Fournier gangrene, a form of necrotizing fasciitis, most frequently occurs in a middle-aged diabetic man who presents with swelling, erythema, and severe pain of the entire scrotum, but it is also known to occur in women. In men, the scrotal contents often cannot be palpated because of the marked inflammation. The patient has constitutional symptoms with fever and frequently is in shock. There is often a history of recent urethral instrumentation, an indwelling Foley catheter, or perirectal disease. A localized area of fluctuance usually cannot be appreciated.
Management and Disposition
These patients require aggressive fluid resuscitation and early surgical consultation for immediate debridement and surgical drainage. Give broad-spectrum antibiotics effective against gram-positive, gram-negative, and anaerobic organisms as soon as possible in the emergency department.
Pain out of proportion to the clinical findings may represent an early presentation of Fournier gangrene.
CT imaging can delineate the depth and extent of disease but should not delay operative intervention.
Fournier gangrene is usually quite painful but has been known to present with only a mildly uncomfortable necrosis of the scrotal wall and exposed testis.
Fournier Gangrene. Middle-aged diabetic man with fever and scrotal pain. Final diagnosis is polymicrobial Fournier gangrene. (Photo contributor: Eugene C. Eiland, MD.)
Fournier Gangrene. Swollen, tender, erythematous labia, perineum, and inner thighs in a female patient with Fournier gangrene. (Photo contributor: Daniel L. Savitt, MD.)
Fournier Gangrene. Necrosis of overlying scrotal skin along with swelling, erythema, high fever, and severe pain was noted in this diabetic patient with Fournier gangrene. (Photo contributor: R. Jason Thurman, MD.)
Fournier Gangrene. The extent of necrosis in Fournier gangrene can be formidable, as seen in this patient. (Photo contributor: R. Jason Thurman, MD.)