Scrotal Pyocele in a Neonate: Review of the Literature and the Lessons Learned

Abstract

Objective - Bacterial infection of the scrotal appendages (scrotal pyocele) is a rare condition, especially in neonates. It is easy to confuse with other scrotal emergencies that require surgical intervention and orchiectomy. We present a case where pre- and intraoperative diagnosis was not clear and orchiectomy was performed; additionally, review of the literature, diagnostics, treatment options and lessons learned are discussed.

Case report - A ten-day old full term neonate, born with bilateral hydroceles and glandular hypospadias, presented with a six day history of poor feeding and irritability; clinical examination revealed an enlarged, erythematous and tender right hemiscotum. Blood cultures, routine laboratory examinations and ultrasound (US) imaging was performed. Postnatal torsion with non-viable testicle, testicular malignancy and epididymo-orchitis were considered in the differential diagnosis. Upon surgical exploration, the testicle appeared non-viable due to severe inflammation and was removed. The patient was treated initially with ampicillin and gentamicin. After Streptococcus pneumoniae was cultured from specimens, treatment was continued with benzyl penicillin.

Conclusion - Neonatal scrotal pyocele is an extremely rare condition. The main suggestive features are clinical presentation with signs of infection and an enlarged painful scrotum. US is the investigation of  choice to differentiate from a surgical emergency. Free fluid in the scrotal cavity with septae, normal looking testicle on US and no signs of torsion at exploration are diagnostic signs. If diagnosed early, the first line of management is surgical aspiration or decompression, followed by broad-spectrum antibiotic treatment. With delay in diagnosis, the testicle may look non-viable and push surgeons for orchiectomy.