Acute appendicitis presenting as acute scrotum in a toddler: A case report

Abstract : The acute scrotum is a common paediatric emergency presentation most often caused by testicular torsion, epididymo-orchitis, or incarcerated inguinal hernia. We present the rare occurrence of it occurring secondary to perforated appendicitis, further complicated by a post-operative pyocoele requiring surgical intervention. A 2-year-old male initially presented with Influenza A infection and subsequently developed right-sided scrotal swelling, erythema, and tenderness. Clinical examination revealed right iliac fossa tenderness, and ultrasonography demonstrated perforated appendicitis with associated right-sided epididymo-orchitis, without a scrotal collection. The patient underwent laparoscopic appendectomy and was commenced on intravenous ceftriaxone and metronidazole. Despite initial improvement, scrotal swelling and inflammatory markers persisted. Ultrasonography six days postoperatively identified a right-sided pyocoele, prompting escalation of antibiotic therapy; however, symptoms failed to improve. Repeat imaging three days later demonstrated interval enlargement of the collection. Surgical drainage was performed via a transverse right scrotal incision, and temporary drain placement. Although a patent processus vaginalis was not identified intraoperatively, its involvement was considered likely given the clinical course. The patient improved following drainage but re-presented with recurrent pyrexia, requiring recommencement of intravenous antibiotics and a prolonged course of outpatient broad-spectrum oral therapy with metronidazole and cefalexin, requiring over six weeks of antibiotic therapy in total. Patients with acute appendicitis and a concomitant acute scrotum should be evaluated for a patent processus vaginalis, as the acute scrotum may be caused by purulent fluid from the abdomen accumulating in the tunica vaginalis. Surgical drainage of the purulent fluid may be required.