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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 4  |  Issue : 2  |  Page : 129-131

Scrotal abscess, an unusual manifestation of Crohn's disease


Department of Urology, College of Medicine, University of Dammam, Dammam, Saudi Arabia

Date of Web Publication9-Mar-2016

Correspondence Address:
Reem B Aldamanhori
King Faisal University, Po. Box 40036, Al-Khobar 31952
Saudi Arabia
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DOI: 10.4103/1658-631X.178356

PMID: 30787713

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  Abstract 

Crohn's disease (CD) is a chronic inflammatory disorder of the alimentary tract, usually involving the ileum and proximal colon, which is sometimes associated with extra intestinal manifestations. Urologic complications of CD are rarely reported in literature. CD-related complications involving the urinary tract include infections and urolithiasis as the most common manifestations. Rare more serious occurrences associated with penetrating type disease include ureteral obstruction and enterovesical fistulization. Here, a rare case of CD complicated with a recto-scrotal fistula and the scrotal abscess is presented.

  Abstract in Arabic 

ملخص البحث :

يعتبر مرض كرون من التهابات الجهاز الهضمي المزمنة التي تؤثر غالباً على الجزء الأخير من الأمعاء الدقيقة والقولون الصاعد وربما تصاحبه التهابات عدة خارج الجهاز الهضمي. وقد تنذر مضاعفات هذا المرض في الجهاز البولي. أكثر هذه المضاعفات شيوعاً هي الالتهابات وتكون الحصى. ومن المضاعفات النادرة الخطرة للمرض انسداد الحالب وناسور المثانة. يعرض الباحثون في هذا التقرير نادرة لمرض كرون بناسور المستقيم مع وعاء الخصيتين وخراج الصفن.

Keywords: Abscess, Crohn′s disease, fistula, scrotum


How to cite this article:
Aldamanhori RB, Elkhouly W, Elhami M, Kamal B. Scrotal abscess, an unusual manifestation of Crohn's disease. Saudi J Med Med Sci 2016;4:129-31

How to cite this URL:
Aldamanhori RB, Elkhouly W, Elhami M, Kamal B. Scrotal abscess, an unusual manifestation of Crohn's disease. Saudi J Med Med Sci [serial online] 2016 [cited 2021 Mar 2];4:129-31. Available from: https://www.sjmms.net/text.asp?2016/4/2/129/178356


  Introduction Top


Crohn's disease (CD) usually involves the ileum and proximal colon. Urologic complications of CD are seldom reported. CD-related complications involving the urinary tract include infections and urolithiasis. This patient presented with scrotal abscess which then was revealed to be a rare complicated case of CD.


  Case Report Top


A 32-year-old male presented to the emergency room with a high-grade fever complaining of huge painful and right scrotal swelling. The swelling started 5 days prior to the presentation, increasing progressively in size. The patient had no history of trauma, neither burning micturition nor similar swelling in the past. The patient had previously been diagnosed with Crohn's disease (CD) with a documented vesicointestinal fistula [Figure 1].
Figure 1: Cystogram showing a vesicointestinal fistula.

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The physical examination reviled an ill-looking toxic cachectic patient. The temperature was 39.5°C; blood pressure was within normal range; there was a huge tense and severely tender right scrotal swelling measuring approximately 20 cm × 15 cm [Figure 2]. The overlying skin was warm and edematous. The testis could not be palpated. Digital rectal examination was done; no obvious fistulas were felt although some tenderness was encountered at the anterior part of the rectum.
Figure 2: Huge tense and right scrotal swelling measuring about 20 cm × 15 cm.

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The laboratory investigations showed elevated leukocytic count and raised ESR. Ultrasound was performed and it showed normal testes with normal intratesticular flow using Doppler. Marked scrotal wall thickening was present. There was an evident right-sided fluid collection with the appearance of internal septation and loculation [Figure 3]. The patient was informed about his condition; the need for emergency incision and drainage was explained. However, the patient refused admission and was discharged against medical advice.
Figure 3: Ultrasound of the right test is showing marked scrotal wall thickening and fluid collection with the appearance of internal septation and loculation.

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Two days later, the patient presented with increased swelling, persistent fever, and septic shock. He was admitted, resuscitated, and shifted to the operating room for emergency incision and drainage; almost 500cc of puss was drained from the right hemiscrotum [Figure 4]. There was an associated ischiorectal fossa abscess. Intraoperatively, the right testis was examined, and it appeared normal; the wound was left open. The patient was kept on intravenous antibiotics and daily dressing until his condition stabilized, and his laboratory results returned to normal. The culture of the drained puss showed heavy growth of Proteus mirabilis and Escherichia coli, were both sensitive to the already prescribed antibiotics. The patient was discharged in good condition on oral antibiotics and daily dressing. On follow-up, he was feeling well; the wound was healing with the formation of healthy granulation tissue.
Figure 4: Operating room photo showing incision and drainage of right hemiscrotal abscess, almost 500 cc of pure puss was drained from the right hemiscrotum.

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  Discussion Top


CD is a chronic granulomatous inflammatory disorder of the intestine. Crohn et al. first described it in 1932. [1] The incidence of IBD is increasing worldwide, including Saudi Arabia. [2] Urogenital complications in CD are not frequently encountered. The most frequent conditions include fistulous disease involving the genitourinary tract, nephrolithiasis, and intrinsic renal diseases. [3]

A study by Steinberg et al. followed 360 patients with CD for a mean of 13 years. Abscess and/or fistulae were found in 65 patients. A total of 44 patients had 59 abscesses, of which 33 were in the abdominal wall, and 26 were found within the abdomen. Thirteen of these abscesses occurred spontaneously, and the remainders were in patients who had had a previous operation. Of the 13 patients presenting with a spontaneous abscess, three presented on the skin's surface and required drainage. [4]

A review of literature did not reveal any examples of scrotal abscess as a complication of CD. Fahmi et al. reported a case of labial abscess in an Indian female in 2010. [5] They reported a trans-sphincteric fistula extending from the rectum anteriorly and bilaterally into the labia and inflammatory changes in the left ischioanal fossa. The patient was diagnosed as having a colo-labial fistula with associated abscess formation. Similarly, our patient had a recto-scrotal fistula extending from the ischiorectal fossa.

When compared to females, male patients with CD rarely suffer from genital involvement. Few reports described the prostate gland and proximal urethra abscess formation from direct extension of perianal inflammatory disease. Clinical presentation includes local swelling or ulcerations, usually associated with perianal fistulae. [5],[6]

In summary, the involvement of the urinary tract and genital organs is not uncommon in patients suffering from CD. Urological complications are often clinically unsuspected because of the dominant intestinal or systemic symptoms. Knowledge of their manifestations and imaging appearances is necessary to recognize and report them. [7],[8],[9] The topic of urogenital complications of CD is rare but clinically important.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Crohn BB, Ginzburg L, Oppenheimer GD. Regional ileitis. J Am Med Assoc 1932;99:1323-9.  Back to cited text no. 1
    
2.
Al-sulaiman R, Yasawy M, Ismaeel M, Al-Ateeq S, Abdelrashid M, Eddin MA, et al. Association of NOD2/CARD15, DLG5, OCTN1 and Toll-like receptor 4 gene polymorphisms with inflammatory bowel disease in the Eastern Province of Saudi Arabia. Saudi J Med Med Sci 2014;2:81-5.  Back to cited text no. 2
  Medknow Journal  
3.
Feller ER, Ribaudo S, Jackson ND. Gynecologic aspects of Crohn's disease. Am Fam Physician 2001;64:1725-8.  Back to cited text no. 3
    
4.
Steinberg DM, Cooke WT, Alexander-Williams J. Abscess and fistulae in Crohn's disease. Gut 1973;14:865-69.  Back to cited text no. 4
[PUBMED]    
5.
Fahmy N, Kalidindi M, Khan R. Direct colo-labial Crohn's abscess mimicking Bartholinitis. J Obstet Gynaecol 2010;30:741-2.  Back to cited text no. 5
    
6.
Madnani NA, Desai D, Gandhi N, Khan KJ. Isolated Crohn's disease of the vulva. Indian J Dermatol Venereol Leprol 2011;77:342-4.  Back to cited text no. 6
[PUBMED]  Medknow Journal  
7.
Ben-Ami H, Ginesin Y, Behar DM, Fischer D, Edoute Y, Lavy A. Diagnosis and treatment of urinary tract complications in Crohn's disease: An experience over 15 years. Can J Gastroenterol 2002;16:225-9.  Back to cited text no. 7
    
8.
Van Assche G, Dignass A, Reinisch W, van der Woude CJ, Sturm A, De Vos M, et al. The second European evidence-based Consensus on the diagnosis and management of Crohn's disease: Special situations. J Crohns Colitis 2010;4:63-101.  Back to cited text no. 8
    
9.
Ruffolo C, Angriman I, Scarpa M, Polese L, Pagano D, Barollo M, et al. Urologic complications in Crohn's disease: Suspicion criteria. Hepatogastroenterology 2006;53:357-60.  Back to cited text no. 9
    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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