Right sided epididymoorchitis with rif abscess

2. A 63 year old buissinessman Mr.Basheer,
from Pudunagaram, came to surgery OPD
on 2/1/2013 with H/O right sided
abdominal pain of 3 days duration .
 There was no H/O nausea, vomiting,
anorexia, fever or weight loss.
 Bowel & bladder was normal
 He is neither a smoker nor an alcoholic

3. 1. He is a known hypertensive on
treatment
2. He has H/O tuberculosis 30 years
back completed Antitubercular
treatment under category 1
3. Morbid obesity +

4. On examination
 Vitals stable, afebrile
 abdomen was distended ,
 umbilical hernia + ,
 dialated veins + on the right flank, flow from below
upwards.
 Diffuse tenderness + involving the right hypochondrium & RIF
 No organomegaly
 No free fluid
 Bowel sounds heard
 External genitalia appeared normal
 Hernial orifices free except for umbilical hernia

 Clinical diagnosis of Subhepatic appendicitis was
suspected & was worked up.

5.  T.C-14800
 ESR-40 mm/hr
 USG abdomen – mild fatty changes in
liver, umbilical hernia ,subhepatic
appendicitis

6. His Alvarado [MANTRELS] score was 4
 Tenderness in the RIF 2
 Leucocytosis 2
He was advised conservative management with oral
antibiotics & analgesics and was sent home.

7.  The abdominal pain did not subside with
the oral antibiotics and antiinflammatory
drugs . 2 days later, on 4/1/13 he got
admitted in MSW
 TREATMENT
 IVF & parenteral broad spectrum antibiotics
 Catheterised
 Kept in NPO
 Abdominal girth charting

8.  On the next day on 5/2/13 patient developed
difficulty in breathing

 O/E basal crepts heard bilaterally
 Chest X ray –bilateral basal pneumonia
 Patient was given inhalational & intravenous
bronchodilators and steroids.
 Sputum AFB & gramstaining was not done
since the patient could not produce sputum

9.  2 days later, on 7/1/13 , a swelling was
observed in the right inguinal region, cord
was thickened .
 USG scrotum- bilateral acute epididymitis R > L &
bilateral minimal hydrocele
 On 8/1/13 ,His breathing difficulty persisted ,O/E
coarse inspiratory crepts heard in the left
infrascapular area,
 Chest X-ray - nonhomogenous opacity on left lower
zones
 Diagnosis – left lower lobe pneumonia
 He was given I.V antibiotics .

10.  C.T. ABDOMEN - liver normal size with fatty
changes and calcified focus,umbilical hernia ,
minimal fluid collection in RIF,right cord
appear thickened with minimal surrounding
fluid,minimal gaseous distention of small bowel
loops.
 C.T.THORAX – consolidation seen in posterior
segment of left upper lobe,trace of left pleural
effusion seen

11.  WORKING DIAGNOSIS –
1) Left pneumonia
2) Right epididymitis
3) Subhepatic appendicitis
4) Chronic liver disease

12.  His total count & abdominal girth was
progressively increasing over 8 days.
 On 12/1/13 screening USG showed focal
collection in RIF & USG guided aspiration
was done which yielded 5ml of frank pus &
was sent for culture & sensitivity.
 D/D 1.R epididymitis
2.appendicular abscess
 Patient was planned for exploratory
laparotomy.

13.  EXPLORATORY LAPAROTOMY WITH RIGHT
HIGH INGUINAL ORCHIDECTOMY was done
on 12/1/13 under epidural anaesthesia
through low right paramedian incision.
 FINDINGS – Dilatation of bowel + RIF
explored ,PUS COLLECTION + ,APPENDIX
NORMAL, ASCENDING INFLAMMATION OF
CORD STRUCTURES WITH NECROSIS &
ABSCESS FORMATION found
 PROCEDURE - RIF explored , Pus evacuated ,
peritoneal wash given ,R orchidectomy done

14.  Pus c/s-organism isolated was E.coli
sensitive to amikacin, ceftazidime, ofloxacin
& pipiracillin/tazobactum
 HPE reports –
1) Epididymis – Non specific epididymitis with
duct obstruction ,Epididymal cyst
2) Testes – No significant pathology
3) Spermatic cord - funiculitis

15.  ASCENDING INFECTION OF RIGHT CORD
STRUCTURES RESULTING IN RIF ABSCESS

16.  Post operative period was uneventful except for
oozing from drain tube site
 Pus c/s from drain tube site : organism isolated
was E.coli sensitive to
amikacin,ampicillin,sulbactum,ofloxacin,pipiracillin,t
azobactum,imipenam

 On 28/1/13 USG Abdomen showed 8 *2.1 cm ,
25 cc collection seen in the abdominal wall in
the right lower abdomen, a diagnosis of anterior
abdominal wall abscess was made for which
USG guided wound debridement done under L/A
on 9/2/13 &
 the patient was discharged on the 30 th post -
operative day on 11/2/13 after check USG.

17.  Inflammation confined to epididymis -
EPIDIDYMITIS
 Infection spreading to testes - EPIDIDYMO-
ORCHITIS

18.  Mode of infection
1. Primary infection of urethra, prostate or seminal
vesicles → via vas → epididymis
2. In men with BOO – high pressure in the prostatic
urethra→reflux of infected urine up the vasa
3. Young men – STD –Chlamydia & gonococci – asso .
With urethritis
4. Bloodborne - if E.coli,streptococci,proteus without
evidence of urinary infection

19.  Acute epididymitis can follow any form of urethral
instrumentation or catheterisation
 Acute tuberculous epididymitis - if vas is thickened
& there is little response to antibiotics
 Mumps – at any age
 Infections with other enteroviruses,
brucellosis,lymphogranuloma venerum also can
cause epididymitis

20.  initial symptoms of urinary infection
 Ache in groin
 Fever
 Epididymis &testes swell and become painful
 Scrotal wall – first red edematous & shiny & may
become adherent to epididymis
 Occasionally an abscess can form & discharge pus
through scrotal skin
 Resolution may take 6-8 weeks

21.  Urine analysis & urine culture & sensitivity should
be obtained in all cases
 Need aggressive treatment with parenteral
antibiotics
 Doxycycline – DOC- for chlamydial infection
 Broad spectrum antibiotic against urinary tract
pathogens
 Analgesics
 Plenty of oral fluids
 SCROTAL ELEVATION
 If suppuration + - drainage is necessary

22.  reactive hydrocoele,
 ABSCESS FORMATION
 infarction of the testicle,
 testicular atrophy,
 reduced fertility.

23.  Due to retrograde infection from a tuberculous focus in
seminal vesicles –so lower pole of epididymis is involved
first
 Clinical features – fiirm discrete swelling of lower pole
of epididymis which aches a little ,the disease progresses
until the whole epididymis is firm & craggy behind a
normal feeling testes
 Lax secondary hydrocele
 Beading of vas
 Seminal vesicles indurated & swollen
 Cold abscess formation & discharge
 Investigations – examination of urine & semen for
tubercle bacilli ,IVU & chest X ray

24.  TREATMENT
 ATT
 If no resolution within 2 months - epididymectomy
or orchidectomy