A 28-year-old married male sought medical advice at a urology clinic in his rural hometown after complaining of painful scrotal swelling for 1 week. On a spot diagnosis, the urologist identified the patient as having bilateral EO. The only requested investigation, at that time, was a urine analysis, which indicated 12-15 pus cells/HPF. The patient received a prescription containing ciprofloxacin 500 mg tablet/12 hours, and some analgesics. Five days later, the patient noticed stepping pain in his scrotum, along with worsening scrotal swelling. Also, he started to have a fever (40 C), chills, a sense of unease, anorexia, and nausea. The patient, therefore, consulted another urologist in his hometown for these emerging symptoms. This second urologist clinically confirmed the previous diagnosis of bilateral EO. Sulbacef (sulbactam & cefoperazone) 1.5 g vial/day and Voltaren injection every 12 hours were prescribed by the urologist. This treatment was planned to last for 7 days. Until the fourth day, the patient did not show any improvement, although he strictly followed the recently scheduled treatment regimen. Instead, the patient got extremely sick. The fever rose (41.5 C), and he started vomiting. He could not sleep for 24 hours a day, and he was exceptionally exhausted. A laboratory biochemical check-up, at that time, showed an elevated leucocytic count (24. 3 x 103/mL; the normal is 4-11 x 103/mL), neutrophilic predominance (88%; the normal is 35%-80%), and high C-reactive protein (96 mg/dL; the normal is <6 mg/dL). Blood urea and serum creatinine were normal. A digital rectal examination revealed tender cystic structures over the prostate, indicating enlarged seminal vesicles. Because transrectal ultrasound (TRUS) was not available, transabdominal ultrasound was done first in the urologist's office. The scanning showed markedly dilated seminal vesicles. The urologist requested TRUS to further clarify the pathological nature of the dilated vesicles. The TRUS confirmed the existence of markedly distended seminal vesicles (up to 4 cm in diameter) with hyperechogenic contents suggesting abscesses formation (Figure 1), and a midline prostatic cyst (5 mm in diameter) (Figure 2). A cystourethroscopy was done, and an enlarged cystic prostatic utricle was seen, which was immediately resected. During the resection, a gush of frank pus appeared coming from the right side of the utricle. A urethral catheter was fixed for 24 hours and the patient was kept again on Sulbacef in the emergency department. The patient showed considerable improvement starting the next day. The fever disappeared, and the body temperature was around 37 C. He could sleep after several days of continuous insomnia. His appetite improved, and oral feeding was resumed. However, 4 days later, the previously annoying symptoms recurred.
Herein, the patient's family sought counsel at the Urology Outpatient Clinic, Alexandria Main University Hospital. The patient denied a history of any genital trauma, diabetes, tuberculosis, urethral discharge, sexually transmitted diseases, extramarital relations, or previous similar conditions. He had a history of primary infertility for 7 years. The repeated semen analyses showed azoospermia with a low semen volume (0.7-0.9 mL), and the FSH assay was high-normal (11.5; the normal level is 1.5-12.4 mIU/mL). Physical examination disclosed tachycardia (112 beats/minute), low blood pressure (100/65), and fever (40.5 C). The upper abdomen was lax, but the supra-pubic area and both inguinal regions were tender and rigid. The scrotum was erythematous and swollen, with excoriated skin on its left side. On palpation, the scrotum was tender and indurated, and the epididymes were not palpable from the testes. The spermatic cords were also tender and indurated. A digital rectal examination revealed remarkably enlarged and tender seminal vesicles. The patient received a magnetic resonance imaging (MRI)-pelvis examination. The image showed notably dilated seminal vesicles (Figure 3) with diverse signal intensities from normal. The left testis also suspiciously showed a fluid collection in its lower pole, suggesting an impending abscess formation (Figure 3). An immediate transrectal aspiration of seminal vesicles was done under MRI guidance. The aspiration yielded frank yellowish pus, around 75 mL in volume. The aspirate was referred for bacteriologic examination, and the culture later grew Escherichia coli (E. coli) with susceptibility to Merional (Meropenem). The patient was scheduled to receive Merional (1 gm/12 hours) for 5 days on an outpatient basis immediately after the aspiration and before getting the bacteriologic report. Three days later, the patient came for a follow-up. He showed distinct clinical improvement. His laboratory results returned close to the normal ranges (total leucocytic count fell to 12 x 103/mL, neutrophils subpopulation fell to 77%, and C-reactive protein fell to 48 mg/dL). The right testis started recovering but on the contrary, the left testis was still tender and enlarged. The next day, while at home, pus started to come from the lower pole of the left testis. The patient was immediately re-admitted to the hospital and received surgical exploration of the scrotum. An abscess (2 cm x 3 cm) in the lower pole of the markedly left swollen testis was detected (Figure 4) with areas of necrosis. A fibrous capsule surrounded the abscess except at the site of the discharge. The drainage of the abscess produced a frank yellow discharge. Testicular sparing surgery with debridement of the necrosed parts was expedited. The testicular tissue around the abscess seemed viable. The patient left the hospital after a few hours and continued on Merional for 2 days. The patient then began a 2-week course of oral Augmentin 1 g/12 hours until his first follow-up visit. Two weeks later, the patient attended the outpatient clinic. His general condition was fine. The scrotal incision healed, and the previous tenderness and swelling of the left testis almost disappeared. A repeat transabdominal ultrasound showed normal-sized seminal vesicles. The total leucocytic count was 9 x 103/mL and CRP was 5 mg/dL. The patient continued to be symptomless for 5 months after ending the Augmentin course. A scrotal duplex, at that time, showed unremarkable findings. Two repeated semen analyses revealed normal semen volumes (4.5 cc and 3.8 cc) but with azoospermia.