Case

A 37-year-old white male with no past medical history presented to the emergency department (ED) for left testicular pain, redness, and swelling. He had presented to urgent care for the same complaint a week before, but did not seek follow-up at an ED despite their recommendation. The pain and swelling returned days later, which prompted the patient to present to the ED. He described the pain as sharp, throbbing and radiating to the groin. He denied any urinary symptoms such as pain with urination or increased frequency. He was found to have a fever of 101.2 degrees Fahrenheit and tachycardia at 101 beats per minute on arrival to the ED. On physical exam the left testicle was diffusely erythematous and enlarged compared to the right. There was also focal tenderness to palpation near the top of the testicle. There were no rashes, discharge, or palpable inguinal hernias. The testicle did not appear to be malpositioned.

Left testicle trans upper-lower scan image. (Click to enlarge.)

Diagnosis: Complex Hydrocele (Pyocele)

The testicular ultrasound revealed a small left complex hydrocele suspicious for pyocele. Laboratory examinations demonstrated leukocytosis with a WBC of 32.51 k/mcL. On admission the patient had 3 of 4 Systemic Inflammatory Response Syndrome criteria with leukocytosis, fever, and tachycardia. The patient was immediately started on intravenous clindamycin and acetominophen and an emergent urology consult was sought. Blood, urine, and sexually-transmitted disease cultures were negative. His treatment course was uncomplicated and he was eventually discharged home with a course of oral doxycycline.

Left epididymis sag scan image. (Click to enlarge.)

Discussion

A scrotal pyocele is a collection of purulent fluid in the potential space between the visceral and parietal tunica vaginalis surrounding the testicle.¹ It is a rare complication of epididymo-orchitis and is considered a urologic emergency which requires urgent identification and treatment as it can lead to testicular damage or Fournier’s gangrene.¹ Infections associated with epididymo-orchitis are commonly caused by sexually transmitted Neisseria gonorrhoeae or Chlamydia trachomatis in men under 35 years old. Infections in men over 35 are often caused by E. coli.^2,3 Management involves empiric broad-spectrum antibiotics and, occasionally, surgical drainage. Some patients will end up with orchiectomy.^1,2

Teaching points:

• Scrotal pyocele can mimic other testicular etiologies, but should always be included in the differential, as it is a urologic emergency.
• Early treatment with broad-spectrum antibiotics is essential to prevent sepsis and preserve testicular function.
• Serial scrotal examinations are required to monitor for testicular ischemia in order to prevent need for orchiectomy.

V. Morgan Leadbetter works at Michigan State University College of Osteopathic Medicine.

Dr. Rader works at Ascension Macomb-Oakland Hospital.

Dr. Fishman is an associate program director at Ascension Macomb-Oakland Hospital.

References

1. Bruner DI, Ventura EL, Devlin JJ. Scrotal pyocele: uncommon urologic emergency. J Emerg Trauma Shock. 2012;5(2):206.
2. Hackett B, Sletten Z, Bridwell RE. testicular abscess and ischemia secondary to epididymo-orchitis. Cureus. 2020;12(7):e8991.
3. Trojian TH, Lishnak TS, Heiman D. Epididymitis and orchitis: an overview. Am Fam Physician. 2009;79(7):583-7.