Scrotal Abscess
You are the urology CT1 asked to see a gentleman with painful, swollen testicles. He has had 10 days of oral antibiotics from his GP for epididymo-orchitis without improvement. He is an insulin dependent diabetic. How would you proceed?
Example answer introduction
I would be concerned about a possible testicular abscess or Fournier’s gangrene due to his history of diabetes. I would take a focused history, perform a focused examination and request the relevant investigations depending on my clinical suspicions. I would then initiate treatment and escalate to my registrar for senior review.
Initial Assessment and Simultaneous Resuscitation
On arrival, manage the patient using an A to E approach according to the Advance Life Support algorithm.
-
Airway
-
Breathing - check oxygen saturations, respiratory rate, listen to chest, assess work of breathing, breathing depth - if concerns give high flow oxygen
-
Circulation
-
Pulse, Blood pressure, capillary refill time, mucus membranes, skin turgor, fluid input/output, catheter is septic
-
IV access - large bore and bloods including CRP
-
Give fluid challenge of 250ml crystalloid solution if evidence of shock
-
If suspecting bleeding, you may need to activate the Major Haemorrhage Protocol
-
-
Disability - GCS, pupillary response, blood sugar, temperature
-
Exposure - rashes, systemic signs of shock - expose the whole abdomen - there may be clues!!
During this acute phase state remember to provide constant reassessment
During initial assessment I would send bloods for FBC, U&E, LFTs, CRP, Lactate, blood glucose, clotting studies, Group and Save and blood and urine cultures if spiking a temperature.
Focused history
-
Allergies
-
Medications
-
Past medical history – immunocompromised, previous urological procedures
-
Last meal
-
Events leading up to this point – history of trauma, duration of symptoms, antibiotics used, pyrexia, anorexia
Examination
Testicular examination – ask for chaperone
-
Inspect – swelling, erythrema, ulceration, necrosis
-
Palpate – tenderness, warmth, transillumination
-
Abdominal examination
I would request further investigations:
-
Urine dip + MSU
Example questions to progress the station
Q1 He has raised white cells and CRP and is septic. His testicle appears like this:
Q1 Answer
This is a picture showing a swollen, inflamed right hemi-scrotum with areas of necrosis in keeping with a Fournier’s gangrene (Necrotising fasciitis). This is a surgical emergency and I would inform the urology registrar immediately.
Q2 He has a dramatic rise in CRP and WBCs, he is spiking temperatures and on examination of the testis you find a grossly swollen, erythematous and fluctuant swelling without features of necrosis. How would you initiate management?

Initial management
-
Swabs for MC&S
-
IV antibiotics as per local protocol
-
Fluid resuscitation
-
Analgesia according to the WHO pain ladder
-
Keep nil-by-mouth
-
Sliding scale if diabetic and on insulin
-
Prep for theatre – surgical drainage
-
Inform emergency theatres and anaesthetist
-
Keep patient and any relatives informed
-
Document, document, document!!!