A Dessanti

A Thakur

AHM Ibrahim

BS Gan

FM Robertson

J Kollias

JL Martins

k Satchithananda

KMI Pal

L Lantsberg

M Bengol-kologlu

Mohammad M Saleem

PJ Shmit

S Singh

SB Sharma

SC Friedman

WS McKerrow

Yung-chin Lee

English

PubMed

Springer - Publisher Connector

BioMed CentralCases Journal
ssOpen AcceCase Report
Scrotal abscess as a complication of perforated appendicitis: A case 
report and review of the literature
Mohammad M Saleem
Address: The Department of Pediatric Surgery, Jordan University Hospital, University of Jordan, Amman, Jordan
Email: Mohammad M Saleem - mohomari@hotmail.com
Abstract
Introduction: Abscess formation following appendectomy is well known, especially when
complicated by perforation. Infectious complications are the most common. Intraabdominal
abscess formation, Pelvic abscess and wound infection are the most common sites of infection.
Scrotal abscess following acute perforated appendicitis is very rare.
Cases presentation: We report two cases of scrotal abscess following perforated appendicitis,
one was 1983 and the other in 1997. The first patient developed acute left hemiscrotum two weeks
following correction of a tetralogy of Fallot that was diagnosed since infancy. Scrotal drainage as
well as open appendectomy and abdominal drainage were followed by uneventful recovery. Six
weeks later left groin exploration revealed patent processus vaginalis which was ligated. The
second patient developed redness, swelling and pain in his left hemiscrotum 10 days after open
appendectomy for perforated appendicitis. Groin exploration, ligation of a PPV and scrotal drainage
was made. Recent reports on the subject, review of the literature, the rarity of the complication,
and the possible association with recent introduction of laparoscopic appendectomy.
Conclusion: Acute scrotal swelling is frequently a surgical emergency. Developing in the post-
operative period is no exception. Symptoms and signs may be hampered by analgesia, pain, and
antibiotics, usually administered in this period. Reporting these rare complications following such
a common procedure, especially now a day in the era of laparoscopic surgery. Only high degree of
suspicion and vigilant intervention will accomplish a safe diagnosis and treatment. The appropriate
time and approach to both abscess and PPV is still controversial. Until enough case reports
treatment is to be individualized.
Introduction
The scrotum develops as a part of the abdominal cavity,
and the processus vaginalis remains patent 80–90% of
newborns, and gradually declines to 15–37% during
adulthood. In recent years several case reports of intraab-
dominal pathologies finding their way into the scrotum
especially during peritoneal dialysis, or after placement of
ventriculo-peritoneal shunt. The present cases and the lit-
erature review show that intraabdominal purulent collec-
tion may find its way to the scrotum via a PPV. The sine
qua non of all these cases is the PPV.
Cases presentation
Case No 1
A 10-year-old male presented with 3 days history of
abdominal pain, Anorehxia, and vomiting, admitted with
the diagnosis of acute appendicitis. Abdominal examina-
tion revealed tenderness and rebound tenderness in the
Published: 19 September 2008
Cases Journal 2008, 1:165 doi:10.1186/1757-1626-1-165
Received: 29 July 2008
Accepted: 19 September 2008
This article is available from: http://www.casesjournal.com/content/1/1/165
© 2008 Saleem; licensee BioMed Central Ltd. 
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), 
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 4
(page number not for citation purposes)
Cases Journal 2008, 1:165 http://www.casesjournal.com/content/1/1/165right lower quadrant of the abdomen. Temperature was
37.9°C and leucocytosis was 16,000 mm3, with left shift.
At surgery acute perforated appendicitis was removed and
because of the abscess cavity and difficulty in removing
the appendix drainage was instituted, the peritoneal fluid
was sent for culture and broad-spectrum antibiotic cover-
age was started. On post-operative day 5 the patient com-
plained of swelling and redness of his left scrotal sac.
There was minimal pain, US examination and Doppler US
revealed a normal testis with normal blood flow, the fluid
to contain debris suspected to be an abscess. Groin explo-
ration revealed an abscess in a patent prcessus vaginalis
(PPV). The PPV was ligated and the abscess was drained
via the scrotum as shown in figure (1). The culture from
the scrotal fluid did not grow any organism, while the
peritoneal fluid grew gram negative E-coli. They were
removed when the drainage stopped and the patient
made a good recovery.
Case No 2
A 4-year-old male complained of lower abdominal pain,
fever and swelling of the left scrotal sac of two days dura-
tion. He is known to have congenital heart disease, Tetral-
ogy of Fallot, for which he underwent surgical correction
two weeks earlier. Examination revealed a swollen left
scrotal sac with tenderness in the scrotum, groin and
lower abdomen. Temperature was 39.2°C, WBC 14,200
mm3. Diagnosis of acute scrotum was entertained and
scrotal exploration was made. There was purulent scrotal
fluid but the testis and epidydimis were normal. The fluid
was thought to come from the abdomen as by pressing the
lower abdomen the fluid was coming more. The scrotum
was drained. On exploring the abdomen acute perforated
pelvic appendicitis in a situs inversus situation was
encountered. Appendectomy and drainage of the pelvis
was performed Figure (2). Cultures from both the scrotum
and peritoneum grew the same organism, Enterobacter.
The drains were removed in one week. Antibiotic coverage
was continued for two weeks and the patient made une-
ventful recovery. Six weeks later exploration of the groin
revealed PPV, which was ligated.
Discussion
The relationship between the scrotum and the peritoneal
cavity has long been known. Examination of the scrotum
is part of the abdominal examination. Patent processus
vaginalis (PPV) is thought to remain patent in 15–37% of
people beyond neonatal period. Suppuration following
acute appendicitis is well known and occurs in 3–9% fol-
lowing acute appendicitis [1]. Abscess formation com-
monly occurs in the pelvis, between intestinal loops and
in the subphrenic space. Scrotum as an extension of the
peritoneal cavity is very rarely considered as a site of
abscess formation following appendicitis. Only recently
this subject has been recognized and reported. About 30
Scrotal drainage following groin explorationFigure 1
Scrotal drainage following groin exploration.
Pelvic drainage after appendectomyFigure 2
Pelvic drainage after appendectomy. Notice the scrotal 
swelling and redness of the left scrotal sac.Page 2 of 4
(page number not for citation purposes)
Cases Journal 2008, 1:165 http://www.casesjournal.com/content/1/1/165pediatric cases have been reported in the literature includ-
ing neonates and adolescents. There were two previous
reviews [2,3]. Ours is the largest one [2-17]. We have
reviewed 22 cases in which enough information was avail-
able (Table 1). Three were neonates and three were ado-
lescents [4-8]. All were males except one female 3 years
old developed an abscess in the labial fold, seven days fol-
lowing appendectomy for perforated appendicitis and
had a patent processus vaginalis. This is the only female
reported with this complication [9]. Fifteen patients had a
PPV and 14 required secondary operation following their
primary appendectomy procedure. These were 1–10 days
postoperatively. Five patients had their primary surgery
inguino-scrotal to manage both the appendectomy as well
as the drainage of the scrotal suppuration [4-6,10-12]. It is
postulated that laparoscopic appendectomy with insuffla-
tions of the peritoneal cavity may potentiate the patent
processus vaginalis and increase the incidence of scrotal
contamination by peritoneal fluid. Three cases were fol-
lowing laparoscopic appendectomy [3,7,8]. Sixteen of the
reported cases and our two cases were not following lapar-
oscopic appendectomy. Five scrotal abscesses were
approached through the scrotum and three were
approached inguinally. Six cases including one of ours the
inguino-scrotal exploration preceded the appendectomy
procedure, and five of them required no further procedure
[4-6,10-12]. Absence of history of inguinal hernia or
hydrocele was common to all patients including ours; the
timing of abscess development was between the 1st and
the 10th day following appendectomy. Presentation was
scrotal swelling and redness in all the reported cases. Pain
was not the outstanding feature and if this was present it
was not excruciating, as this happen in the cases of torsion
of the testis, or strangulated hernia. All the patients were
explored with the provisional diagnosis of inguinal hernia
strangulation or incarceration. There is a reported case of
testicular damage the mechanism of which is obscured
[13]. In our cases the PPV were wide open at the time of
abscess formation. Ligation of the PPV was performed in
the first presented case during the emergency groin explo-
ration while in the second case this was accomplished six
weeks later after appendectomy.
Conclusion
Acute appendicitis with scrotal involvement in children
may present with scrotal abscess or with appearance of
acute scrotum mimicking acute testicular torsion or incar-
cerated inguinal hernia. This may precede the diagnosis of
acute appendicitis or as a postoperative complication of
suppurative or perforated appendicitis.
Acute scrotal swelling is frequently a surgical emergency.
Developing in the post-operative period is no exception.
Analgesia, and antibiotics may hamper symptoms and
Table 1: a literature cases of scrotal abscess in children and adolescents as a complication of perforated appendicitis
Author Age (years) Surgery (Primary) Surgery (Secondary) PPV
Thakur(2001)3 Case1 9 Open appy, Inguinal I&D, (4) +
Case2 7 Lap appy Inguinal & scrotal I&D (10) +
Dessanti (1995)4 18 Days Rt. inguinal herniotomy, appy No further surgery +
Ibrahim & Malki (2000)5 22 Days Scrotal exploration No further surgery -
Martin (2001)6 4 Days Groin exploration, Open appy, herniotomy No further surgery +
Lantsberg & Mor (1997)7 20 Lap appy Scrotal I&D (1) -
Kollias & Gallery (1996)8 17 Lap appy Scrotal I&D (4) -
Bengol-kologlu (2006)9 3 Female Open appy Groin exploration (7) +
4 Open appy Groin exploration (5) +
7 Open appy Groin exploration (4) -
7 Open appy Groin exploration (5) -
9 Open appy Groin exploration (5) -
Sharma (2004)10 6 Rt. Inguinal, herniotomy, Open appy No further surgery +
Singh (2003)11 2 Rt. Inguinal I&D, Open appy No further surgery +
Satchthananda (2000)12 3 Open appy No further surgery +
Robertson (1993)13 7 Open appy Scrotal exploration and orchiectomy +
Pal KMI(1995)14 8 Open appy Scrotal I&D -
Gan&Sweeny(1992)15 8 Open appy Inguinal I&D (2) -
McKerrow & Thomson(1982)16 9 Open appy Scrotal I&D (2) -
Lee Yung-chin(2003)17 19 Open appy Scrotal exploration (3) Drainage of 
retroperitoneal abscess
-
Present cases Case 1 10 Open appy, Inguinal I&D (5) +
Case 2 4 Scrotal exploration Herniotomy later +
Total 22
Key: Appy: appendectomy, Lap: laparoscopic, PPV: patent processus vaginalis, postoperative days in parenthesis.Page 3 of 4
(page number not for citation purposes)
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signs, as these are usually administered the postoperative
period. The unusual complication might follow common
surgical procedures such as appendectomy, especially in
laparoscopic surgery.
Only high degree of suspicion and vigilant intervention
will accomplish a safe diagnosis and treatment. The
appropriate time and approach to both abscess and PPV is
still controversial. Until enough case reports treatment is
to be individualized.
Abbreviations
PPV: patent processus vaginalis; US: Ultrasound.
Consent
Written informed consent was obtained from the patients'
parents for publication of this case report and accompany-
ing images. A copy of the written consent is available for
review by the Editor-in-Chief of this journal.
Competing interests
The author declares that they have no competing interests.
Authors' contributions
This author has managed this case and prepared the man-
uscript.
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Scrotal abscess as a complication of perforated appendicitis: a case report and literature review

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