Scrotal Abscess Complicating Appendicular Perforation Peritonitis

Sir, The sequelae of appendicular perforation peritonitis include appendicular abscess, pelvic or intra-abdominal abscess, intestinal obstruction, fecal fistula, and very rarely, extra-abdominal abscesses, i.e. scrotal abscess.[1,2] A 5-year-old male presented with a 2-day history of lower abdominal pain and fever (100.5°F), along with redness, swelling, and tenderness in the right hemi-scrotum. Laboratory investigations revealed polymorpholeukocytosis (white blood cell [WBC] - 16,300 mm3). An inguino-scrotal ultrasound [Figure 1] confirmed a scrotal abscess and was drained. The purulent fluid was collecting in the wound on pressing the lower abdomen. Subsequent abdominal ultrasound suggested appendicular perforation peritonitis. Appendectomy (perforated subhepatic appendicitis), drainage of the abscess cavity, and ligation of the right patent processus vaginalis (PPV) were performed. The patient had a favorable recovery.Figure 1: Inguino-scrotal ultrasound of patient 1 (a) showing the right testis (white arrow) with epididymis (+) and echogenic collection in the right inguino-scrotal region (red arrow); (b and c) color Doppler ultrasound of patient 2 showing increased vascularity and inflammation of the right hemi-scrotum (yellow arrow) with echogenic collection (red arrow), pushed right testis (white arrow), and edematous spermatic cord (green arrow)A 2-year-old male child presented with a 4-day history suggestive of appendicitis along with swelling and tenderness in the right hemi-scrotum. Ultrasound abdomen revealed dilated small bowel loops, echogenic ascites, and scrotal collection. Laboratory investigations showed polymorpholeukocytosis (WBC – 23,300 mm3). An exploratory laparotomy revealed appendicular perforation with gross peritoneal contamination. Peritoneal toileting and appendectomy were performed. The right hemi-scrotum contained pus and turbid fluid; it was drained through PPV. Postoperatively, there was minimal collection in the tunica vaginalis, which was managed conservatively [Figure 1]. The patient did not require ligation of PPV on follow-up. Atypical presentation with scrotal abscess formation following suppurative appendicitis is very rare. The peritoneal contents, especially pus, trickle down and migrate into the scrotum through PPV.[1,2] PPV is seen in 90% of the newborns and gradually declines to 20% in the adults.[1,2] Scrotal abscess may present concurrently with complicated appendicitis or may be encountered after 1–10 days of appendectomy (open/laparoscopy).[1,2] Symptoms and signs may be masked by analgesics and antibiotics, frequently administered during admission.[1,2] A meticulous and comprehensive clinical examination should be performed in a patient presenting with inguino-scrotal symptoms before jumping directly on the basis of ultrasound findings. The appropriate time and approach to both scrotal abscess and PPV should be individualized depending on the size of the internal ring/defect.[2] As far as possible, both appendectomy and drainage of the scrotal abscess (scrotal/inguino-scrotal approach) should be contemplated in a single setting. Ligation of the PPV has been performed, weeks or days following appendectomy.[1,2] Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.