Emergent surgical complications of genitourinary infections

Conservative management of scrotal pyoceles - A case series and literature review

STUDY OBJECTIVE

We describe the common presenting signs and symptoms, treatment modalities, and outcomes of acutely presenting scrotal pyoceles.

METHODS

We conducted a retrospective chart review of all adult patients treated for ultrasound-confirmed scrotal pyoceles between 2010 and 2020 at two sites within the [redacted]. Vitals at presentation, microbiology, and inpatient courses including antibiotic treatment and surgical procedures were collected.

RESULTS

A total of 360 scrotal ultrasounds were reviewed identifying 15 patients with pyoceles, 11 patients presenting to the emergency department and 4 hospitalized patients. The most common chief complaint was testicular pain (67%). Only seven patients (47%) met SIRS criteria upon presentation. All patients were initially treated with broad-spectrum antibiotics and observation; 11 (73%) responded to this management alone, while four patients (27%) required surgical drainage due to persistent infection. No patients contracted Fournier's gangrene.

CONCLUSION

This study reports the largest published database of scrotal pyoceles to date and describes our clinical approach to management. While pyoceles have traditionally been treated aggressively with surgical drainage, this case series suggests that most patients improve with broad-spectrum antibiotic treatment and observation alone, requiring surgical drainage if infection persists. Future investigations including multi-institutional data will be necessary to validate our institution's approach.

More Than Just Torsion: An Unusual Case of Testicular Pain

Testicular pain has a wide differential and the nonspecific presentation should be triaged rapidly for urgent diagnosis and treatment. Scrotal pyoceles are uncommon collections of purulent fluid between the visceral and parietal tunica vaginalis, usually secondary to acute epididymo-orchitis, intra-abdominal infection, or trauma. Epididymitis and epididymo-orchitis are generally secondary to sexually transmitted infections or urinary tract pathogens. Epidymo-orchitis can compromise the testicular blood supply, leading to a microinfarction and rupture through the tunica albuginea; inflammatory and infectious material then translocate into the tunica vaginalis leading to the formation of a pyocele. Ultrasonography is the preferred method of diagnostic imaging, which can show a classic "falling snow" sign, loculations, or gas. The treatment for a scrotal pyocele is pain control, fluid resuscitation, broad-spectrum antibiotics, and early urology/general surgery consultation. In such cases, Fournier gangrene (FG) should be clinically ruled out and the presence of signs of Fournier gangrene should be met with an urgent surgical consult.

Testicular ischemia following mesh hernia repair and acute prostatitis

We present a case of a man admitted to our Hospital for right acute scrotum that six months before had undergone a right hernioplasty with mesh implantation. Clinical history and testicular color Doppler sonography (CDS) patterns suggested an orchiepididymitis following acute prostatitis. After 48h the clinical picture worsened and testicular CDS showed a decreased telediastolic velocity that suggested testicular ischemia. The patient underwent surgical exploration: spermatic cord appeared stretched by an inflammatory tissue in absence of torsion and releasing of spermatic cord was performed.

In patients with genitourinary infection who previously underwent inguinal mesh implantation, testicular CDS follow-up is mandatory.

An unusual cause of pelvic pain and fever: periurethral abscess from an infected urethral diverticulum

BACKGROUND

The evaluation of patients with pelvic pain is a common task for emergency physicians. Accurate diagnosis of the underlying cause of pelvic pain in women is often difficult given the diversity of pathology that can generate pelvic pain.

OBJECTIVE

To report a rare but clinically significant cause of acute pelvic pain in women.

CASE REPORT

We describe a rare case of a periurethral abscess secondary to an infected urethral diverticulum in a 41-year-old woman. She presented to our Emergency Department with pelvic pain, dysuria, and fever of 4 days duration.

CONCLUSION

Physical examination, imaging studies, and surgery aided in confirming the diagnosis of a periurethral abscess.

Urinary tract infections

Urinary tract infection (UTI), with its diverse clinical syndromes and affected host groups, remains one of the most common but widely misunderstood and challenging infectious diseases encountered in clinical practice. Antimicrobial resistance is a leading concern, with few oral options available to treat infections caused by Gram-negative organisms resistant to trimethoprim-sulfamethoxazole and fluoroquinolones, especially for patients with upper tract disease. Efforts should be made not to detect or treat asymptomatic bacteriuria and funguria; to ensure an appropriate duration of therapy for symptomatic infections; and to limit the use of broad-spectrum agents, especially fluoroquinolones, if narrower spectrum agents are available. Further research is needed regarding rapid diagnosis of UTI, accurate presumptive identification of patients with resistant pathogens, and development of new antimicrobials for drug-resistant UTI.