/article/pii/S1930043320300017.

4. Rahman, N, and K Lakhoo. Patent Processus Vaginalis: a Window to the Abdomen. African Journal of Paediatric Surgery , 2009, www.afrjpaedsurg.org/.

5. Avery, Laura L., et al. “Imaging of Penile and Scrotal Emergencies.” RadioGraphics, 3 May 2013, pubs.rsna.org/doi/10.1148/rg.333125158.

6. Bruner, D I, and J J Devlin. “Scrotal Pyocele: Uncommon Urologic Emergency .” Europe PMC, Journal of Emergencies, Shock, and Trauma , Mar. 2012, europepmc.org/article/pmc/pmc3391854.

7. LR. Delaney, B. Karmazyn, et al. “Pediatric Scrotal Ultrasound: Review and Update.” Pediatric Radiology, Springer Berlin Heidel-berg, 1 Jan. 1970, link.springer.com/article/10.1007/s00247-017-3923-9.

8. Martin, Clyde Donald, et al. “More Than Just Torsion: An Unusual Case of Testicular Pain.” OUP Academic, Oxford University Press, 28 Oct. 2019, academic.oup.com/milmed/article/185/5-6/e900/5607595.

9. Farber, Nicholas J., et al. “Multidrug Resistant Epididymitis Progressing to Testicular Infarct and Orchiectomy.” Case Reports in Urology, Hindawi, 27 Nov. 2013, www.hindawi.com/journals/criu/2013/645787/.

10. Chia, Daniel, et al. “Testicular Infarction and Rupture: an Uncommon Complication of Epididymo-Orchitis.” Journal of Surgical Case Reports, Oxford University Press, 10 May 2016, www.ncbi.nlm.nih.gov/pmc/articles/PMC4862172/.

11. Drake, Tamsin. “Fournier’s Gangrene.” Urology News, 1 May 2015, www.urologynews.uk.com/features/features/post/fourni-er-s-gangrene.

12. Thwaini, A, et al. “Fournier’s Gangrene and Its Emergency Management.” Postgraduate Medical Journal, BMJ Group, Aug. 2006, www.ncbi.nlm.nih.gov/pmc/articles/PMC2585703/