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Original Article

Scrotal abscess: Varied etiology, associations, and management

Raghu S. Ramareddy, Anand Alladi
Department of Pediatric Surgery, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India

Address for correspondence: Dr. Anand Alladi, Department of Pediatric Surgery, Bangalore Medical College and Research Institute,
Bengaluru, Karnataka, India. E-mail: alladianand@gmail.com

ABSTRACT Access this article online

Website: www.jiaps.com
Aim: To report a series of scrotal abscess, a rare problem, their etiology, and DOI: 10.4103/0971-9261.186545
management. Materials and Methods: A retrospective study of children who Quick Response Code:
presented with scrotal abscess between January 2010 and March 2015, analyzed
with respect to clinical features, pathophysiology of spread and management.
Results: Eight infants and a 3-year-old phenotypically male child presented with
scrotal abscess as a result of abdominal pathologies which included mixed gonadal
dysgenesis (MGD) [1]; three anorectal malformations with ectopic ureter [1], urethral
stricture [1], and neurogenic bladder [1]; meconium peritonitis with meconium
periorchitis [2], ileal atresia [1], and intra-abdominal abscess [1]; posturethroplasty
for Y urethral duplication with metal stenosis [1] and idiopathic pyocele [1].
Transmission of the organism had varied routes include fallopian tube [1], urethra
ejaculatory reflux [4], hematogenous [2], and the patent process of vaginalis [2].
Two of the nine required extensive evaluation for further management. Treating
the predisposing pathology resolved scrotal abscesses in eight of nine patients,
one of whom, required vasectomy additionally. Idiopathic pyocele responded to
needle aspiration and antibiotics. Conclusion: Scrotal abscess needs a high index
of suspicion for predisposing pathology, especially in infants. Laparoscopy is safe
and effective in the management of the MGD and ectopic ureter.

KEY WORDS: Ectopic ureter, laparoscopy, mixed gonadal dysgenesis, prostatic utricle,
scrotal abscess

INTRODUCTION (MGD), resulting in scrotal abscess, associations like,

renal agenesis (RA), anorectal malformation (ARM)
In infants and prepubertal children, anatomical with congenital/acquired urethral problem, meconium
urinary tract abnormality predisposes for recurrent peritonitis, and the success of minimally access surgery
epididymitis.[1-3] Urethro ejaculatory reflux (UER) can
(MAS).
be pathological or idiopathic.[1-3] Epididymitis is the
most frequent cause of the scrotal abscess. Prostatic
utricle (PU) is a tubular or vesicular, midline cystic
This is an open access article distributed under the terms of the
structure which communicates with the urethra. Blind-
Creative Commons Attribution-NonCommercial-ShareAlike 3.0
ending ectopic ureter into the prostatic urethra may
License, which allows others to remix, tweak, and build upon the
mimic PU. Cystoscopic-guided laparoscopy is the most work non-commercially, as long as the author is credited and the
useful investigation in delineating, differentiating and new creations are licensed under the identical terms.
managing of PU and ectopic ureter.
For reprints contact: reprints@medknow.com

We are reporting unusual retrograde urinary reflux into Cite this article as: Ramareddy RS, Alladi A. Scrotal abscess: Varied
the genital tract secondary to varied predisposing factors etiology, associations, and management. J Indian Assoc Pediatr Surg
2016;21:164-8.
such as PU, ectopic ureters, mixed gonadal dysgenesis
© 2016 Journal of Indian Association of Pediatric Surgeons | Published by Wolters Kluwer ‑ Medknow 164
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Ramareddy and Alladi: Scrotal abscess has varied causes
MATERIALS AND METHODS
A retrospective study of children with scrotal abscess
between 2010 January and 2015 March were analyzed
with respect to clinical features, pathophysiology of
spread and management options.
RESULTS
A 3-year-old child reared as male presented with
pyuria, left recurrent scrotal abscesses and mid penile
hypospadias. On radiological evaluation, he had right
RA, partial duplex left kidney and a PU, left scrotal
abscess without testicular elements. And normal
opposite testis. Karyotype revealed a mosaic pattern
(45XO/46XY: 45%/55%). Child under went cystoscopy
guided laparoscopic excision of PU, left hemi uterus and
fallopian tube while gonad with vas and its vessels were
retrieved from the inguinal incision [Table 1].
Histopathology of specimen [Figure 1] demonstrated
PU lined by stratified squamous epithelium, fallopian
tube, vas deferens and epididymal tubules without a
testicular tissue. Follow-up cystoscopy and micturating
cystourethrogram (MCU) at 4 months were normal. The
child was asymptomatic during 2 years follow-up.
The second baby was a 2 weeks old boy with abdominal
mass since 1 week followed by right scrotal swelling.
The clinical and radiological evaluation was suggestive
of subhepatic and scrotal abscess without testicular
vascularity. He underwent drainage of abscess, excision
of right necrotic tissue and contralateral orchidopexy.
Histology of excised tissue revealed inflammatory
cells, fibro-collagenous tissues, tubules, and vas.
Postoperative recovery was uneventful.
Figure 1: Gross specimen showing excised prostatic utricle with
attached fallopian tube (Split arrow) along with remaining fallopian
tube and gonad removed by inguinal exploration kept in continuity
(Broken arrow)
165 Journal of Indian Association of Pediatric Surgeons / Oct-Dec 2016 / Vol 21 / Issue 4
Three children with ARM had scrotal abscess due
to varied predispositions and included, one each of
urethral stricture, dysfunctional elimination and ectopic
ureter [Figure 2]. All of them developed the scrotal
abscess due to UER. All responded to the management
of predisposing causes.
Two neonates with meconium peritonitis one of which
was associated with ileal atresia presented with right
inguinal hernia. Both of them responded well to
laparotomy and treatment of the primary pathology.
One of them had an antenatal diagnosis of an inguinal
hernia.
An 11-month- old boy underwent composite
urethroplasty for Y urethral duplication and anal
transposition for anterior ectopic anus. He had voiding
problem due to meatal stenosis and later presented
with left scrotal abscess due to UER. He responded to
calibrations.
The last child was a 6 months old idiopathic scrotal
pyocele which responded aspiration.
DISCUSSION
A scrotal abscess may result from the extension of
epididymo-orchitis or neglected testicular torsion,
spread of intra-abdominal abscess via patent process
vaginalis, idiopathic, and hematogenous route of
systemic infection.[3,4] Oblique, narrow terminal course
of ejaculatory duct and its sphincter muscle with
valves prevents UER.[3] Ejaculatory duct dysfunction
is multifactorial. Wolffian duct caudal obstruction
or abnormal insertion into the posterior urethra are
predisposing factors for epididymitis.[5] Scrotal abscess
Figure 2: Preoperative micturating cystourethrogram with distal loop
gram (hollow arrow) and cystoscopy with bug bee delineating refluxing
ureter; laparoscopy view showing ectopic blind dilated ureter with endo-
loop knot (vertical solid arrow) and preserved vas (vertical hollow arrow)
and postoperative residual stump (horizontal solid arrow)
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Ramareddy and Alladi: Scrotal abscess has varied causes

Table 1: Clinical profile of scrotal abscess children

Age Clinical presentation Etio- pathogenesis of Primary Associations Treatment/follow-up
scrotal abscess Diagnosis
3 yrs Pyuria, left recurrent Wide opening of of Mixed gonadal Left solitary duplex Laparoscopy excision of abnormal internal
scrotal abscess, prostatic utricle with dysgenesis kidney. genitalia and inguinal exploration for left
hypospadias urinary reflux via (45XO/46XY) Prostatic utricle, gonad.
fallopian tube Ipsilateral hemi Asymptomatic-2 yrs
uterus, anorcha
2 weeks Right para falciparum Hematogenous ?Necrotizing Nil Laparoscopy, drainage of abdominal abscess,
ligament abscess, enterocolitis or right orchiectomy, contralateral orchidopexy
scrotal abscess testicular abscess Asymptomatic-1 yrs.
2 monthsRecurrent left scrotal Left ectopic ureter ARM Congenital heart Laparoscopy excision of left blind ending
abscess, with urinary opening in prostatic disease [CHD], ectopic ureter, staged ARM repair, left
tract infections TI) urethra distorting Right solitary vasectomy.
ejaculatory duct, kidney Asymptomatic-1 yrs
resulting in UER
1 yrs Recurrent left scrotal UER secondary to ARM, CHD Staged ARM repair, bladder neck closure with
abscess acquired urethral appendicovesicostomy in view of failure of
strcture urethroplasty for urethral stricture.
Asmptomatic-1 year
8month Recurrent UTI with left UER with acquired ARM CHD Staged ARM repair, CIC
scrotal abscess dysfunctional elimination Asymptomatic- ½ yrs.
1 Week Antenatal right inguinal Migration of meconium Meconium ? Antenatally Laparotomy and inguinal exploration for
hernia and postnatal through patent process peritonitis obstructed inguinaldrainage of meconium, pus, wall debridement
abdominal distention vaginalis resulting in hernia Asymptomatic-1/2 yrs.
with right scrotal swelling peri-orchitis
2 Weeks Abdominal distention, Migration of meconium Ileal atresia Nil Bowel resection and primary anastomoses
bilious vomiting, through patent process with Meconium Asymptomatic-1/2 yrs
reducible inguinal hernia vaginalis-resulting peritonitis
peri-orchitis
1.5 yrs. Left scrotal abscess UER due to meatal Urethral CHD, Anterior Urethral calibration
post bladder mucosa stenosis duplication ectopic anus Asymptomatic -1 yr.
tube urethroplasty for Y
duplication and anterior
ectopic anus
6 month Right scrotal swelling, hematogenous Right pyocele Aspiration, antibiotics
tenderness Asymptomatic-2 months

may be solitary or multiple, unilateral/bilateral,
rarely recurrent and often secondary to pathological
UER.[1-3] Scrotal pus may yield Escherichia coli and
staphylococcus organisms and often sterile due to
previous treatment with antibiotics.[4]
In the first patient, the spread of infection was either
through UER or more likely due to wide opened mouth
of fallopian tube on PU and least resistance to retrograde
urinary reflux which was demonstrated by clinical
examination of compressing the scrotum yielding pus
discharge per urethral meatus and histology of vas and
the tube in our case. This type of spread is rare. Sertoli
cells secrete Mullerian Inhibiting Substance (MIS) and
cause complete degeneration of mullerian ducts in male
within 9-10 weeks. PU is embryologically/histologically
derived from the urogenital sinus and Wolffian cells
caudally and the Mullerian duct cells cranially.[5]
Normal testis and contralateral gonadal agenesis are one
of the rare presentations of MGD.[6] Abnormal or agenesis
of testes associated with MGD can cause incomplete
Journal of Indian Association of Pediatric Surgeons / Oct-Dec 2016 / Vol 21 / Issue 4
regression of Mullerian duct due to deficiency of MIS.[5]
Paracrine action of growth signals are needed in the
concomitant development of ipsilateral Wolffian ducts,
Mullerian ducts, and urogenital ridge.[7-9] Inappropriate
level of gonadal normal cell line in the mosaic,[6] receptor
quantity[5] deficiency, quantitative defects of local
testosterone/dihydrotestosterone[8] and improper exocrine
transport of testosterone and MIS along Wolffian duct,[7]
can cause errors in differentiation of the Wolffian duct/
Mullerian duct derivatives, incomplete masculinization
of the urogenital sinus and genital tubercle which
ultimately result in ipsilateral presence of fallopian tube,
hemi uterus, PU, and hypospadias. Embryological assault
after 7 weeks may cause reproductive tract anomaly.[8-10]
There is no single embryological combination etiology
which explains the association of unilateral RA and
contralateral anorchia. Hence, our MGD is a complex
genetically heterogeneous developmental disorder with
variable phenotype presentation.
The 2 rd child presented with abdominal swelling
initially, followed by scrotal swelling. There was bag of
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Ramareddy and Alladi: Scrotal abscess has varied causes
pus in tunica albuginea without any features of torsion.
The route of seeding may have been hematogenous, as
laparoscopy did not reveal any communication between
the two cavities. Scrotal pathology often reflects intra-
abdominal disease.[4,11] Necrotizing epididymorchitis
and neglected perinatal torsion of testis may both
result in a scrotal abscess.[11] Clinical, radiological,
operative findings, and histology may all not be to
differentiate between the above two causes, in cases
of severe scrotal abscess and both usually ends up in
orchiectomy.[12] Omphalitis or necrotizing enterocolitis
and hematogenous spread might have caused an abscess
in abdomen and scrotum. Treatment modalities of
epididymorchitis are early diagnosis with antibiotic,
drainage/aspiration, and rarely gonad excision.[12]
Idiopathic pyocele can be treated with needle aspiration
and antibiotic.
The child with ARM had recurrent scrotal abscess
due to ectopic ureter distorting protective mechanism
of the ejaculatory duct. Loss of glial cell line-derived
neurotrophic factor (GDNF) leads to RA and mutations
in tyrosine kinase receptor (RET) is associated with
RA, duplex kidney, ectopic hydroureter, congenital
heart diseases and gonadal abnormalities. This can
also be due to defects of genes related to GDNF/
RET pathway, like Spry1, Gata3, Bmp4, Slit2/Robo2,
Foxc1/2, Pax2, Eya1/Six1, and Sall1.[10] Quantitative
difference in the apoptosis of caudal Wolffian duct/
common nephrogenic cord,[10,13] failure of reciprocal
interaction between ureteric bud and metanephric
blastemal,[10] obstructive ectopic ureter and cranial
origin of ureter bud,[14-17] and proliferative mesenchymal
abnormality around common mesonephric duct[8] can
cause RA, persistent mesonephric duct, ectopic ureter,
and ureter-genital fistula.[10,14,17] Severe mesenchymal
abnormality may also result in ARM.[8] Embryological
event before 7th week affects ureteric bud, reproductive
tract, and cloacal division.[10] Single system unilateral
blind ending hydro ureter in males may be reflexing/
obstructive, or both. Ectopic ureter may terminate in
to the supra sphincteric genitourinary tract, usually
involving the seminal vesicle, vas, prostatic urethra
and rarely presents as recurrent scrotal abscess due
to urogenital reflux.[13-17] Persistent mesonephric duct,
ectopic vas, ectopic ureter are common causes for
recurrent unilateral epididymitis postpull thorough
in the young infantile ARMs.[15,16] Magnetic resonance
urography with gadolinium contrast enhancement
is the investigation of choice as it gives anatomy
and functioning aspect of the kidney and ureters.[14]
MCU with distal loop gram and dimercaptosuccinic
acid (DMSA) scan can sometimes pick up refluxing
blind ending tubular ureter behind the bladder as in
our case. DMSA reveals site and functioning status
of the kidney. In our patient, it also depicted grossly
167 Journal of Indian Association of Pediatric Surgeons / Oct-Dec 2016 / Vol 21 / Issue 4
dilated, atonic, blind ending reflexing ectopic ureter.
Ectopic ureter presenting as a giant paravertebral
tubular structure terminating in posterior urethra has
to be differentiated from PU by its orientation and
histology.[17] Transabdominal open, MIS, Posterior
sagittal approaches have been used for corrections of
the ectopic ureter, a division of rectourethral fistula
and pull through of rectum in ARM cases. Long-term
surveillance of urological system is required in these
children.[18] ARM cases developed UER due to acquired
stricture and neurogenic bladder. Urogenital infections
settled after clean intermittent catheterization (CIC).
Dysfunctional voiding, neurogenic bladder, ectopic
ureter, acquired/congenital urethral fistula or stricture,
distal loop wash may cause urogenital infection in
ARM.
Meconium pseudocyst with sealed off antenatal
bowel perforation and flow of meconium into
scrotum causes a meconium periorchitis which
can be misinterpreted as a reducible or obstructed
hernia in a neonate leading to emergency inguinal
exploration. In the presence of antenatal findings of
the echogenic bowel, postnatal abdominal distension/
mass, a high index of suspicion should be kept,
and further evaluation by an X-ray and ultrasound
should be carried out before inguinal exploration.
These children would normally require a laparotomy.
Differential diagnosis of echogenic space occupying
lesion in scrotum includes a hernia, hydrocele, and
meconium periorchitis. [19] Meconium periorchitis
generally require only follow-up and no surgical
intervention. In our patient by having a high index
of suspicion and ultrasonography of abdomen which
would have picked up a pseudocyst surgery-both
the inguinal exploration and the laparotomy could
have been avoided. This was especially so as the
bowel was normally moving with no features of
obstruction.[19,20] Meconium peritonitis with bowel
obstruction responds well after bowel surgery. Soft
reducible meconium hydrocele is often mistaken as a
reducible hernia in the perinatal period. All our cases
reemphasis management of the abdominal pathology
in addition to treating scrotal disease.
Recurrent scrotal abscess requires thorough
complete genitourinary evaluation and corrections
of the associated anomalies early could prevent
vasectomy.[3,15-17] Laparoscopic management of PU with
disorder of sex development (DSD) and blind ending
ectopic ureter is a safe and viable alternative with the
added benefit of minimally invasive surgery. In addition,
it provides a magnified view of the internal genitalia and
ureter. Cystoscopic-guided laparoscopic excision of PU
and ectopic ureter is reported sparsely.[9,14-18]
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Ramareddy and Alladi: Scrotal abscess has varied causes
CONCLUSION
Recurrent scrotal abscess has varied genitourinary
or gastrointestinal associated anomalies and requires
comprehensive evaluation and prolonged follow-up.
Laparoscopy with the assistance of cystoscopy is safe in
planning and devising surgical option for the excision
of PU and ectopic ureter terminating into the posterior
urethra. Acquired urethral obstructions in ARM may
present with complicated urogenital infections.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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