Case 11: Scrotal pain
Tuesday, March 8th, 2011A 55 year old male presents to the ED with a one week history of pruritus and pain in his scrotum. He has developed a fever and vomited 5 times prior to attending but now states the pain is easing. His medical history includes diabetes and hypertension.
His observations on arrival are: HR 120 BP 92/70 T 39.4 RR 22 BM 15.2
1. What is the likely diagnosis?
Click to see the answerThis patient has evolving Fournier’s Gangrene. This is defined as a polymicrobial necrotizing fasciitis of the perineal, perianal, or genital areas. There is an obliterative endarteritis, and the subsequent cutaneous and subcutaneous vascular necrosis leads to localized ischemia and further bacterial proliferation. Incredibly Rates of fascial destruction can be as high as 2-3 cm/h.
2. Name three likely precipitants?
Click to see the answerLocalized infection adjacent to a portal of entry is often the inciting event in the development of FG. Colorectal, genitourinary, and dermatologic sources are implicated in the pathogenesis of the disease.
The most common causes in Europe are perianal, perirectal, and ischiorectal abscesses . Chronic urinary tract infections, epididymitis and orchitis may often also lead to the disease.FG can also occur in women and is most often seen with septic abortions, Bartholin gland abscesses and episiotomy are documented sources. In children, circumcision, strangulated inguinal hernia, and omphalitis have led to the disease.
3. How would you mange this patient in the ED?
Click to see the answerThe mortality with FG can be as high as 75% so emergent treatment is essential. The patient requires aggressive resuscitation in anticipation of surgery addressing likely septic shock. Early, broad-spectrum antibiotics are indicated and tetanus prophylaxis is indicated if soft-tissue injury is present.
Fournier gangrene is a surgical emergency and immediate urologic consultation is crucial.