Necrotising epididymo-orchitis with scrotal abscess
M Muttarak, MD, W
Na Chiangmai, MD, P Kitirattrakarn,
Departments of Radiology and Surgery, Chiang Mai University, Chiangmai,
A 55-year-old man presented with a painful left scrotal enlargement
and fever for 6 weeks. He was treated with antibiotics at
the community hospital. His fever and scrotal pain were improved
but the scrotum became enlarged. He was referred to our hospital
to have testicular tumour ruled out. He had history of left
renal calculi and urethral stricture with off and on urinary
tract infection. Physical examination revealed left scrotal
erythema with an enlarged, tender left scrotum. Laboratory
investigations were notable for mild elevation of blood urea
nitrogen 36 mg/dL (normal 7-24 mg/dL), and creatinine 1.7
mg/dL (normal 0.6-1.6 mg/dL). Urinalysis revealed cloudy urine
with numerous white blood cells and red blood cells. Blood
leucocyte count was 6.9 ? 103 per dL with 59.6% neutrophils,
31.8% lymphocytes, and 3.5% monocytes. Urine culture showed
no growth of organism. Scrotal ultrasonography (US) was performed.
The patient underwent left orchiectomy. His post-operative
period was uneventful. One month later, left nephrolithotomy
Scrotal US showed a normal right testis and epididymis (Figure
1a). The left testis was small with inhomogeneous echogenicity
and loss of normal surrounding contour (Figure 1b). The left
scrotal skin was thickened. A complex echoic mass in the left
scrotal sac with connection to the left testis (Figure 2)
was demonstrated, compatible with scrotal abscess. Colour
Doppler US at the left hemiscrotum showed increased peritesticular
flow but no intratesticular flow (Figure 3).
Figure 1 (a) Longitudinal US
scan of the right hemiscrotum shows a normal homogeneous
echoic epididymis (E) and testis (T). The testicular
contour is well defined; (b) Longitudinal US scan
of the left hemiscrotum shows an inhomogeneous small
testis (T) with loss of normal well-defined contour.
The scrotal skin is thickened on the left side compared
to the right side.
Figure 2 Transverse US scan of
the left hemiscrotum shows an inhomogeneous small
testis (T), an inhomogeneous echoic tract (thick
arrows) connecting to the scrotal abscess (thin
arrows), which is seen as a complex echoic mass.
Figure 3 Colour Doppler US of
the left testis shows increased peritesticular vascularity
but absence of intravascularity indicating testicular
At operation, the scrotal skin was thickened and inflamed.
There was thick pus in the left scrotal sac (Figure 4). The
left testis and epididymis were necrotic (Figure 5). Left
orchiectomy was performed.
Figure 4 At operation, (a) thick
pus was found in the left scrotum; and (b) the left
testis was necrotic (arrow).
Epididymitis and epididymo-orchitis are two most common causes
of acute scrotal pain in adults. The infection usually originates
in the genitourinary tract, particularly the bladder, urethra,
and prostate. The most common pathogens are Neisseria gonorrhoea,
Chlamydia trachomatis, Escherichia coli, or Proteus mirabilis.
The inflammation usually starts in the epididymis and then
spreads to the testis [1-3].
If the patients do not receive appropriate treatment it could
result in many complications including pyocoele, testicular
infarction, testicular abscess, scrotal abscess, and fulminant
fasciitis (Fournier’s gangrene) .
Patients with epididymo-orchitis usually present with fever,
dysuria, and a painful scrotal enlargement. The pain is usually
insidious in onset and increases slowly over 1 to several
days. Physical examination may not be possible to differentiate
the epididymis and testis due to pain and swelling, making
it difficult to evaluate the real extent of the lesion. Differential
diagnosis with acute testicular torsion can sometimes be a
problem because of similar clinical presentation. US with
colour Doppler is helpful in evaluating these patients to
prevent unnecessary surgical exploration [1-4].
Grayscale US findings of epididymo-orchits are enlarged hypoechoic
epididymis and testis. These findings are non-specific and
indistinguishable from testicular torsion but colour Doppler
US findings are different. Vascularity is increased in epididymo-orchits
but decreased in testicular torsion. However, advanced epididymo-orchitis
may cause testicular infarction as a result of extrinsic compression
of testicular vascular supply by enlarged epididymis and spermatic
cord and pyocoele [1,4-6],
therefore, intratesticular vascularity is decreased. This
finding suggests the need for surgical intervention. In addition,
severe epididymo-orchitis may also cause testicular abscess
and scrotal abscess, which is demonstrated as a complex echoic
The presented case shows a severe epididymo-orchitis spreading
from a urinary tract infection complicated with testicular
necrosis and scrotal abscess.
Feld R, Middleton WD. Recent advances in sonography of the testis and scrotum. Radiol Clin North Am 1992;30(5):1033-51.
Muttarak M, Lojanapiwat B. The painful scrotum: an ultrasonographical approach to diagnosis. Singapore Med J 2005;46(7):352-7; quiz 358.
Dogra VS, Gottlieb RH, Oka M, et al. Sonography of the scrotum. Radiology 2003;227(1):18-36.
Pavlica P, Barozzi L. Imaging of the acute scrotum. Eur Radiol 2001;11(2):220-8.
Horstman WG. Scrotal imaging. Urol Clin North Am 1997;24(3):653-71.
Berman JM, Beidle TR, Kunberger LE, et al. Sonographic evaluation of acute intrascrotal pathology. AJR Am J Roentgenol 1996;166(4):857-61.
Received 19 August 2005; accepted
26 September 2005
Correspondence: Department of Radiology, Chiang Mai University, Chiang Mai 50200, Thailand.. Tel.: 66-53-945450; Fax: 66-53-217144; E-mail: email@example.com (Malai Muttarak).
Please cite as: M Muttarak, W Na Chiangmai,
Necrotising epididymo-orchitis with scrotal abscess, Biomed Imaging Interv J 2005; 1(2):e11
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