What is the appropriate treatment for a patient with bilateral scrotal abscesses, epididymo-orchitis, and varicocele?

Management of Bilateral Scrotal Abscesses with Epididymo-Orchitis

This patient requires immediate broad-spectrum intravenous antibiotics covering polymicrobial infection, urgent surgical consultation for abscess drainage, and close monitoring for testicular viability, as scrotal abscesses with epididymo-orchitis represent a surgical emergency that can progress to testicular infarction and loss despite appropriate antibiotic therapy.

Immediate Antibiotic Therapy

Initiate broad-spectrum IV antibiotics immediately upon diagnosis, as the presence of bilateral scrotal abscesses indicates severe, complicated infection requiring parenteral therapy. 1

Recommended Antibiotic Regimens

The European Association of Urology 2024 guidelines provide specific regimens for severe scrotal infections with abscess formation:

• Piperacillin-tazobactam 4.5 g IV every 6-8 hours PLUS vancomycin 15 mg/kg IV every 12 hours 1
• Alternative: Meropenem 1 g IV every 8 hours (provides excellent polymicrobial coverage including Enterobacterales and anaerobes) 1
• Alternative: Imipenem-cilastatin 1 g IV every 6-8 hours 1

Rationale for Parenteral Therapy

The presence of bilateral scrotal abscesses with heterogeneous collections (3.6 cc right, 2.1 cc left) and diffusely enlarged epididymides with increased vascularity indicates severe infection requiring IV antibiotics rather than oral therapy. 1 The polymicrobial nature of scrotal abscesses necessitates coverage for Enterobacterales, anaerobes, and potentially resistant organisms. 1

Urgent Surgical Intervention

Surgical drainage is mandatory for scrotal abscesses, as failure to drain can lead to testicular infarction and loss even with appropriate antibiotic therapy. 2, 3, 4

Indications for Surgery

• Presence of organized fluid collections (abscesses) on ultrasound - this patient has bilateral collections measuring 3.2 x 0.9 x 2.3 cm (right) and 2.4 x 1.3 x 1.3 cm (left) 2, 3
• Failure to improve within 48-72 hours of IV antibiotic therapy 1, 2
• Clinical signs of testicular compromise (malacia, loss of differentiation between epididymis and testis) 2

Surgical Approach

• Perform organ-sparing surgery with abscess drainage and debridement of necrotic tissue whenever possible, particularly given bilateral involvement 5, 2
• Send intraoperative cultures to guide antibiotic therapy (common organisms include Enterobacterales, Morganella morganii, and anaerobes) 5, 2
• Orchiectomy should be reserved for cases with complete testicular infarction or non-viable tissue 5, 2, 3, 4

Critical Monitoring for Testicular Viability

Serial clinical examinations and repeat scrotal ultrasound are essential, as testicular infarction can occur despite appropriate antibiotic therapy and may not be evident on initial imaging. 3, 4

Warning Signs of Testicular Infarction

• Persistent or worsening pain despite 48-72 hours of IV antibiotics 2, 3, 4
• Loss of palpable differentiation between epididymis and testis 2
• Development of testicular malacia (softening) 2
• Decreased or absent central testicular blood flow on color Doppler ultrasound (may show peripheral hyperemia with central avascularity) 3, 4

Ultrasound Limitations

Routine ultrasonography may not detect early testicular ischemia or abscess formation, requiring high clinical suspicion when imaging is inconsistent with clinical presentation. 3, 4 This patient's ultrasound shows homogeneous testicular parenchyma, but clinical deterioration would mandate repeat imaging or surgical exploration. 3, 4

Duration and Transition of Antibiotic Therapy

• Continue IV antibiotics for at least 48 hours after clinical improvement (resolution of fever, decreased scrotal swelling and tenderness) 1
• Transition to oral antibiotics after clinical improvement with doxycycline 100 mg orally twice daily for 10-14 days total therapy 1
• Consider adding metronidazole 500 mg orally twice daily if anaerobic coverage is needed based on culture results 1

Management of Associated Findings

Varicocele

The bilateral varicocele (0.4 cm right, 0.3 cm left) requires no acute intervention and should be reassessed after resolution of infection. 1 Varicocele does not contribute to the infectious process and surgical correction, if needed, should be deferred until complete recovery. 1

Testicular Microcalcifications

Bilateral testicular microcalcifications are an incidental finding requiring no immediate treatment but warrant long-term surveillance for testicular malignancy risk, particularly if other risk factors are present. 1 This should be addressed after resolution of acute infection. 1

Reactive Inguinal Lymphadenopathy

The right inguinal lymph node (1.0 x 0.7 cm with fatty hilum) is reactive to the scrotal infection and requires no specific intervention beyond treating the primary infection. 1

Common Pitfalls to Avoid

• Do not delay surgical consultation - scrotal abscesses require drainage, and delayed intervention increases risk of testicular loss 2, 3, 4
• Do not rely solely on initial ultrasound findings - testicular infarction may develop despite normal initial imaging 3, 4
• Do not use oral antibiotics alone - the presence of abscesses mandates IV therapy 1
• Do not perform bilateral orchiectomy without attempting organ-sparing surgery - testicular salvage is possible even with significant abscess formation 5, 2
• Do not discharge without 48-72 hour reassessment - failure to improve mandates surgical intervention 1, 2

Mandatory Follow-Up

• Clinical reassessment within 48-72 hours to evaluate response to therapy 1, 2
• Repeat scrotal ultrasound if clinical improvement is not evident or if testicular viability is questioned 3, 4
• Post-treatment ultrasound to document resolution of abscesses and assess testicular parenchyma 5, 2