Scrotal pain and swelling
Authors:
Ralph J. Riviello, MD
Andrew T. Harris, MD
Stephen Perez, MD
Affiliations:
Allegheny University of the Health Sciences
Allegheny General Hospital Department of Surgery
Division of Emergency Medicine (RJR), (ATH), (SP)
Chief Complaint:
Scrotal pain and swelling
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History of present illness:
A 77-year-old male
presents to the emergency department (ED) with a four-day history
of scrotal pain and swelling. He reports generalized fatigue
had anorexia but denies fever, chills, abdominal pain, dysuria,
and trauma. He has not been able to walk for three days secondary
to lower extremity pain. His past medical history includes chronic
left lower extremity ulcer for nearly 40 years. He also has a
history of alcohol and tobacco abuse, but has abstained from both
for the past six years. He denies any previous surgeries. He takes
no medications.
Physical examination:
The patient is an alert, oriented,
cooperative male in no acute distress. His vital signs are: temperature
38.6 C (rectal), pulse 104 beats/min., blood pressure 120/70 torr,
and respiratory rate 16 breaths/min. Head and neck examination
is significant for pale conjunctiva and mucous membranes. Lung
auscultation reveals clear lung fields. His heart sounds are
regular and tachycardic, without murmur, gallop or rub. His abdomen
is soft, distended, and non-tender with normal bowel sounds.
His scrotum has generalized edema, erythema, and tenderness with
superficial ulceration on the left anterior scrotum (figure 1)
without odor or discharge. There is crepitance of the scrotum.
The testicles are equal in size and are tender to palpation.
His penis has no lesions or discharge. Rectal examination was
extremely tender diffusely without occult blood. The left midcalf
has a 10 cm wide, circumferential ulcer with granulation tissue
throughout. There is no erythema or discharge. The neurological
exam is normal.
Laboratory:
The white count is 14.0 x 103 with 86 polys
and 5 bands. The hemoglobin and hematocrit are 5.5g/dl and 17.4
% , respectively with a platelet count of 521 x 103. Electrolyte
values are sodium of 140 mmol/l, potassium of 3.9 mmol/l, chloride
of 106 mmol/l, CO2 of 20 mmol/l, BUN of 24 mg/dl, creatinine of
1.6 mg/dl, glucose of 103 mg/dl, calcium of 7.1 mmol/l, and albumin
of 2.3 mmol/l. Liver enzymes are normal. Urinalysis shows 8
RBCs/HPF and 2 WBCs/HPF.
Radiology evaluation:
A pelvic radiograph demonstrates
gas in the left buttocks (figure 2). The left lower leg radiograph
shows muscle calcification and new periosteal bone formation.
The chest radiograph is normal. A computed tomographic (CT)
scan, obtained by the surgical consultant, shows a gas-producing
soft tissue process that extends from the scrotum into the subcutaneous
fat of the perineum and medial thigh.
The patient course, diagnosis and discussion
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