Severe scrotal pain

Clinical History

A 66-year-old man presented to the ER with increasing severe scrotal pain that started 7 days before. His physical examination revealed a hardened right hemiscrotum with associated inflammatory signs. His past medical history included type 2 diabetes mellitus and alcoholic chronic liver disease. Laboratory tests demonstrated moderate leukocytosis.

Imaging Findings

A scrotal ultrasound was requested revealing an enlarged heterogeneous right testicle with multiple round hypoechoic lesions, with low-level internal echoes, compatible with testicular abscesses (Fig. 1). An increased overall testicular and scrotal wall vascularity was noted (Fig. 2). Additionally a fluid collection with internal echoes, septations and loculations was observed in the tunica vaginalis external to the testicle (Fig. 3) representing a pyocele. Compare with the contralateral normal-sized testicle (Fig. 4).

Discussion

A. An acute scrotum is defined as a painful swelling of the scrotum and its contents, developed over a short period of time, with or without accompanying symptoms. [3]
Its differential diagnosis includes testicular torsion, incarcerated or strangulated inguinal hernia, testicular trauma and ischaemic or infectious conditions. [4]
Infectious causes of scrotal pain include epididymitis, epididymo-orchitis, testicular abscess, pyocele, and Fournier's gangrene. [1]

B. These conditions are organ-threatening, potentially affecting the patient's fertility, and some are life-threatening, representing surgical emergencies.
The physical examination findings in these cases may be nonspecific, making the use of ultrasound imaging pivotal for the differential diagnosis. [4]

C. Scrotal pyoceles represent purulent collections within the potential space of the tunica vaginalis surrounding the testicle. [2]
Sonographic findings suggestive of a pyocele include a fluid collection with internal echoes, loculations, septae, and fluid-fluid or air-fluid levels in the tunica vaginalis external to the testicle.
A round hypoechoic lesion in the testicular parenchyma, with internal low-level echoes and a central lack of flow at Doppler interrogation, is suggestive of testicular abscess in the appropriate clinical context.

D. Treatment requires broad spectrum antibiotics and surgical drainage; some patients may need an orchiectomy. [2]
Sepsis and Fournier's gangrene are possible complications; the latter is a polymicrobial necrotizing infection that involves the perineum. These patients usually have a history of diabetes mellitus or immunocompromising conditions. It constitutes a urologic emergency and demands aggressive treatment with surgical debridement and intravenous antibiotic therapy.
The modality of choice for Fournier’s gangrene is CT to delineate the presence and extension of soft tissue gas and facilitate surgical planning.

E. Epididymitis and epididymo-orchitis are two of the most common causes of acute scrotum; if left untreated, may be complicated by testicular abscess formation or pyocele. [1]
The imaging modality of choice to diagnose a testicular abscess and/or a scrotal pyocele is ultrasound.
A scrotal pyocele and/or testicular abscess must be recognized and treated promptly to avoid further testicular damage or Fournier's gangrene.

Differential Diagnosis List

Final Diagnosis

Scrotal pyocele and multiple intra-testicular abscesses

URL:	https://eurorad.org/case/14036
DOI:	10.1594/EURORAD/CASE.14036
ISSN:	1563-4086