What is the recommended treatment for scrotal cellulitis and abscess?

Treatment of Scrotal Cellulitis and Abscess

For scrotal cellulitis and abscess, the recommended treatment includes prompt surgical drainage of any abscess followed by appropriate antibiotic therapy targeting both aerobic and anaerobic organisms, with consideration for coverage against MRSA in high-risk patients. 1

Initial Assessment and Management

Diagnostic Approach

• Evaluate for systemic signs of infection (fever, tachycardia, hypotension)
• Assess for fluctuance suggesting abscess formation
• Consider blood cultures in patients with systemic signs of infection 1
• Ultrasound may help differentiate abscess from cellulitis in unclear cases 2
• Rule out testicular torsion, which is a surgical emergency requiring immediate intervention 1

Surgical Management

• Incision and drainage is the primary treatment for any scrotal abscess 1
• Linear incisions may be necessary to decompress fluid accumulation and prevent skin devascularization 3
• Cultures of abscess material should be obtained during drainage to guide antibiotic therapy 1

Antibiotic Therapy

For Mild to Moderate Scrotal Cellulitis (Outpatient)

• First-line therapy:
  • Cephalexin 500 mg orally four times daily for 5-10 days 1
  • OR Clindamycin 300-450 mg orally four times daily for 5-10 days (if MRSA suspected or penicillin allergy) 1, 4

For Severe Cellulitis or Abscess (Consider Hospitalization)

• Intravenous therapy options:
  • Vancomycin 15 mg/kg IV every 12 hours (for MRSA coverage) 1
  • PLUS one of the following for broad-spectrum coverage:
    • Piperacillin-tazobactam 3.375 g IV every 6 hours 1
    • OR Ceftriaxone 1 g IV daily plus metronidazole 500 mg IV every 8 hours 1, 5

Special Considerations

• For perineal/scrotal infections, coverage for both aerobic and anaerobic organisms is essential 1
• Duration of therapy: 5 days is typically sufficient, but extend if infection has not improved 1, 6
• Consider MRSA coverage if:
  • Previous MRSA infection
  • Purulent drainage
  • Injection drug use
  • Systemic inflammatory response syndrome (SIRS) 1

Adjunctive Measures

• Scrotal elevation to reduce edema 1
• Adequate analgesia 1
• Bed rest until fever and local inflammation have subsided 1
• Consider adding an anti-inflammatory agent (such as ibuprofen) to hasten resolution of inflammation 7

Hospitalization Criteria

• Severe pain suggesting deeper infection or other diagnoses
• Presence of fever or systemic toxicity
• Concern for necrotizing infection (Fournier's gangrene)
• Immunocompromised status
• Failed outpatient therapy 1

Follow-Up

• Reassess within 48-72 hours of initiating therapy
• Failure to improve within 3 days requires reevaluation of both diagnosis and treatment 1
• Consider alternative diagnoses if swelling and tenderness persist after completion of therapy (tumor, infarction, testicular cancer, tuberculosis) 1

Important Pitfalls to Avoid

1. Failing to distinguish between simple cellulitis and Fournier's gangrene (necrotizing fasciitis), which requires immediate surgical debridement
2. Delaying surgical drainage of a scrotal abscess, which can lead to skin necrosis 3
3. Using inadequate antibiotic coverage for polymicrobial infections in the perineal/scrotal region
4. Missing testicular torsion, which requires immediate surgical intervention
5. Failing to extend antibiotic therapy when clinical improvement is inadequate after 5 days 1

Remember that scrotal cellulitis and abscess can progress rapidly, and early aggressive management is essential to prevent serious complications including tissue necrosis and systemic infection.