Complicated Perineal Abscess with Post-Drainage Scrotal Swelling

Case at a Glance

A 38-year-old obese male smoker presented with recurrent perineal abscess that spontaneously ruptured, followed by development of scrotal swelling raising concerns for potential necrotizing fasciitis.

Patient's Story

The patient, a 38-year-old male (BMI 40.8, 300 lbs, 6'1"), tobacco user, presented with an 8-day history of recurrent perineal abscess located beneath the right side of his scrotum. He reported severe pain that prevented ambulation due to pressure. While being transported to the hospital, the abscess spontaneously ruptured with significant purulent drainage. The patient had a previous episode of similar abscess in the same location 5 months prior, as well as recurrent abscesses on bilateral inner thighs approximately 5 years ago. He also has a history of diverticulitis.

Initial Assessment

Upon emergency department evaluation, the patient was prescribed oral antibiotics and ibuprofen. Incision and drainage was recommended but declined by the patient who wished to clean the wound at home first. The patient went home and immediately cleansed the area with chlorhexidine solution.

The Diagnostic Journey

Twenty-four hours post-rupture, the patient developed diffuse scrotal swelling without significant pain, only mild discomfort. Initial phone follow-up suggested this was normal post-abscess healing. However, given the patient's risk factors (obesity, smoking, recurrent perineal infections) and clinical presentation, there was significant concern for potential Fournier's gangrene - a necrotizing fasciitis of the perineum that constitutes a urological emergency.

Final Diagnosis

Complicated perineal abscess with suspected hidradenitis suppurativa, requiring urgent evaluation to rule out necrotizing fasciitis (Fournier's gangrene). The recurrent nature and anatomical location suggested possible underlying hidradenitis suppurativa.

Treatment Plan

The patient was advised immediate return to emergency department for urgent evaluation including wound culture and sensitivity testing, possible surgical debridement, and intravenous antibiotics. Management required multidisciplinary approach involving emergency medicine, urology/surgery, and dermatology consultation. The wound required proper drainage of any remaining loculated collections, as antibiotics alone cannot penetrate undrained abscesses.

Outcome and Follow-up

Patient initially hesitated to return due to lack of pain but ultimately presented to emergency department when he developed fever and dysuria. He received morphine suggesting preparation for surgical intervention. Long-term management included dermatology referral for evaluation and management of suspected hidradenitis suppurativa to prevent future recurrences. Patient education emphasized the importance of immediate medical attention for perineal infections due to risk of life-threatening complications.