What is the appropriate diagnosis and treatment for a painful single ulcerated scrotal lesion?

Painful Single Ulcerated Scrotal Lesion: Diagnosis and Management

A painful single ulcerated scrotal lesion requires immediate evaluation with duplex Doppler ultrasound to exclude testicular torsion and other surgical emergencies, followed by consideration of infectious etiologies (epididymo-orchitis, sexually transmitted infections), malignancy (squamous cell carcinoma, sarcoma), and rare inflammatory conditions (Lipschütz ulcer, ecthyma gangrenosum). 1

Initial Diagnostic Approach

Immediate ultrasound evaluation is mandatory to assess for life-threatening conditions that require urgent surgical intervention within 6-8 hours 2:

• Duplex Doppler ultrasound of the scrotum is the first-line imaging modality, with sensitivity of 96-100% for detecting testicular torsion 1, 2
• Grayscale examination should assess for testicular homogeneity, the "whirlpool sign" of twisted spermatic cord, and characteristics of the ulcerated lesion 1, 2
• Color and Power Doppler assessment evaluates testicular perfusion—decreased or absent flow suggests torsion requiring immediate urological consultation 1, 2

Critical Time-Sensitive Differential Diagnoses

Testicular Torsion (Surgical Emergency)

• Abrupt onset of severe scrotal pain with decreased/absent testicular blood flow on Doppler requires immediate surgical exploration 2
• Testicular viability is compromised if not treated within 6-8 hours of symptom onset 2
• Even with a visible ulcer, underlying torsion must be excluded as it can present atypically 2

Epididymo-Orchitis (Most Common in Adults)

• Gradual onset of pain with enlarged epididymis showing increased blood flow on Doppler 1
• Scrotal wall thickening and hydrocele are common findings 1
• Up to 20% have concomitant orchitis 1

Infectious Etiologies Causing Ulceration

Sexually Transmitted Infections

For epididymitis with ulceration in sexually active men, empiric treatment should cover both gonococcal and chlamydial infections 3:

• Ceftriaxone 250 mg IM single dose PLUS Doxycycline 100 mg PO twice daily for 10 days 3
• Add bed rest, scrotal elevation, and analgesics until inflammation subsides 3
• Failure to improve within 3 days requires reevaluation of diagnosis and consideration of abscess, tumor, or atypical organisms 3

Herpes Simplex Virus

If painful genital ulcers with vesicular appearance are present:

• Valacyclovir 1 gram PO twice daily for 7-10 days for initial episode 4
• Acyclovir 400 mg PO 5 times daily is an alternative 5
• Treatment is most effective when initiated within 72 hours of symptom onset 4, 5

Ecthyma Gangrenosum

• Ulcerating lesion with central necrosis and eschar surrounded by erythema in immunocompromised patients suggests Pseudomonas aeruginosa infection 6
• Requires immediate broad-spectrum antibiotics and surgical debridement 6
• Blood and tissue cultures are essential for confirming diagnosis 6

Lipschütz Ulcer (Ulcus Vulvae Acutum - Male Counterpart)

• Acute excruciating genital ulcer with self-limited course associated with systemic infection, most commonly primary Epstein-Barr virus 7
• Preceded by symptomatic pharyngeal infection with fever and constitutional symptoms 7
• Diagnosis of exclusion after ruling out sexually transmitted infections and malignancy 7

Malignant Etiologies

Squamous Cell Carcinoma of Scrotum

• Ulcerated-bleeding lesion in older men (typically >60 years) requires biopsy 8
• Radical surgical excision is the definitive treatment for localized disease 8
• Any chronic non-healing scrotal ulcer warrants tissue diagnosis 8

Leiomyosarcoma

• Large ulcerated scrotal mass originating from subcutaneous tissue 9
• Radical orchiectomy with high ligation of spermatic cord is required 9
• Early diagnosis and surgical excision offer good prognosis; delayed diagnosis has poor outcomes 9

Leukemia Cutis

• Chronic genital ulcer failing antibiotic therapy in patients with history of leukemia 10
• May herald relapse of acute myelogenous leukemia 10
• Any skin lesion in a leukemia patient requires biopsy 10

Algorithmic Management Approach

1. Immediate ultrasound with Doppler to exclude torsion and assess vascular flow 1, 2

2. If torsion suspected: Immediate urological consultation for surgical exploration within 6-8 hours 2

3. If increased epididymal flow with ulceration:

   • Obtain urinalysis and cultures 3
   • Start empiric antibiotics: Ceftriaxone + Doxycycline 3
   • Supportive care: bed rest, scrotal elevation, analgesics 3
   • Reassess in 3 days—if no improvement, consider imaging for abscess and tissue biopsy 3

4. If vesicular/ulcerative lesions suggest HSV:

   • Start antiviral therapy: Valacyclovir 1 gram twice daily 4
   • Viral culture or PCR for confirmation

5. If immunocompromised with necrotic ulcer:

   • Broad-spectrum antibiotics immediately 6
   • Surgical debridement 6
   • Blood and tissue cultures 6

6. If chronic non-healing ulcer or suspicious for malignancy:

   • Tissue biopsy is mandatory 10, 8
   • Referral to urology or surgical oncology for definitive management 9, 8

Critical Pitfalls to Avoid

• Never delay imaging for suspected torsion—false-negative Doppler can occur in partial torsion or spontaneous detorsion, but clinical suspicion should drive immediate surgical consultation 2, 11
• Normal urinalysis does not exclude epididymitis or torsion 2
• Any non-healing ulcer after 3 days of appropriate antibiotics requires tissue diagnosis to exclude malignancy, abscess, or atypical infection 3, 10
• Immunocompromised patients require aggressive early intervention as necrotizing infections can progress rapidly 6
• In patients with leukemia history, biopsy any new skin lesion as it may represent cutaneous relapse 10