What is the recommended treatment for scrotal cellulitis?

Treatment of Scrotal Cellulitis

The recommended first-line treatment for scrotal cellulitis is broad-spectrum antibiotics targeting common pathogens like Enterobacterales, along with surgical intervention if there is evidence of abscess formation or progression to Fournier's gangrene. 1

Antibiotic Therapy

Initial Empiric Treatment

• First-line antibiotics:
  • Cephalexin 500 mg 3-4 times daily for 5-6 days 2
  • Amoxicillin-clavulanate 875/125 mg twice daily orally for 5-6 days 2

Alternative Options (for penicillin-allergic patients):

• Clindamycin 300-450 mg orally three times daily for 5-6 days 2

Duration of Treatment:

• Standard duration: 5-7 days for uncomplicated cases 2, 3
• Extended treatment may be necessary if:
  • No improvement within 72 hours
  • Presence of systemic symptoms
  • Immunocompromised patients
  • Elderly patients or those with diabetes 2

Assessment and Monitoring

• Clinical improvement should be assessed within 72 hours of starting therapy 2
• If no improvement is seen, consider:
  • Changing antibiotic regimen
  • Surgical evaluation for possible abscess or deeper infection
  • Imaging studies to rule out Fournier's gangrene

Surgical Management

• Surgical intervention is essential if:
  • Abscess develops
  • Signs of tissue necrosis are present
  • Progression to Fournier's gangrene is suspected 1, 4
• Linear incisions may be needed to decompress fluid accumulation between Colles' and Buck's fascia to prevent devascularization and gangrene 5
• Radical debridement is necessary if gangrene develops 5, 4

Special Considerations

Fournier's Gangrene

• Requires immediate aggressive treatment:
  • Broad-spectrum antibiotics on presentation
  • Urgent surgical debridement
  • Possible colostomy to maintain a clean environment for healing 1, 4
• High index of suspicion needed, especially in:
  • Immunocompromised patients
  • Diabetic patients
  • Patients with high BMI 1

Pediatric Patients

• In neonates and infants, scrotal cellulitis may require distinct antibiotic coverage:
  • Consider coverage for anaerobic bacteria 6
  • Antibiotics should be adjusted based on clinical response 7, 6

Clinical Pitfalls and Caveats

1. Delayed diagnosis risk: Insidious onset with undiagnosed pain can delay treatment in up to 40% of cases, particularly in obese patients 1
2. Misdiagnosis risk: Scrotal swelling may be confused with testicular torsion; proper evaluation is crucial 7
3. Inadequate debridement: Insufficient surgical intervention in cases with abscess or necrosis can lead to progression of infection 5
4. Failure to recognize Fournier's gangrene: This aggressive infection requires immediate surgical intervention; delay can be fatal 1, 4
5. Inadequate antibiotic coverage: Consider local resistance patterns when selecting empiric therapy 2

When to Consider Hospitalization

• Presence of systemic symptoms (fever, tachycardia)
• Signs of deeper or necrotizing infection
• Poor response to outpatient treatment
• Immunocompromised patients
• Need for surgical intervention 2

Early diagnosis and appropriate antibiotic treatment are essential to prevent spread of infection and serious complications like Fournier's gangrene, which carries significant morbidity and mortality.