A Diabetic Male With a Suprapubic Mass and Painful Penis and Scrotum

Abstract

Fournier's gangrene is a life-threatening necrotizing synergistic fasciitis of the perineum, abdominal wall, and genitalia [Surg Clin North Am 2002;82:1213; Urol Clin North Am 1991;26:841]. We describe a case of a 66-year-old man whose atypical presentation posed a diagnostic and clinical challenge of such a urological emergency. Clinicians need to have a high index of suspicion for this disease in individuals with predisposing or associated conditions, given the risk for widespread extension and impact on patients' outcome. (Infect Dis Clin Pract 2006;14:65-67) CASE REPORTA 66-year-old African American male with a history of diabetes mellitus and peripheral vascular disease was admitted in December 2004 to a hospital emergency department with fever, chills, dysuria, and fluctuating blood sugars. He denied any penile discharge, unprotected intercourse, or costovertebral tenderness. He reported falling without loss of consciousness before arrival to the emergency department. Physical examination was unremarkable; there was no prostate tenderness. Values for standard laboratory tests revealed the following: white blood cell count 41 Â 1000/mm 3 , 70% neutrophils, 19% bands; urinalysis, 30 white blood cells per high-power field, negative nitrite, 2+ leukocyte esterase, moderate bacteria; sodium 133 mmol/L, potassium 3.3 mmol/L, bicarbonate 15 mmol/L, creatinine 1.1 mg/dL, lactate 2.9 mmol/L (range 0.5-2.2). No abnormalities were seen on chest radiograph and renal ultrasound.The patient was treated for a presumptive urinary infection with a fluoroquinolone. One day after discharge, the patient represented after awaking from sleep with a painful penis and scrotum and a weak interrupted urinary stream. Findings on physical examination revealed a nontoxic man with stable vital signs and a tender nonfluctuant suprapubic mass with scrotal, penile, and perineal edema. Laboratory analysis revealed white blood cell count 70.2 Â 1000/mm 3 , 86% neutrophils, 7% bands; sodium 132 mmol/L, potassium 4.0 mmol/L, bicarbonate 18 mmol/L, creatinine 0.7 mg/dL, lactate 0.7 mmol/L. Blood and urine cultures were negative. Computed tomography examination of the abdomen and pelvis demonstrated air in the subcutaneous tissue overlying the pelvis and perineum, along the fascial planes, extending halfway to the umbilicus (Fig. 1). These findings were suggestive of Fournier's gangrene.The patient was immediately taken to surgery for debridement of the perineum and corpora spongiosum. The patient was treated with intravenous imipenem and clindamycin. Wound Gram stain and culture revealed budding yeast that cultured out as Candida albicans; pathological tissue examination from the perineum revealed necrotic involvement of the skin and subcutaneous fat and fascia. Special stains for bacteria, acid-fast bacilli, and fungi were negative. The patient was taken to the operating room daily for repeated examination and debridement ultimately requiring a penectomy 21 days after initial debridement. Perineal wound vacuum cultures from 6 days after p...