Urinary Catheter-Induced Urethro-Scrotal Fistula With Scrotal Abscess From A Descending Pyonephrotic Infection: A Case Report

Abstract

Background: Scrotal abscesses are typically caused by local or ascending genitourinary infections, with chronic Foley catheter use being a well-established risk factor. Urethro-scrotal fistula (USF) is a rare complication that may be iatrogenic or secondary to trauma. However, a descending infection from an upper urinary tract source leading to catheter-induced fistula formation has not been previously described.

Case Presentation: A 63-year-old Saudi male with a history of left pyelonephritis and difficult double-J (DJ) stent placement nine months prior presented with acute left scrotal swelling and fever. He had been lost to follow-up and managed voiding dysfunction with a chronically indwelling Foley catheter exchanged monthly at home. Examination revealed a tender, distended bladder and an erythematous, indurated left hemiscrotum with purulent drainage from the catheter. Laboratory investigations showed marked leukocytosis (WBC 23 × 10³/µL), and blood cultures grew Klebsiella pneumoniae. Scrotal ultrasound demonstrated a dense turbid fluid collection in the left hemiscrotum with the Foley catheter balloon visualized within the abscess cavity, confirming false passage. CT imaging revealed a markedly dilated left pelvicalyceal system with an in-situ DJ stent. The patient underwent urgent incision and drainage, revealing a 6 × 2 cm urethro-scrotal fistula. Following sepsis control, a nephrectomy was performed, with histopathology confirming chronic pyelonephritis and end-stage renal disease. The scrotal wound healed completely.

Conclusion: This case represents a rare dual pathophysiology: a descending pyonephrotic infection creating vulnerable periurethral tissues, predisposing to iatrogenic urethro-scrotal fistula formation during routine catheter exchange. Clinicians should maintain a high index of suspicion for upper tract pathology in chronically catheterized patients presenting with scrotal infections, as definitive management requires addressing both the local complication and the remote infectious source.