罕見病例：肝膿瘍破裂導致陰囊膿腫

王惟弘¹、林郁淳²、唐靖³

¹國泰綜合醫院 外科部 泌尿科；²汐止國泰綜合醫院 外科部 一般外科，³泌尿科

Scrotal Pyocele Originating from Ruptured Liver Abscess: A rare case

Wei-Hung Wang¹, Yu-Chun Lin², Chin Tang³

¹Division of Urology, Department of Surgery, Cathay General Hospital, Taipei, Taiwan

²Division of General Surgery and ³Urology, Department of Surgery, Sijhih Cathay General Hospital, New Taipei, Taiwan

Abstract

               We present a case of a 53-year-old man, a smoker for 20 years with diabetes and hepatitis B, who presented with persistent right subcostal pain. Elevated infection markers were found on laboratory tests. Abdominal and pelvic computed tomography (CT) revealed a subcapsular liver abscess extending to the anterior chest wall muscle, pericolonic space, and right inguinal canal. Antibiotics were administered, followed by successful CT-guided drainage of the liver abscess, revealing Klebsiella pneumoniae on culture. However, the patient experienced scrotal and penile swelling subsequently, with testicular ultrasound showing an isoechoic fluid collection around the right testis and epididymis, suggesting a right scrotal pyocele. A follow-up pelvic CT scan showed the abscess extending from the right paracolic gutter, pelvic wall, inguinal region, to the scrotum. Additional CT-guided drainage for the paracolic gutter abscess was performed, and debridement and fasciectomy were done twice for the scrotal pyocele. After meticulous wound care for 5 days, the scrotum was repaired. The wound culture confirmed Klebsiella pneumoniae, indicating liver abscess origin. After adequate drainage for 18 days, both pigtails were removed, and the patient was discharged, with follow-up ultrasounds showing no residual abscess or pyocele.

               Scrotal pyoceles are purulent collections within the potential space between the visceral and parietal tunica vaginalis surrounding the testicle. Although sparsely reported, they are most described as a complication of acute epididymo-orchitis. Scrotal pyocele secondary to intra-abdominal inflammation is very rare, typically observed in pediatric patients with a patent processus vaginalis (PPV) and often associated with perforated appendicitis. Prompt diagnosis and appropriate management, including imaging with ultrasound and CT scan, along with surgical drainage and antibiotic therapy, are crucial for successful treatment. To the best of our knowledge, scrotal pyocele originating from a ruptured liver abscess in a middle-aged adult without PPV has never been reported in the literature. We present this case to highlight the importance of considering scrotal pyocele as a potential sign of underlying intra-abdominal issues, even in middle-aged adults without a patent processus vaginalis.