The Scrotum Narrates the Inside Story…

Abstract

Pyoscrotum is rarely encountered in neonates and is secondary to a local pathology such as neglected torsion or epididymo-orchitis. Pyoscrotum from an intra-abdominal pathology is possible in the presence of a patent processus vaginalis and has been rarely reported in the context of acute appendicitis. We report our experience with a case of antenatal bowel perforation presenting postnatally after an absolutely asymptomatic “honeymoon” period.

INTRODUCTION

We report a case of in utero bowel perforation presenting as benign, multicolored inguinoscrotal swelling postnatally after a “honeymoon” period.

CASE REPORT

A 6-day-old thriving neonate presented to us with a 4-h history of irritability following sudden appearance of a reddish-green right scrotal swelling. There were no constitutional symptoms, distention of the abdomen, vomiting or obstipation, respiratory symptoms, or lymphadenopathy.

The child was born to a primigravida mother at term by a lower segment cesarean section for cephalopelvic disproportion. The mother was a known hypertensive for almost 5 years and developed gestational diabetes in 15^th week of gestation. Level II antenatal sonography was suggestive of the presence of a single umbilical artery.

Upon examination, the baby was well preserved, irritable but consolable with no evidence of sepsis. The right inguinoscrotal swelling was associated with local erythema although the local temperature was equivocal. Cough impulse was not appreciated. The testis could not be palpated separately from the swelling which was extending cranially to involve the cord structures. Attempt to raise the testis was painful. The swelling was fluctuant, noncompressible, and nonreducible with atypical transillumination. An attempt at detorsion was not satisfying.

The blood counts were within normal range; sonography revealed preserved vascularity of the right testis, debris with fluid in the tunica vaginalis on the right with heterogeneous contents within.

The patient was planned for prompt exploration.

Operative findings

In view of the swelling being inguinoscrotal, the right inguinal canal was explored by the right inguinal skin crease incision after discussion with the senior author. The testis was delivered, tunica vaginalis opened, and 7 ml of greenish mucoid viscid material (without feculent contents or odor) was drained. Similar exudate was noted from the patent processus at the deep ring. The testis was hyperemic with tiny surface hemorrhages, though healthy [Figure 1]. The incision was extended proximally through the deep ring for abdominal exploration. The abdominal cavity revealed localization of the omentum to the region of adhered bowel loops in the right upper quadrant. Adhesiolysis revealed that the surface of the hepatic flexure and the proximal transverse colon had intimately adhered to the omentum and the wall exhibited a rough texture with irregular thickening. However, there was no perforation and continuity of serosa was maintained throughout.

Figure 1.

Intraoperative picture depicting the pathological findings. (a) Right tunical vaginalis has been opened, the right testis is hyperemic with tiny surface hemorrhages. (b) Inner surface of the tunica vaginalis has been stained with the contents trickling from the abdominal cavity through the patent processus vaginalis. This discoloration was responsible for the reddish-green discoloration of the scrotum noticed on preoperative clinical examination. (c) The region of the patent processus vaginalis. (d) The region of hepatic flexure of the colon. The intimately adherent omentum has been removed; the adherent pus flakes, the rough texture, and the irregular wall thickening are evident. However, there is no perforation and the bowel continuity is maintained throughout.

The remaining bowel, stomach, lesser sac, and biliary system were unremarkable. The abdomen was closed after a peritoneal lavage and establishment of intraperitoneal and scrotal drains.

The postoperative course was uneventful, but the baby presented with a right inguinal hernia after 3 weeks which was repaired.

Diagnosis

In utero bowel perforation in the region of the hepatic flexure had sealed spontaneously. The child became symptomatic when the intraperitoneal collection seeped into the tunica vaginalis through the patent processus.

DISCUSSION

Common causes of acute scrotum include strangulation or incarceration of inguinal hernia, torsion of the testis or one of its appendages, and acute epididymo-orchitis.

Pyoscrotum is rarely encountered in neonates and is secondary to a local pathology such as neglected torsion or epididymo-orchitis. Pyoscrotum from an intra-abdominal pathology has been reported in the context of acute appendicitis.[1,2]

The index case is unique and is being reported for its merit of learning. The baby is likely to have developed a perforation in the region of the hepatic flexure of the colon during the intrauterine life which sealed off spontaneously without causing generalized peritonitis. This may be attributed to the sterile nature of the bowel contents. The contents that leaked out of the perforation site evolved into an interloop collection further walled off by the omentum. After birth, the baby was absolutely asymptomatic and was tolerating feeds well. There was no evidence of any intrauterine intra-abdominal event. However, on the 6^th day of postnatal life, the collection probably leaked out of its “wall” and tracked all the way down into the scrotum through the patent processus vaginalis, hence the sudden appearance of the inguinoscrotal swelling and the reddish discoloration of the right hemiscrotum. Sudden stretching of the tunica vaginalis by the influxing contents may be responsible for local pain and made the child irritable. Due to the noninflammatory nature of the pathology, the local temperature was not raised nor was the child febrile. The testicular hyperemia and surface hemorrhages may be related to chemical irritation. The thick viscid nature of the contents gave the impression of omentum-like structure inside the sac on sonographic evaluation.

CONCLUSIONS

The presence of turbid or purulent contents during exploration of acute scrotum without any apparent local cause must always alert the operating surgeon towards the possibility of a patent processus vaginalis and a search for an intraabdominal cause is indicated.

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.