Torsion of a large appendix testis misdiagnosed as pyocele

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.