Case Study - March 2012

A 53 year old man presented to A+E with a 2 week history of testicular swelling. He had complained of left inguinal swelling and pain 2 weeks prior and was admitted with a suspected incarcerated inguinal hernia. He was subsequently discharged on antibiotics. The swelling in his left groin disappeared but was replaced by gross testicular swelling and pain. His past medical history includes hypothyroidism and dilated cardiomyopathy. He was haemodynamically normal on admission with no fever. His inflammatory markers revealed a high WCC and a CRP>250. He went on to having a CT.

What does the CT show?

What are the possible causes?

What would you do next?

.What would the definitive management be?


Reveal Answer

What does the CT show?
This is a CT scan with IV contrast demonstrating an air/fluid level in the scrotum. There is some inflammatory stranding but no air in the scrotal wall.

What are the possible causes?
Given the CT appearances and the clinical history, the differentials for this appearance are an inguinoscrotal hernia or a scrotal abscess.

What would you do next?
The patient needs treatment according to the ABC protocol. After stabilising, they need IV fluid, high dose IV antibiotics including anaerobe cover (IV Tazocin and Vancomycin in this case), fasting for surgery and review by plastics with a view to the potential need for tissue grafting.

What would the definitive management be?
The patient underwent incision and drainage of his scrotum. Initially pus was removed and sent for microbiology. The area was widely debrided to bleeding tissue and the wound left open over a corrugated drain. Having had 48 hours antibiotics, primary closure was successful over a drain.

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