|Year : 2016 | Volume
| Issue : 4 | Page : 164-168
Scrotal abscess: Varied etiology, associations, and management
Raghu S Ramareddy, Anand Alladi
Department of Pediatric Surgery, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India
|Date of Web Publication||19-Jul-2016|
Department of Pediatric Surgery, Bangalore Medical College and Research Institute, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Aim: To report a series of scrotal abscess, a rare problem, their etiology, and management. Materials and Methods: A retrospective study of children who presented with scrotal abscess between January 2010 and March 2015, analyzed with respect to clinical features, pathophysiology of spread and management. Results: Eight infants and a 3-year-old phenotypically male child presented with scrotal abscess as a result of abdominal pathologies which included mixed gonadal dysgenesis (MGD) ; three anorectal malformations with ectopic ureter , urethral stricture , and neurogenic bladder ; meconium peritonitis with meconium periorchitis , ileal atresia , and intra-abdominal abscess ; posturethroplasty for Y urethral duplication with metal stenosis  and idiopathic pyocele . Transmission of the organism had varied routes include fallopian tube , urethra ejaculatory reflux , hematogenous , and the patent process of vaginalis . Two of the nine required extensive evaluation for further management. Treating the predisposing pathology resolved scrotal abscesses in eight of nine patients, one of whom, required vasectomy additionally. Idiopathic pyocele responded to needle aspiration and antibiotics. Conclusion: Scrotal abscess needs a high index of suspicion for predisposing pathology, especially in infants. Laparoscopy is safe and effective in the management of the MGD and ectopic ureter.
Keywords: Ectopic ureter, laparoscopy, mixed gonadal dysgenesis, prostatic utricle, scrotal abscess
|How to cite this article:|
Ramareddy RS, Alladi A. Scrotal abscess: Varied etiology, associations, and management. J Indian Assoc Pediatr Surg 2016;21:164-8
| Introduction|| |
In infants and prepubertal children, anatomical urinary tract abnormality predisposes for recurrent epididymitis. ,, Urethro ejaculatory reflux (UER) can be pathological or idiopathic. ,, Epididymitis is the most frequent cause of the scrotal abscess. Prostatic utricle (PU) is a tubular or vesicular, midline cystic structure which communicates with the urethra. Blind-ending ectopic ureter into the prostatic urethra may mimic PU. Cystoscopic-guided laparoscopy is the most useful investigation in delineating, differentiating and managing of PU and ectopic ureter.
We are reporting unusual retrograde urinary reflux into the genital tract secondary to varied predisposing factors such as PU, ectopic ureters, mixed gonadal dysgenesis (MGD), resulting in scrotal abscess, associations like, renal agenesis (RA), anorectal malformation (ARM) with congenital/acquired urethral problem, meconium peritonitis, and the success of minimally access surgery (MAS).
| Materials and methods|| |
A retrospective study of children with scrotal abscess between 2010 January and 2015 March were analyzed with respect to clinical features, pathophysiology of spread and management options.
| Results|| |
A 3-year-old child reared as male presented with pyuria, left recurrent scrotal abscesses and mid penile hypospadias. On radiological evaluation, he had right RA, partial duplex left kidney and a PU, left scrotal abscess without testicular elements. And normal opposite testis. Karyotype revealed a mosaic pattern (45XO/46XY: 45%/55%). Child under went cystoscopy guided laparoscopic excision of PU, left hemi uterus and fallopian tube while gonad with vas and its vessels were retrieved from the inguinal incision [Table 1].
Histopathology of specimen [Figure 1] demonstrated PU lined by stratified squamous epithelium, fallopian tube, vas deferens and epididymal tubules without a testicular tissue. Follow-up cystoscopy and micturating cystourethrogram (MCU) at 4 months were normal. The child was asymptomatic during 2 years follow-up.
|Figure 1: Gross specimen showing excised prostatic utricle with attached fallopian tube (Split arrow) along with remaining fallopian tube and gonad removed by inguinal exploration kept in continuity (Broken arrow)|
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The second baby was a 2 weeks old boy with abdominal mass since 1 week followed by right scrotal swelling. The clinical and radiological evaluation was suggestive of subhepatic and scrotal abscess without testicular vascularity. He underwent drainage of abscess, excision of right necrotic tissue and contralateral orchidopexy. Histology of excised tissue revealed inflammatory cells, fibro-collagenous tissues, tubules, and vas. Postoperative recovery was uneventful.
Three children with ARM had scrotal abscess due to varied predispositions and included, one each of urethral stricture, dysfunctional elimination and ectopic ureter [Figure 2]. All of them developed the scrotal abscess due to UER. All responded to the management of predisposing causes.
|Figure 2: Preoperative micturating cystourethrogram with distal loop gram (hollow arrow) and cystoscopy with bug bee delineating refluxing ureter; laparoscopy view showing ectopic blind dilated ureter with endo-loop knot (vertical solid arrow) and preserved vas (vertical hollow arrow) and postoperative residual stump (horizontal solid arrow)|
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Two neonates with meconium peritonitis one of which was associated with ileal atresia presented with right inguinal hernia. Both of them responded well to laparotomy and treatment of the primary pathology. One of them had an antenatal diagnosis of an inguinal hernia.
An 11-month-old boy underwent composite urethroplasty for Y urethral duplication and anal transposition for anterior ectopic anus. He had voiding problem due to meatal stenosis and later presented with left scrotal abscess due to UER. He responded to calibrations.
The last child was a 6 months old idiopathic scrotal pyocele which responded aspiration.
| Discussion|| |
A scrotal abscess may result from the extension of epididymo-orchitis or neglected testicular torsion, spread of intra-abdominal abscess via patent process vaginalis, idiopathic, and hematogenous route of systemic infection. , Oblique, narrow terminal course of ejaculatory duct and its sphincter muscle with valves prevents UER.  Ejaculatory duct dysfunction is multifactorial. Wolffian duct caudal obstruction or abnormal insertion into the posterior urethra are predisposing factors for epididymitis.  Scrotal abscess may be solitary or multiple, unilateral/bilateral, rarely recurrent and often secondary to pathological UER. ,, Scrotal pus may yield Escherichia coli and staphylococcus organisms and often sterile due to previous treatment with antibiotics. 
In the first patient, the spread of infection was either through UER or more likely due to wide opened mouth of fallopian tube on PU and least resistance to retrograde urinary reflux which was demonstrated by clinical examination of compressing the scrotum yielding pus discharge per urethral meatus and histology of vas and the tube in our case. This type of spread is rare. Sertoli cells secrete Mullerian Inhibiting Substance (MIS) and cause complete degeneration of mullerian ducts in male within 9-10 weeks. PU is embryologically/histologically derived from the urogenital sinus and Wolffian cells caudally and the Mullerian duct cells cranially. 
Normal testis and contralateral gonadal agenesis are one of the rare presentations of MGD.  Abnormal or agenesis of testes associated with MGD can cause incomplete regression of Mullerian duct due to deficiency of MIS.  Paracrine action of growth signals are needed in the concomitant development of ipsilateral Wolffian ducts, Mullerian ducts, and urogenital ridge. ,, Inappropriate level of gonadal normal cell line in the mosaic,  receptor quantity  deficiency, quantitative defects of local testosterone/dihydrotestosterone  and improper exocrine transport of testosterone and MIS along Wolffian duct,  can cause errors in differentiation of the Wolffian duct/Mullerian duct derivatives, incomplete masculinization of the urogenital sinus and genital tubercle which ultimately result in ipsilateral presence of fallopian tube, hemi uterus, PU, and hypospadias. Embryological assault after 7 weeks may cause reproductive tract anomaly. ,, There is no single embryological combination etiology which explains the association of unilateral RA and contralateral anorchia. Hence, our MGD is a complex genetically heterogeneous developmental disorder with variable phenotype presentation.
The 2 rd child presented with abdominal swelling initially, followed by scrotal swelling. There was bag of pus in tunica albuginea without any features of torsion. The route of seeding may have been hematogenous, as laparoscopy did not reveal any communication between the two cavities. Scrotal pathology often reflects intra-abdominal disease. , Necrotizing epididymorchitis and neglected perinatal torsion of testis may both result in a scrotal abscess.  Clinical, radiological, operative findings, and histology may all not be to differentiate between the above two causes, in cases of severe scrotal abscess and both usually ends up in orchiectomy.  Omphalitis or necrotizing enterocolitis and hematogenous spread might have caused an abscess in abdomen and scrotum. Treatment modalities of epididymorchitis are early diagnosis with antibiotic, drainage/aspiration, and rarely gonad excision.  Idiopathic pyocele can be treated with needle aspiration and antibiotic.
The child with ARM had recurrent scrotal abscess due to ectopic ureter distorting protective mechanism of the ejaculatory duct. Loss of glial cell line-derived neurotrophic factor (GDNF) leads to RA and mutations in tyrosine kinase receptor (RET) is associated with RA, duplex kidney, ectopic hydroureter, congenital heart diseases and gonadal abnormalities. This can also be due to defects of genes related to GDNF/RET pathway, like Spry1, Gata3, Bmp4, Slit2/Robo2, Foxc1/2, Pax2, Eya1/Six1, and Sall1.  Quantitative difference in the apoptosis of caudal Wolffian duct/common nephrogenic cord, , failure of reciprocal interaction between ureteric bud and metanephric blastemal,  obstructive ectopic ureter and cranial origin of ureter bud, ,,, and proliferative mesenchymal abnormality around common mesonephric duct  can cause RA, persistent mesonephric duct, ectopic ureter, and ureter-genital fistula. ,, Severe mesenchymal abnormality may also result in ARM.  Embryological event before 7 th week affects ureteric bud, reproductive tract, and cloacal division.  Single system unilateral blind ending hydro ureter in males may be reflexing/obstructive, or both. Ectopic ureter may terminate in to the supra sphincteric genitourinary tract, usually involving the seminal vesicle, vas, prostatic urethra and rarely presents as recurrent scrotal abscess due to urogenital reflux. ,,,, Persistent mesonephric duct, ectopic vas, ectopic ureter are common causes for recurrent unilateral epididymitis postpull thorough in the young infantile ARMs. , Magnetic resonance urography with gadolinium contrast enhancement is the investigation of choice as it gives anatomy and functioning aspect of the kidney and ureters.  MCU with distal loop gram and dimercaptosuccinic acid (DMSA) scan can sometimes pick up refluxing blind ending tubular ureter behind the bladder as in our case. DMSA reveals site and functioning status of the kidney. In our patient, it also depicted grossly dilated, atonic, blind ending reflexing ectopic ureter. Ectopic ureter presenting as a giant paravertebral tubular structure terminating in posterior urethra has to be differentiated from PU by its orientation and histology.  Transabdominal open, MIS, Posterior sagittal approaches have been used for corrections of the ectopic ureter, a division of rectourethral fistula and pull through of rectum in ARM cases. Long-term surveillance of urological system is required in these children.  ARM cases developed UER due to acquired stricture and neurogenic bladder. Urogenital infections settled after clean intermittent catheterization (CIC). Dysfunctional voiding, neurogenic bladder, ectopic ureter, acquired/congenital urethral fistula or stricture, distal loop wash may cause urogenital infection in ARM.
Meconium pseudocyst with sealed off antenatal bowel perforation and flow of meconium into scrotum causes a meconium periorchitis which can be misinterpreted as a reducible or obstructed hernia in a neonate leading to emergency inguinal exploration. In the presence of antenatal findings of the echogenic bowel, postnatal abdominal distension/mass, a high index of suspicion should be kept, and further evaluation by an X-ray and ultrasound should be carried out before inguinal exploration. These children would normally require a laparotomy. Differential diagnosis of echogenic space occupying lesion in scrotum includes a hernia, hydrocele, and meconium periorchitis.  Meconium periorchitis generally require only follow-up and no surgical intervention. In our patient by having a high index of suspicion and ultrasonography of abdomen which would have picked up a pseudocyst surgery-both the inguinal exploration and the laparotomy could have been avoided. This was especially so as the bowel was normally moving with no features of obstruction. , Meconium peritonitis with bowel obstruction responds well after bowel surgery. Soft reducible meconium hydrocele is often mistaken as a reducible hernia in the perinatal period. All our cases reemphasis management of the abdominal pathology in addition to treating scrotal disease.
Recurrent scrotal abscess requires thorough complete genitourinary evaluation and corrections of the associated anomalies early could prevent vasectomy. ,,, Laparoscopic management of PU with disorder of sex development (DSD) and blind ending ectopic ureter is a safe and viable alternative with the added benefit of minimally invasive surgery. In addition, it provides a magnified view of the internal genitalia and ureter. Cystoscopic-guided laparoscopic excision of PU and ectopic ureter is reported sparsely. ,,,,,
| Conclusion|| |
Recurrent scrotal abscess has varied genitourinary or gastrointestinal associated anomalies and requires comprehensive evaluation and prolonged follow-up. Laparoscopy with the assistance of cystoscopy is safe in planning and devising surgical option for the excision of PU and ectopic ureter terminating into the posterior urethra. Acquired urethral obstructions in ARM may present with complicated urogenital infections.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]