What is the treatment for a scrotal abscess?

Treatment of Scrotal Abscess

The primary treatment for a scrotal abscess is immediate surgical incision and drainage, followed by appropriate antibiotic therapy if systemic signs of infection are present or in immunocompromised patients. 1

Diagnostic Approach

• Scrotal abscess presents with:

  • Pain and swelling of the scrotum
  • Erythema and warmth of scrotal skin
  • Possible fever and elevated white blood cell count
  • May have systemic symptoms in severe cases

• Differentiate from other causes of scrotal pain:

  • Testicular torsion (surgical emergency with sudden onset)
  • Epididymitis (may progress to abscess if untreated)
  • Fournier's gangrene (rapidly progressive necrotizing infection)

• Diagnostic tools:

  • Scrotal ultrasound with Doppler to confirm abscess and rule out torsion 2
  • Urinalysis and urine culture if urinary tract infection suspected
  • Blood cultures if systemic infection present

Treatment Algorithm

1. Surgical Management (Primary Treatment)

• Prompt incision and drainage of the abscess 1, 3
• For large abscesses, use multiple counter incisions rather than a single long incision to prevent step-off deformity and delayed wound healing 1
• Debridement of necrotic tissue if present
• Collection of pus for culture and sensitivity testing

2. Antibiotic Therapy

• Simple, localized abscess with adequate drainage:

  • May not require antibiotics if drainage is complete and patient is immunocompetent 1

• Complex abscess or with systemic signs of infection:

  • Empiric broad-spectrum antibiotics covering Gram-positive, Gram-negative, and anaerobic bacteria 1
  • Initial regimen options:
    • Piperacillin-tazobactam 4.5g IV every 6-8 hours, or
    • Ceftriaxone 1-2g IV daily plus Metronidazole 500mg IV every 6 hours 1
  • Adjust antibiotics based on culture results and clinical response

• If sexually transmitted infection is suspected:

  • Ceftriaxone 250mg IM single dose PLUS
  • Doxycycline 100mg orally twice daily for 10 days 1, 2

3. Supportive Care

• Bed rest and scrotal elevation until inflammation subsides 1, 2
• Adequate pain management with NSAIDs or stronger analgesics as needed
• Regular wound care and dressing changes

Special Considerations

Diabetic Patients

• More aggressive treatment approach due to higher risk of progression to Fournier's gangrene 3
• Tight glycemic control is essential
• Lower threshold for broader antibiotic coverage and longer duration

Immunocompromised Patients

• Lower threshold for antibiotic therapy even with adequate drainage 1
• Consider longer duration of antibiotics
• Closer follow-up to ensure resolution

Fournier's Gangrene Risk

• If rapid progression, crepitus, or extensive tissue necrosis is present, treat as Fournier's gangrene 4
• More aggressive surgical debridement
• Consider broader antibiotic coverage with regimens such as:
  • Piperacillin-tazobactam plus Vancomycin, or
  • Imipenem-cilastatin, or
  • Meropenem plus Clindamycin 1

Follow-up

• Clinical improvement should be seen within 3 days of treatment 2
• If no improvement:
  • Re-evaluate diagnosis
  • Consider repeat imaging to assess for residual collection
  • Consider repeat surgical exploration
  • Adjust antibiotics based on culture results

Potential Complications

• Progression to Fournier's gangrene
• Testicular ischemia or infarction
• Chronic scrotal pain
• Infertility
• Abscess recurrence

By following this treatment approach, most scrotal abscesses can be successfully managed with good outcomes and minimal morbidity. Early recognition and prompt surgical intervention are key to preventing progression to more serious conditions like Fournier's gangrene.