Vol. 118, October Printed in U.SA.
THE JOURNAL OF UROLOGY
Copyright © 1977 by The Williams & Wilkins Co.
HIDRADENITIS SUPPURATIVA OF THE SCROTUM BISWAMAY RAY* From the Division of Urology, Department of Surgery, University of Illinois College of Medicine and West Side Veterans Administration Hospital, Chicago, Illinois
ABSTRACT
A patient with hidradenitis suppurativa of the scrotum is described. The clinical presentation and treatment are discussed. Hidradenitis suppurativa, a chronic suppurative disease of the apocrine sweat glands, is seen most frequently in the axilla, less often in the inguinal and perianal regions and infrequently in the scrotum. A patient with hidradenitis suppurativa involving only the scrotum is reported herein. CASE REPORT
H. H., 345-20-7916, a 49-year-old black man, was hospitalized with a history of multiple sinuses on the lateral aspect of both sides of the scrotum, with intermittent seropurulent drainage for many years and continuous drainage during the last 1½ years. He denied any urinary symptoms, tuberculosis, venereal diseases, epididymo-orchitis, urinary tract infection or trauma. A right thoracotomy had been done elsewhere in March 1976 for spontaneous pneumothorax and the patient had bullous emphysema of the right upper lobe. Pertinent physical findings included thickened and indurated areas, measuring 8 by 3 cm. on the right and 7 by 3 cm. on the left posterolateral areas of the scrotum with multiple sinuses draining thick, creamy pus (part A of figure). The testes, epididymides and cord structures were normal. There was no inguinal adenopathy. Laboratory studies, including a complete blood count and chemistry studies, were normal except for a mildly elevated fasting blood sugar. An intradermal skin test, using purified protein derivative (intermediate strength) tuberculin was positive. Urinalysis was normal. Sputum and urine cultures, including tubercle bacilli cultures, were negative. The culture of the sinus tract drainage yielded Staphylococcus epidermidis but fungal and tubercle bacilli cultures were negative. A chest x-ray revealed emphysema in the right upper lobe. An excretory urogram, voiding cystourethrogram, retrograde urethroAccepted for publication June 17, 1977. *Requests for reprints: Division of Urology, P. 0. Box 6998, University of Illinois Hospital, Chicago, Illinois 60680.
gram and cystourethroscopy were normal. A sinogram showed multiple branching sinuses on both sides of the scrotum without any communication with the urethra (part B of figure). The upper and lower gastrointestinal and small bowel series, as well as proctosigmoidoscopy were normal. On December 6, 1976 a wide excision of all indurated areas, fluctuant lesions, cavities and sinus tracts on both sides of the scrotum was done by sharp dissection followed by primary closure of the skin. The disease was confined to the skin and subcutaneous tissue and did not involve the tunica vaginalis or other scrotal contents. Postoperatively, the patient was placed on ampicillin for 1 week and convalescence was uneventful. The histologic diagnosis was hidradenitis suppurativa. DISCUSSION
Hidradenitis suppurativa is a chronic recurrent infection of the apocrine sweat glands located deep in the corium and subcutaneous tissues in the axilla, perianal, inguinal, genitalia, posterior neck, areola of the breast and periumbilical areas. The disease is found generally in adults between 20 and 40 years old. Blacks are affected more commonly than whites and orientals are affected rarely. The axilla is involved most commonly followed by the perianal and genital areas. The etiology is obscure but most investigators consider hidradenitis suppurativa to be a follicular occlusion disorder. Usually, the contributing factors are poor hygiene, and mechanical and chemical irritation. The infection in most cases is owing to hemolytic Staph. aureus, Staph. epidermidis or Aerobacter aerogenes. 1• 2 The disease is insidious at onset. Inflammatory lesions lead to subcutaneous nodules, which at first are firm but later develop into abscesses that may resolve, rupture spontaneously or require incision. In most cases new lesions continue to develop and eventually there is a chronic deep-seated proc-
A, large sinus opening draining thick, creamy pus. B, sinogram shows extensive nature of intercommunicating sinus tracts. Residual dye in urethra from retrograde urethrogram. 686
687
HIDRADENITIS SUPPURATIVA OF SCROTUM
ess, scarring with abscess cavities and intercommunicating sinuses draining thick, creamy mucopurulent material. Although undermining and burrowing into adjacent areas can be extensive the deep fascial barrier usually prevents the spread of the disease deep to the subcutaneous tissues. Rarely, the sinus tracts may extend deep and may form urethral, vesical and rectal fistulas. 3 In this patient there was extensive involvement of the subcutaneous tissues but the tunica vaginalis and other scrotal contents in both sides were spared. One of the rare complications is development of squamous cell carcinoma, which has been reported in several cases of perianal hidradenitis suppurativa. 4 The differential diagnosis includes tuberculosis, urethral fistulas, lymphogranuloma venereum, granuloma inguinale and carcinoma. 5 Occasionally, hidradenitis suppurativa may masquerade as single or multiple perinea! urethral fistulas. 6 The disease in its early stage may respond to local moist heat, topical and systemic antibiotics or incision and drainage. For chronic recurrent disease complete surgical excision of the diseased skin and scar usually down to the fascia is the treatment of choice. While skin grafting may be necessary in cases
of extensive involvement, redundancy of the scrotal skin allows a primary closure even after a moderately extensive excision as was performed in this case. Dr. J. E. Gonzales provided technical assistance. REFERENCES 1. Fosnaugh, R. P. and Ramchand, S. C.: Hidradenitis suppura-
2.
3. 4. 5. 6.
tiva. In: Current Therapy. Edited by H. F. Conn. Philadelphia: W. B. Saunders Co., pp. 620-621, 1976. Mladick, R. A., Horton, C. E., Adamson, J.E. and Carraway, J.: Hidradenitis suppurativa of the perineum. In: Plastic and Reconstructive Surgery of the Genital Area. Edited by C. E. Horton. Boston: Little, Brown and Co., pp. 515-521, 1973. Moschella, S. L.: Hidradenitis suppurativa. Complications resulting in death. J.A.M.A., 198: 201, 1966. Humphrey, L. J., Playforth, H. and Leavell, U. W., Jr.: Squamous cell carcinoma arising in hidradenitis suppurativum. Arch. Derm., 100: 59, 1969. Ray, B. and Whitmore, W. F., Jr.: Experience with carcinoma of the scrotum. J. Urol., 117: 741, 1977. Carter, A. E.: Hidradenitis suppurativa masquerading as perineal urinary fistulae. Brit. J. Surg., 49: 686, 1962.
THE JOURNAL OF UROLOGY
Copyright © 1977 by The Williams & Wilkins Co.
HIDRADENITIS SUPPURATIVA OF THE SCROTUM BISWAMAY RAY* From the Division of Urology, Department of Surgery, University of Illinois College of Medicine and West Side Veterans Administration Hospital, Chicago, Illinois
ABSTRACT
A patient with hidradenitis suppurativa of the scrotum is described. The clinical presentation and treatment are discussed. Hidradenitis suppurativa, a chronic suppurative disease of the apocrine sweat glands, is seen most frequently in the axilla, less often in the inguinal and perianal regions and infrequently in the scrotum. A patient with hidradenitis suppurativa involving only the scrotum is reported herein. CASE REPORT
H. H., 345-20-7916, a 49-year-old black man, was hospitalized with a history of multiple sinuses on the lateral aspect of both sides of the scrotum, with intermittent seropurulent drainage for many years and continuous drainage during the last 1½ years. He denied any urinary symptoms, tuberculosis, venereal diseases, epididymo-orchitis, urinary tract infection or trauma. A right thoracotomy had been done elsewhere in March 1976 for spontaneous pneumothorax and the patient had bullous emphysema of the right upper lobe. Pertinent physical findings included thickened and indurated areas, measuring 8 by 3 cm. on the right and 7 by 3 cm. on the left posterolateral areas of the scrotum with multiple sinuses draining thick, creamy pus (part A of figure). The testes, epididymides and cord structures were normal. There was no inguinal adenopathy. Laboratory studies, including a complete blood count and chemistry studies, were normal except for a mildly elevated fasting blood sugar. An intradermal skin test, using purified protein derivative (intermediate strength) tuberculin was positive. Urinalysis was normal. Sputum and urine cultures, including tubercle bacilli cultures, were negative. The culture of the sinus tract drainage yielded Staphylococcus epidermidis but fungal and tubercle bacilli cultures were negative. A chest x-ray revealed emphysema in the right upper lobe. An excretory urogram, voiding cystourethrogram, retrograde urethroAccepted for publication June 17, 1977. *Requests for reprints: Division of Urology, P. 0. Box 6998, University of Illinois Hospital, Chicago, Illinois 60680.
gram and cystourethroscopy were normal. A sinogram showed multiple branching sinuses on both sides of the scrotum without any communication with the urethra (part B of figure). The upper and lower gastrointestinal and small bowel series, as well as proctosigmoidoscopy were normal. On December 6, 1976 a wide excision of all indurated areas, fluctuant lesions, cavities and sinus tracts on both sides of the scrotum was done by sharp dissection followed by primary closure of the skin. The disease was confined to the skin and subcutaneous tissue and did not involve the tunica vaginalis or other scrotal contents. Postoperatively, the patient was placed on ampicillin for 1 week and convalescence was uneventful. The histologic diagnosis was hidradenitis suppurativa. DISCUSSION
Hidradenitis suppurativa is a chronic recurrent infection of the apocrine sweat glands located deep in the corium and subcutaneous tissues in the axilla, perianal, inguinal, genitalia, posterior neck, areola of the breast and periumbilical areas. The disease is found generally in adults between 20 and 40 years old. Blacks are affected more commonly than whites and orientals are affected rarely. The axilla is involved most commonly followed by the perianal and genital areas. The etiology is obscure but most investigators consider hidradenitis suppurativa to be a follicular occlusion disorder. Usually, the contributing factors are poor hygiene, and mechanical and chemical irritation. The infection in most cases is owing to hemolytic Staph. aureus, Staph. epidermidis or Aerobacter aerogenes. 1• 2 The disease is insidious at onset. Inflammatory lesions lead to subcutaneous nodules, which at first are firm but later develop into abscesses that may resolve, rupture spontaneously or require incision. In most cases new lesions continue to develop and eventually there is a chronic deep-seated proc-
A, large sinus opening draining thick, creamy pus. B, sinogram shows extensive nature of intercommunicating sinus tracts. Residual dye in urethra from retrograde urethrogram. 686
687
HIDRADENITIS SUPPURATIVA OF SCROTUM
ess, scarring with abscess cavities and intercommunicating sinuses draining thick, creamy mucopurulent material. Although undermining and burrowing into adjacent areas can be extensive the deep fascial barrier usually prevents the spread of the disease deep to the subcutaneous tissues. Rarely, the sinus tracts may extend deep and may form urethral, vesical and rectal fistulas. 3 In this patient there was extensive involvement of the subcutaneous tissues but the tunica vaginalis and other scrotal contents in both sides were spared. One of the rare complications is development of squamous cell carcinoma, which has been reported in several cases of perianal hidradenitis suppurativa. 4 The differential diagnosis includes tuberculosis, urethral fistulas, lymphogranuloma venereum, granuloma inguinale and carcinoma. 5 Occasionally, hidradenitis suppurativa may masquerade as single or multiple perinea! urethral fistulas. 6 The disease in its early stage may respond to local moist heat, topical and systemic antibiotics or incision and drainage. For chronic recurrent disease complete surgical excision of the diseased skin and scar usually down to the fascia is the treatment of choice. While skin grafting may be necessary in cases
of extensive involvement, redundancy of the scrotal skin allows a primary closure even after a moderately extensive excision as was performed in this case. Dr. J. E. Gonzales provided technical assistance. REFERENCES 1. Fosnaugh, R. P. and Ramchand, S. C.: Hidradenitis suppura-
2.
3. 4. 5. 6.
tiva. In: Current Therapy. Edited by H. F. Conn. Philadelphia: W. B. Saunders Co., pp. 620-621, 1976. Mladick, R. A., Horton, C. E., Adamson, J.E. and Carraway, J.: Hidradenitis suppurativa of the perineum. In: Plastic and Reconstructive Surgery of the Genital Area. Edited by C. E. Horton. Boston: Little, Brown and Co., pp. 515-521, 1973. Moschella, S. L.: Hidradenitis suppurativa. Complications resulting in death. J.A.M.A., 198: 201, 1966. Humphrey, L. J., Playforth, H. and Leavell, U. W., Jr.: Squamous cell carcinoma arising in hidradenitis suppurativum. Arch. Derm., 100: 59, 1969. Ray, B. and Whitmore, W. F., Jr.: Experience with carcinoma of the scrotum. J. Urol., 117: 741, 1977. Carter, A. E.: Hidradenitis suppurativa masquerading as perineal urinary fistulae. Brit. J. Surg., 49: 686, 1962.
