How should I manage an 82‑year‑old man with a left epididymal abscess and a large partially reducible left indirect inguinal scrotal hernia?

Management of 82-Year-Old with Left Epididymal Abscess and Large Partially Reducible Inguinal Scrotal Hernia

This patient requires urgent urological consultation for surgical drainage of the epididymal abscess combined with broad-spectrum intravenous antibiotics, followed by staged or simultaneous hernia repair once the infection is controlled.

Immediate Management Priority: The Epididymal Abscess

The 59 x 41 x 41 mm complex cystic lesion with septations and no internal vascularity communicating with the inflamed epididymis tail represents a surgical emergency that takes precedence over the hernia repair. While the EAU guidelines 1 address acute epididymitis extensively, abscess formation represents a complicated infection requiring source control beyond antibiotics alone.

Step 1: Initiate Broad-Spectrum IV Antibiotics Immediately

• Start empiric broad-spectrum IV antibiotics covering Enterobacterales (most common in this age group) before drainage
• In an 82-year-old, likely pathogens are Enterobacterales (E. coli, Klebsiella) rather than sexually transmitted organisms 1
• Consider fluoroquinolones (levofloxacin) or third-generation cephalosporins plus aminoglycosides
• Adjust based on culture results from abscess drainage

Step 2: Urgent Surgical Drainage of Abscess

Percutaneous ultrasound-guided drainage should be attempted first, with open surgical drainage reserved for failure of percutaneous approach 2. The case report from 2014 2 demonstrates successful management of spermatic cord abscess (similar pathology) with initial ultrasound-guided percutaneous drainage followed by open incision and drainage when pus accumulated in the scrotum, achieving complete resolution after 2 months.

Critical pitfall: Do not delay drainage waiting for antibiotics alone to work. Abscesses require source control, and antibiotics penetrate poorly into abscess cavities.

Step 3: Obtain Cultures

• Send abscess fluid for aerobic/anaerobic cultures and sensitivities
• Obtain urine culture
• Blood cultures if patient appears systemically ill

Secondary Priority: The Inguinal Hernia

The large partially reducible left indirect inguinal scrotal hernia containing bowel, fat, and fluid presents a significant but non-emergent surgical problem that must be addressed after infection control.

Timing of Hernia Repair

Delay elective hernia repair until the infection is completely resolved (typically 4-8 weeks after abscess drainage) 2. Operating in an infected field dramatically increases mesh infection risk and recurrence rates. The 2014 case report 2 achieved complete resolution after 2 months, suggesting this timeframe for staged repair.

Approach to Hernia Repair in This 82-Year-Old

Despite his age, elective inguinal hernia repair under local or regional anesthesia is feasible and has good outcomes in elderly patients, even with significant comorbidities 3. The 2009 study 3 demonstrated that patients >70 years had less post-operative discomfort and recovered more quickly than younger patients (3.4 vs 6.0 days of analgesics; 13 vs 21 days to normal activities).

Recommended approach:

• Open anterior mesh repair under local anesthesia is the preferred technique for scrotal hernias 4
• For this S2-sized scrotal hernia (extends to middle third of thigh based on the large size described), open approach is superior to minimally invasive techniques
• If minimally invasive approach is chosen, TAPP results in less conversion to open compared to TEP 4

Perioperative Considerations for Hernia Repair

Antibiotic prophylaxis is recommended (upgraded recommendation despite weak evidence) 4. Given the prior abscess, single-dose cefazolin 2g IV at induction is appropriate.

Urinary catheterization is recommended for complex scrotal hernias (S2-3) due to prolonged operative time 4. This patient's large hernia qualifies.

Critical Monitoring During Infection Treatment Phase

Watch for Fournier's Gangrene

The EAU guidelines 1 emphasize that Fournier's gangrene can have insidious onset in up to 40% of cases, with undiagnosed pain resulting in delayed treatment. This 82-year-old with scrotal infection and hernia is at risk.

Red flags requiring immediate surgical exploration:

• Crepitus in scrotal or perineal tissues
• Skin necrosis or discoloration
• Systemic sepsis despite antibiotics and drainage
• Rapidly progressive swelling

If Fournier's is suspected, CT or MRI should be obtained immediately to define extent, and aggressive repeated surgical debridement with broad-spectrum antibiotics is mandatory 1. The degree of internal necrosis vastly exceeds external signs.

Practical Algorithm

1. Day 0-1: Admit, start IV antibiotics, urgent urology consult for ultrasound-guided abscess drainage
2. Day 1-7: Continue IV antibiotics based on cultures, monitor for clinical improvement
3. Week 1-2: Transition to oral antibiotics if improving, discharge when clinically stable
4. Week 4-8: Complete antibiotic course, reassess with ultrasound to confirm abscess resolution
5. Week 8-12: Schedule elective open anterior mesh hernia repair under local/regional anesthesia with antibiotic prophylaxis and urinary catheterization

The hernia is partially reducible and not currently incarcerated/strangulated, so it does not require emergency repair. However, counsel the patient to seek immediate care if the hernia becomes irreducible, painful, or associated with nausea/vomiting (signs of incarceration/strangulation).

Special Consideration: Surgical Risk in Elderly

While age alone should not be a barrier to elective hernia repair 3, scrotal hernia repairs have higher morbidity and mortality compared to non-complex groin hernias 4. Assess this patient's functional status, comorbidities, and life expectancy. If he is frail with limited life expectancy and the hernia remains reducible and asymptomatic after infection resolution, watchful waiting may be reasonable 5.