Fournier Gangrene

SavageGlow · #1 ● 08-22-2024, 04:08 PM

A 58 years old male patient, with poorly controlled diabetes mellitus type 2 presented to the outpatient clinic for 4 days history of redness, blackish discoloration of the penis, painful swelling of penile shaft associated with high grade fever of 40 °C and purulent discharge from the penis. The patient denied any recent sexually transmitted disease, genitourinary trauma, urethral instrumentation. He is non-smoker and non-alcoholic. He had no sexual intercourse during the last few months. His past medical history was unremarkable except for poorly controlled diabetes (last HBA1C of 13% (normal: 4%–5.5%).

On admission, his temperature was 40 °C and the vital signs were stable. Physical examination revealed penile edema, severe tenderness of the penile shaft with no skin breaks, normal glans, blackish discoloration of the penis (Fig. 1). The testicular, digital rectal examinations were normal. No dysuria or frequency or hematuria. He also reported chills and nausea.

Laboratory examination revealed WBC of 22000/mm3 with left shift, CRP of 240 mg/L, random blood sugar 400 mg/dl. Urine analysis showed 1–2 WBC per high power field. Blood urea & serum creatinine were within the normal limits. Purulent material discharge from penis was sent for culture. HIV test and STD panel were negative. Blood, urine, and pus cultures were obtained.

The patient was started on broad-spectrum antibiotics (Ertapenem &Vancomycin) and fluid resuscitation was initiated. Urgent surgical intervention under general anesthesia was done. Before the operation, an 18-Fr Foley catheter was inserted. After degloving of the penis, it was noticed that there was a necrosis of the tissue below the skin on the ventral and dorsal aspect of the penis involving penile dartos layer up to the corpora spongiosa. Adequate debridement with excision of all necrotic tissue was done (Fig. 2). Necrotic tissue was debrided to bleeding edges. Tissue was send for culture and histopathological examination.

Postoperatively, the patient remains stable with no fever or chills. Laboratory studies improved, leukocyte count and CRP decreased. The culture of the pus materials revealed S. aureus and E. coli, the patient was completed a further 3 weeks of antibiotic according to the sensitivity test (Ertapenem 1 g once daily). Blood and urine culture revealed no growth. Regular dressing was done three times daily. After 10 days, the wound bed was granulated and healthy. An unexpanded, meshed, split-thickness skin graft was placed on the ventral and dorsal aspect of the penis (Fig. 3). The patient was discharged on the 18th postoperative day. He was seen in the outpatient clinic 3 weeks after discharge and he was markedly improved with no infection or flap necrosis was noted. A satisfied aesthetical appearance was obtained (Fig. 4). The patient provided a written consent for the publication of this clinical case.