Complications and Treatment of Scrotal Abscess
Scrotal abscess requires prompt surgical drainage to prevent progression to life-threatening Fournier's gangrene, with antibiotics reserved for cases with systemic infection, immunocompromise, or inadequate source control.
Major Complications
Life-Threatening Progression
- Fournier's gangrene (necrotizing fasciitis) is the most devastating complication, requiring emergency surgical debridement and broad-spectrum antibiotics 1
- Progression to Fournier's gangrene is particularly concerning in diabetic patients with poorly controlled glycemia 2, 3
- Systemic sepsis can develop, especially in immunocompromised patients or those with delayed treatment 1
Local Complications
- Testicular ischemia and atrophy from compression or extension of infection 1
- Chronic pain and recurrent abscess formation if inadequately drained 4, 5
- Fistula formation, including urethroscrotal fistulas in cases of iatrogenic injury 2
- Testicular loss requiring orchiectomy when tissue is non-salvageable 1
Treatment Algorithm
Initial Assessment
- Perform focused physical examination looking for scrotal swelling, erythema, tenderness, and ability to palpate testicular contours 1
- Check for systemic signs: fever, tachycardia, hypotension indicating sepsis 1
- Obtain complete blood count, inflammatory markers (CRP, procalcitonin), and blood glucose/HbA1c to screen for diabetes 1
- Ultrasound is the first-line imaging modality for diagnosis, showing fluid collection separate from testicular structures 1
Surgical Management (Primary Treatment)
- Incision and drainage is mandatory for all scrotal abscesses 1, 4, 5
- Perform scrotal exploration with debridement of non-viable tissue and tunical closure when possible 1
- Make incisions as close to the abscess as feasible while ensuring complete drainage 4, 5
- Multiple counter-incisions are preferred over single long incisions for larger abscesses to prevent delayed healing 4, 5
- Send pus for culture, particularly in high-risk patients or those with risk factors for multidrug-resistant organisms 1
Timing of Surgery
- Emergency drainage within hours for patients with sepsis, severe sepsis, septic shock, immunosuppression, diabetes, or diffuse cellulitis 4, 5
- Within 24 hours for all other cases to prevent complications 4, 5
Antibiotic Therapy
- Antibiotics are NOT routinely required after adequate surgical drainage in immunocompetent patients 4, 5
- Indications for antibiotics include:
- Use empiric broad-spectrum coverage for Gram-positive, Gram-negative, and anaerobic bacteria when indicated, as these are polymicrobial infections 4, 5
Conservative Management Exception
- Recent evidence suggests selected patients may respond to antibiotics alone (73% success rate), particularly those without SIRS criteria 6
- However, this approach requires close monitoring and immediate surgical drainage if infection persists 6
- This is NOT recommended as first-line given the risk of Fournier's gangrene progression 3
Post-Operative Management
- Scrotal elevation, bed rest, and analgesics until inflammation subsides 1
- Wound packing remains controversial with no clear benefit demonstrated 4, 5
- Close follow-up to monitor for recurrence or fistula development 4, 5
Critical Pitfalls to Avoid
- Never delay drainage for imaging if clinical suspicion is high 4
- Do not rely on antibiotics alone as primary treatment—this risks progression to Fournier's gangrene 3
- Inadequate drainage is the primary cause of recurrence (up to 44% recurrence rate) 4, 5
- Failure to improve within 3 days requires comprehensive reevaluation for tumor, infarction, tuberculous/fungal infection, or inadequate drainage 1
- Always screen for diabetes in patients with scrotal abscess, as this is a major risk factor for severe complications 1, 3