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!!!

Escalation
I would inform the Registrar to review the patient in a timely manner, to ensure my diagnosis and management plan were correct.
It may be expected of you to put the patient on the emergency list so close communication with theatre staff and anaesthetics may be necessary. 
Useful Resources
Gangrene and Fournier's gangrene. 
Note: You may need an institutional or personal access to view some of these resources. Your medical education department or local NHS library may be able to help with access.
core surgical training interview

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