Scrotal pyocele: Uncommon urologic emergency.

Sir,

A scrotal pyocele is a rarely described urologic emergency that must be recognized and treated quickly to prevent testicular damage or Fournier's gangrene. We present a 74 year-old man with four days of left-sided scrotal pain and swelling. Physical examination revealed edema, erythema, and tenderness on the left side of the scrotum extending onto his penis proximally. A scrotal ultrasound was obtained [Figure 1] demonstrating a large scrotal pyocele. Urology surgically drained the pyocele without performing an orchiectomy.

Figure 1

Scrotal ultrasound showing a normal appearing testicle with a scrotal free fluid with newly developed septations and echogenic debris and thickened scrotal skin without evidence of free air within the scrotal wall

Scrotal pyoceles are purulent collections within the potential space between the visceral and parietal tunica vaginalis surrounding the testicle.[1] They are commonly associated with acute epididymo-orchitis.[1] The presentation of scrotal pyoceles is subacute onset of pain and swelling, which may mimic other pathology. The imaging modality of choice to diagnose a scrotal pyocele is ultrasound.[2] Internal echoes within the pyocele fluid collection typically represent cellular debris. Other sonographic findings include loculations, septae, and fluid-fluid or air-fluid levels in the tunica vaginalis external to the testicle.[3] By contrast, a hydrocele will appear on ultrasound as a simple fluid with an anechoic region that collects anterior and lateral to the testis. If the fluid contains internal echoes on ultrasound, the diagnosis of hematocele (most common in the setting of trauma) or pyocele may be made.[34] Fournier's gangrene is the most concerning complication of a scrotal pyocele. If there are concerns for Fournier's, computed tomography is recommended to delineate the extent of disease and facilitate surgical planning.[5] Early diagnosis using ultrasound, therefore, will help prevent the development of sepsis and preserve a functional outcome.[26] Treatment requires broad spectrum antibiotics and surgical drainage. Many patients, however, ultimately require orchiectomy.[16]