Because the scrotal skin is loose and elastic, dramatic enlargement of the scrotum may occur secondary to either scrotal or testicular pathologic conditions.

SCROTAL EDEMA Simple, isolated scrotal edema is uncommon. It usually occurs secondary to insect or human bites, contact dermatitis, or, in young boys, to idiopathic scrotal edema. Contiguous scrotal and penile edema occurs in older men in conjunction with lower extremity edema in fluid overload states (congestive heart failure), hypoalbuminemia, and generalized anasarca.

SCROTAL ABSCESS The important distinction with a scrotal abscess is whether the phlegmon is localized to the scrotal wall, i.e., simple hair follicle abscess, or involves, and even perhaps originates from, infection in one of the primary intrascrotal organs, i.e., testis, epididymis, bulbous urethra. This distinction can be very difficult late in the course of the disease process when a scrotal mass may be the only discernible finding.

A simple hair-follicle scrotal-wall abscess can be managed by incision and drainage. Oftentimes wound care can be simplified by circumferential excision of the entire roof of the abscess. This allows access for wound care and sitz baths and assures healing from the base outward. Antibiotics are rarely needed in an immunocompetent male.

Contiguous involvement of the scrotal skin by an inflammatory mass in the testis or epididymis is best evaluated by ultrasound. A retrograde urethrogram will delineate the integrity of the urethra. Definitive care of any complex abscesses should be directed by a urologist.

FOURNIER'S GANGRENE Fournier's gangrene is a polymicrobial, synergistic infection of the subcutaneous tissues that originates from one of three sites: skin, urethra, or rectum. This infectious process typically begins as a benign infection or simple abscess that quickly becomes virulent, especially in an immunocompromised host, and leads to end-artery thrombosis in the subcutaneous tissue that promotes widespread necrosis of previously healthy tissue ( Fig.91-4).

Scrotal Edema Penis Disappeared

FIG. 91-4. A patient with Fournier's gangrene of the scrotum. Note the sharp demarcation of gangrenous changes and the marked edema of the scrotum and the penis.

The diabetic male seems to be most at risk. Prompt recognition of Fournier's gangrene in its early stages should prevent extensive tissue loss that accompanies delayed diagnosis. Aggressive fluid resuscitation; gram-positive, gram-negative, and anaerobic antibiotic coverage; and wide surgical debridement sometimes in conjunction with pre- and postoperative hyperbaric oxygen therapy are the mainstays of treatment. Urologic consultation is often required when periurethral abscess is the inciting event, or when other etiologies have secondarily invaded the urinary tract and supravesical urinary drainage is needed. It is imperative that emergency physicians maintain a very high index of suspicion for this entity in immunocompromised patients who present complaining of scrotal, rectal, or any genitalia pain out of proportion to their physical examination findings. Surgical consultation is strongly recommended in all such patients, rather than deciding on symptomatic treatment and discharge from the emergency department.

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