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Pyocele of the Scrotum: A Consequence of Spontaneous Bacterial Peritonitis
Vol 153, 745-747, March 1995 Prinlcd in U.S.A.
PYOCELE OF THE SCROTUM: A CONSEQUENCE OF SPONTANEOUS BACTERIAL PERITONITIS RICHARD A. SANTUCCI
AND
JOHN N. KRIEGER
From the Department of Urology, University of Washington, Seattle, Washington
ABSTRACT
To our knowledge pyocele of the scrotum after spontaneous bacterial peritonitis has not been reported previously. We describe this unusual condition, and discuss diagnosis, pathophysiology a n d treatment. KEYWORDS:peritonitis, scrotum, suppuration, ascites, orchiectomy Pyocele is a well recognized complication of perforated appendix,'," epididymo-orchitis" and t r a ~ m a Pyocele .~ occurs most often after epididymo-orchitis and least often after perforated appendix. Diagnosis can be difficult and the con.~ dition may be present for a long period before d i a g n o ~ i sWe describe clinical and pathological findings in a case of pyocele of the scrotum following spontaneous bacterial peritonitis. This unusual condition most likely arose due to contiguous spread of intraperitoneal bacteria to the scrotum via a patent processus vaginalis. Spontaneous bacterial peritonitis is an acute bacterial peritonitis that develops in cirrhotic patients with ascites and no obvious primary source of infection. Spontaneous bacterial peritonitis may occur with minimal peritoneal symptoms and sometimes only causes worsening jaundice or encephalopathy." To our knowledge it has not been reported previously in association with pyocele of the scrotum. CASE REPORT
A 63-year-old white man had end stage liver disease secondary to hepatitis C. After a rapid clinical decline he presented elsewhere with obtundation, massive ascites and fever. He was started on 1,000 mg. cefotetan disodium intravenously every 12 hours for 10 days and then 500 mg. oral cefuroxime twice daily for another 3 days before transfer to our institution. Analysis of paracentesis fluid was consistent with peritonitis but cultures were negative, presumably due to early antimicrobial treatment. The patient improved clinically. We do not know if a n asymptomatic hydrocele or indirect hernia was present at that time. Four days after paracentesis a n enlarged inflamed right hemiscrotum was noted and presumptive diagnosis was right epididymitis. Urine cultures were negative. Gray scale with Doppler ultrasonography showed a paratesticular fluid collection and increased right testicular flow consistent with orchitis. After 13 days the patient was transferred to our institution for liver transplantation. Physical examination revealed a tender enlarged right hemiscrotum with a tense mass that transmitted light, which is consistent with hydrocele. White blood count was 10,200 units per dl. (normal 4,300 to 10,000). The patient received 400 mg. ciprofloxacin intravenously every 12 hours. Repeat ultrasound showed a right hydrocele with increased internal echoes and a thickened wall (fig. 1). Presumptive diagnosis was pyocele and approximately 60 cc of frank pus were drained immediately. Right orchiectomy was performed with the patient under local anesthesia via an inguinal-scrota1 approach with double ligation of the spermatic cord a t the external ring. The wound was closed loosely Over a Penrose drain. Histological examinaAccepted for publication July 8, 1994.
F,G. 1. Gray scale ultrasonography reveals right testicle with hyperechoic lesions consistent with infarction and paratesticular fluid collection with internal echoes (arrow).
tion showed marked peri-testicular granulation tissue and reactive changes of the tunica albuginea consistent with pyocele (fig. 2). Postoperatively 2 gm. ceftriaxone were 745
PYOCELE OF SCROTUM
746
~ e l e . Trauma ~ * ~ caused pyocele when bacteria were introduced through breaks in the skin into a reactive h y d r ~ c e l e . ~ However, after intra-abdominal infection the mechanism of pyocele formation is thought to be tracking of bacteria from the abdomen via a patent processus vaginalis into the scroEvidence supporting the possible migration of intraabdominal contents into the scrotum is provided by common cases of indirect hernia into the scrotum and rare cases of migration of intra-abdominal ventriculo-peritonea1 shunts into the scrotum? Intra-abdominal infection is the least common cause of pyocele, comprising only 2 of the 10 reported cases. In our case the presence of a patent processus vaginalis was proved by continued ascites leakage a t the spermatic cord stump. The only detectable infection was spontaneous bacterial peritonitis, consistent with the clinical picture and new onset of ascites. Declining clinical status led to administration of broad-spectrum antimicrobials before the peritoneal tap, which presumably sterilized the peritoneal fluid culture, making it impossible to compare the spontaneous bacterial peritonitis organisms and the pyocele organisms. Diagnosis of pyocele was suggested by scrotal ultrasonography, specifically the presence of internal echoes within the fluid collection. Pyoceles can have several sonographic features that distinguish them from simple hydroceles, including internal echoes representing cellular debris, septae or loculations, fluidfluid levels representing a hydrocele/pyocele interface and even gas in cases of gas-forming organism^.^-^ The treatment of pyocele is prompt surgical drainage and orchiectomy accompanied by appropriate antimicrobials. The need for orchiectomy is suggested by the experience of Slavis et al, who treated 2 patients with pyocele by drainage alone only to perform subsequent orchiectomy after necrotic testicular tissue extruded from the wound.3 Pathological analysis of the excised testicle in our case and the later realization that the pyocele was caused by descending abdominal infection imply that orchiectomy may FIG. 2. Photomicrograph shows section of tunica vaginalis with not be required for treatment of every pyocele. Since most prominent inflammatory cell infiltrate with edema, hemorrhage and pyoceles occur after epididymitis, the surgeon must exproliferation of capillaries. Subjacent testicular stroma lacks signif- clude testicular infection in each case of pyocele before icant inflammation. H & E, reduced from X 150. deciding not t o elect orchiectomy. Our experience suggests that a patent processus vaginalis should be ruled out intraoperatively in all cases of pyocele given intravenously every 24 hours. Intraoperative cul- and that high ligation of the processus should be performed, tures yielded Escherichia coli sensitive t o cefotetan, cipro- if necessary. Experience with other patients who presented floxacin and ceftriaxone. with pyocele after intra-abdominal infection indicates that Convalescence was remarkable for drainage of approxi- the clinician must rule out occult intra-abdominal infection mately 1 to 2 1. daily of ascites fluid from the cord stump. On as a cause of pyocele.1,2In the 2 previously described cases of examination leakage was noted from minuscule needle sized pyocele after appendicitis, such infection was ruled out by holes in the patent processus vaginalis. The wound was man- computerized tomography' and a barium enema.' aged expectantly in an attempt t o avoid repeat anesthesia. In summary, we describe clinical findings in a patient with Because of protein losses via the ascitic leak, serum albumin pyocele of the scrotum. Pathophysiology appeared to be seeddecreased to 2.2 gm./dl. (normal 3.5 to 5.2) despite maximal ing from spontaneous bacterial peritonitis via a patent prooral nutritional support, and total parenteral nutrition was cessus vaginalis. Scrota1 ultrasonography proved helpful for instituted. On postoperative day 25 we performed reexplora- diagnosis. Appropriate antimicrobials and orchiectomy are tion, and closed the inguinal canal and scrotal wound with recommended although orchiectomy may not be required in multiple layers to stop the leakage. Convalescence was un- all cases. eventful and the patient received a successful liver transDr. Larry True provided and analyzed the photomicroplant. graph. DISCUSSION
REFERENCES
To our knowledge our case represents a previously undescribed etiology for pyocele of the scrotum. Although well recognized clinically, only 10 cases of pyocele were reported since 1966. Causes included epididymo-or chi ti^,^ trauma4 and pelvic abscess secondary to appendicitis.'," Epidymoorchitis reportedly caused pyocele by compromising the testicular blood supply, leading to infected testicular infarction that ruptured through the tunica albuginea to form the pyo-
1. Ahlering, T. E., Weinberg, A. C. and Lieskovsky, G.: Pelvic abscess following appendicitis presenting as a scrotal abscess. J. Urol., 133 1058, 1985. 2. Carter, B. J. and Wachtel, T. L.: An unusual complication Of perforated appendix. Infect. Urol., p. 51, MarcWApril, 1992. 3. Slavis, S. A., Kollin, J. and Miller, J. B.: Pyocele of scrotum: consequence of spontaneous rupture of testicular abscess. Urology. 3 3 313, 1989.
PYOCELE O F SCROTUM 4. Lupetin, A. R., King, W., 111, Rich, P. J. and Lederman, R. B.: The
traumatized scrotum. Ultrasound evaluation. Radiology, 1 4 8 203, 1983. 5 . Di Donna, A. and Rizzatto, G.: Pyocele of the scrotum: sonographic demonstration of fluid-fluid level and a gas-forming component. J. Ultrasound Med., 5: 99, 1986. 6. Podolsky, D. K and Isselbacker, K J.: Cirrhosis. In: Harrison’s Principles of Internal Medicine, 11th ed. Edited by E. Braunwald,
747
K. J. Isselbacker, R. G. Petersdorf, J. D. Wilson, J. B. Martin and A. S. Fauci. New York: McGraw-Hill, chapt. 249, p. 1349, 1987. 7. Krieger, J. N.: Epididymitis, orchitis, and related conditions. Sex. Transmit. Dis., 11: 173, 1984. 8. Albala, D. M., Danaher, J. W. and Huntsman, W. T.: Ventriculoperitoneal shunt migration into the scrotum. h e r . Surg., 55: 685, 1989.
PYOCELE OF THE SCROTUM: A CONSEQUENCE OF SPONTANEOUS BACTERIAL PERITONITIS RICHARD A. SANTUCCI
AND
JOHN N. KRIEGER
From the Department of Urology, University of Washington, Seattle, Washington
ABSTRACT
To our knowledge pyocele of the scrotum after spontaneous bacterial peritonitis has not been reported previously. We describe this unusual condition, and discuss diagnosis, pathophysiology a n d treatment. KEYWORDS:peritonitis, scrotum, suppuration, ascites, orchiectomy Pyocele is a well recognized complication of perforated appendix,'," epididymo-orchitis" and t r a ~ m a Pyocele .~ occurs most often after epididymo-orchitis and least often after perforated appendix. Diagnosis can be difficult and the con.~ dition may be present for a long period before d i a g n o ~ i sWe describe clinical and pathological findings in a case of pyocele of the scrotum following spontaneous bacterial peritonitis. This unusual condition most likely arose due to contiguous spread of intraperitoneal bacteria to the scrotum via a patent processus vaginalis. Spontaneous bacterial peritonitis is an acute bacterial peritonitis that develops in cirrhotic patients with ascites and no obvious primary source of infection. Spontaneous bacterial peritonitis may occur with minimal peritoneal symptoms and sometimes only causes worsening jaundice or encephalopathy." To our knowledge it has not been reported previously in association with pyocele of the scrotum. CASE REPORT
A 63-year-old white man had end stage liver disease secondary to hepatitis C. After a rapid clinical decline he presented elsewhere with obtundation, massive ascites and fever. He was started on 1,000 mg. cefotetan disodium intravenously every 12 hours for 10 days and then 500 mg. oral cefuroxime twice daily for another 3 days before transfer to our institution. Analysis of paracentesis fluid was consistent with peritonitis but cultures were negative, presumably due to early antimicrobial treatment. The patient improved clinically. We do not know if a n asymptomatic hydrocele or indirect hernia was present at that time. Four days after paracentesis a n enlarged inflamed right hemiscrotum was noted and presumptive diagnosis was right epididymitis. Urine cultures were negative. Gray scale with Doppler ultrasonography showed a paratesticular fluid collection and increased right testicular flow consistent with orchitis. After 13 days the patient was transferred to our institution for liver transplantation. Physical examination revealed a tender enlarged right hemiscrotum with a tense mass that transmitted light, which is consistent with hydrocele. White blood count was 10,200 units per dl. (normal 4,300 to 10,000). The patient received 400 mg. ciprofloxacin intravenously every 12 hours. Repeat ultrasound showed a right hydrocele with increased internal echoes and a thickened wall (fig. 1). Presumptive diagnosis was pyocele and approximately 60 cc of frank pus were drained immediately. Right orchiectomy was performed with the patient under local anesthesia via an inguinal-scrota1 approach with double ligation of the spermatic cord a t the external ring. The wound was closed loosely Over a Penrose drain. Histological examinaAccepted for publication July 8, 1994.
F,G. 1. Gray scale ultrasonography reveals right testicle with hyperechoic lesions consistent with infarction and paratesticular fluid collection with internal echoes (arrow).
tion showed marked peri-testicular granulation tissue and reactive changes of the tunica albuginea consistent with pyocele (fig. 2). Postoperatively 2 gm. ceftriaxone were 745
PYOCELE OF SCROTUM
746
~ e l e . Trauma ~ * ~ caused pyocele when bacteria were introduced through breaks in the skin into a reactive h y d r ~ c e l e . ~ However, after intra-abdominal infection the mechanism of pyocele formation is thought to be tracking of bacteria from the abdomen via a patent processus vaginalis into the scroEvidence supporting the possible migration of intraabdominal contents into the scrotum is provided by common cases of indirect hernia into the scrotum and rare cases of migration of intra-abdominal ventriculo-peritonea1 shunts into the scrotum? Intra-abdominal infection is the least common cause of pyocele, comprising only 2 of the 10 reported cases. In our case the presence of a patent processus vaginalis was proved by continued ascites leakage a t the spermatic cord stump. The only detectable infection was spontaneous bacterial peritonitis, consistent with the clinical picture and new onset of ascites. Declining clinical status led to administration of broad-spectrum antimicrobials before the peritoneal tap, which presumably sterilized the peritoneal fluid culture, making it impossible to compare the spontaneous bacterial peritonitis organisms and the pyocele organisms. Diagnosis of pyocele was suggested by scrotal ultrasonography, specifically the presence of internal echoes within the fluid collection. Pyoceles can have several sonographic features that distinguish them from simple hydroceles, including internal echoes representing cellular debris, septae or loculations, fluidfluid levels representing a hydrocele/pyocele interface and even gas in cases of gas-forming organism^.^-^ The treatment of pyocele is prompt surgical drainage and orchiectomy accompanied by appropriate antimicrobials. The need for orchiectomy is suggested by the experience of Slavis et al, who treated 2 patients with pyocele by drainage alone only to perform subsequent orchiectomy after necrotic testicular tissue extruded from the wound.3 Pathological analysis of the excised testicle in our case and the later realization that the pyocele was caused by descending abdominal infection imply that orchiectomy may FIG. 2. Photomicrograph shows section of tunica vaginalis with not be required for treatment of every pyocele. Since most prominent inflammatory cell infiltrate with edema, hemorrhage and pyoceles occur after epididymitis, the surgeon must exproliferation of capillaries. Subjacent testicular stroma lacks signif- clude testicular infection in each case of pyocele before icant inflammation. H & E, reduced from X 150. deciding not t o elect orchiectomy. Our experience suggests that a patent processus vaginalis should be ruled out intraoperatively in all cases of pyocele given intravenously every 24 hours. Intraoperative cul- and that high ligation of the processus should be performed, tures yielded Escherichia coli sensitive t o cefotetan, cipro- if necessary. Experience with other patients who presented floxacin and ceftriaxone. with pyocele after intra-abdominal infection indicates that Convalescence was remarkable for drainage of approxi- the clinician must rule out occult intra-abdominal infection mately 1 to 2 1. daily of ascites fluid from the cord stump. On as a cause of pyocele.1,2In the 2 previously described cases of examination leakage was noted from minuscule needle sized pyocele after appendicitis, such infection was ruled out by holes in the patent processus vaginalis. The wound was man- computerized tomography' and a barium enema.' aged expectantly in an attempt t o avoid repeat anesthesia. In summary, we describe clinical findings in a patient with Because of protein losses via the ascitic leak, serum albumin pyocele of the scrotum. Pathophysiology appeared to be seeddecreased to 2.2 gm./dl. (normal 3.5 to 5.2) despite maximal ing from spontaneous bacterial peritonitis via a patent prooral nutritional support, and total parenteral nutrition was cessus vaginalis. Scrota1 ultrasonography proved helpful for instituted. On postoperative day 25 we performed reexplora- diagnosis. Appropriate antimicrobials and orchiectomy are tion, and closed the inguinal canal and scrotal wound with recommended although orchiectomy may not be required in multiple layers to stop the leakage. Convalescence was un- all cases. eventful and the patient received a successful liver transDr. Larry True provided and analyzed the photomicroplant. graph. DISCUSSION
REFERENCES
To our knowledge our case represents a previously undescribed etiology for pyocele of the scrotum. Although well recognized clinically, only 10 cases of pyocele were reported since 1966. Causes included epididymo-or chi ti^,^ trauma4 and pelvic abscess secondary to appendicitis.'," Epidymoorchitis reportedly caused pyocele by compromising the testicular blood supply, leading to infected testicular infarction that ruptured through the tunica albuginea to form the pyo-
1. Ahlering, T. E., Weinberg, A. C. and Lieskovsky, G.: Pelvic abscess following appendicitis presenting as a scrotal abscess. J. Urol., 133 1058, 1985. 2. Carter, B. J. and Wachtel, T. L.: An unusual complication Of perforated appendix. Infect. Urol., p. 51, MarcWApril, 1992. 3. Slavis, S. A., Kollin, J. and Miller, J. B.: Pyocele of scrotum: consequence of spontaneous rupture of testicular abscess. Urology. 3 3 313, 1989.
PYOCELE O F SCROTUM 4. Lupetin, A. R., King, W., 111, Rich, P. J. and Lederman, R. B.: The
traumatized scrotum. Ultrasound evaluation. Radiology, 1 4 8 203, 1983. 5 . Di Donna, A. and Rizzatto, G.: Pyocele of the scrotum: sonographic demonstration of fluid-fluid level and a gas-forming component. J. Ultrasound Med., 5: 99, 1986. 6. Podolsky, D. K and Isselbacker, K J.: Cirrhosis. In: Harrison’s Principles of Internal Medicine, 11th ed. Edited by E. Braunwald,
747
K. J. Isselbacker, R. G. Petersdorf, J. D. Wilson, J. B. Martin and A. S. Fauci. New York: McGraw-Hill, chapt. 249, p. 1349, 1987. 7. Krieger, J. N.: Epididymitis, orchitis, and related conditions. Sex. Transmit. Dis., 11: 173, 1984. 8. Albala, D. M., Danaher, J. W. and Huntsman, W. T.: Ventriculoperitoneal shunt migration into the scrotum. h e r . Surg., 55: 685, 1989.