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Right sided epididymoorchitis with rif abscess

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Right sided epididymoorchitis with rif abscess

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Right sided epididymoorchitis with rif abscess

  1. 1. 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
  2. 2. 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 +
  3. 3. 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.
  4. 4.  T.C-14800  ESR-40 mm/hr  USG abdomen – mild fatty changes in liver, umbilical hernia ,subhepatic appendicitis
  5. 5. 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.
  6. 6.  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
  7. 7.  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
  8. 8.  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 .
  9. 9.  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
  10. 10.  WORKING DIAGNOSIS – 1) Left pneumonia 2) Right epididymitis 3) Subhepatic appendicitis 4) Chronic liver disease
  11. 11.  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.
  12. 12.  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
  13. 13.  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
  14. 14.  ASCENDING INFECTION OF RIGHT CORD STRUCTURES RESULTING IN RIF ABSCESS
  15. 15.  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.
  16. 16.  Inflammation confined to epididymis - EPIDIDYMITIS  Infection spreading to testes - EPIDIDYMO- ORCHITIS
  17. 17.  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
  18. 18.  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
  19. 19.  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
  20. 20.  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
  21. 21.  reactive hydrocoele,  ABSCESS FORMATION  infarction of the testicle,  testicular atrophy,  reduced fertility.
  22. 22.  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
  23. 23.  TREATMENT  ATT  If no resolution within 2 months - epididymectomy or orchidectomy

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