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.

BE PREPARED TO JUSTIFY YOUR BLOOD TESTS

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

ASK FOR A CHAPERONE

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.