13/11/2019 Scrotal Abscess Drainage: Overview, Preparation, Technique

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Scrotal Abscess Drainage

Updated: Sep 06, 2018
Author: Pamela I Ellsworth, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS more...

OVERVIEW

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.

Scrotal abscess.

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.

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13/11/2019 Scrotal Abscess Drainage: Overview, Preparation, Technique

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.

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13/11/2019 Scrotal Abscess Drainage: Overview, Preparation, Technique

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.

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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.

Layers of the scrotum.

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13/11/2019 Scrotal Abscess Drainage: Overview, Preparation, Technique

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
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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.

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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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