A paper published in the September 2024 edition of Urology Case Reports included details about a case of a 65-year-old man who was suddenly faced with penis amputation after visiting the emergency department (ED).

Hernández Martínez JO, Bertrand Noriega F, Ramírez Pedraza JM, et al. Ischemic gangrene of the penis due to Fournier's gangrene following traumatic transurethral catheterization: a case report. Urol Case Rep. 2024;56:102820.

 

The patient’s first visit to the ED was due to trouble urinating after drinking too much alcohol. After traumatic urethral catheter placement on the third try, his urine was reportedly cloudy and foul-smelling. He was then treated with antibiotics for his symptoms. 

 

 

What is Fournier’s gangrene?

 

Fournier's gangrene is a relatively rare type of necrotizing fasciitis that affects the tissues of the genitals. Since 1950, over 1,800 cases of this disease have been reported in English-language medical literature. It can affect anyone, including women and children, but it’s more commonly seen in adult males.

Fournier Gangrene. National Organization for Rare Disorders (NORD). January 25, 2024.

 

“The infection is typically caused by multiple microorganisms and results in necrosis or death of the involved tissue,” explains Sarah C. Krzastek, MD, a urologist at VCU Health and clinical associate professor of urology at Virginia Commonwealth University. “The infection can spread quickly and can cause severe sepsis and death.” Group A Streptococci and Staphylococcus aureus, as well as gram-negative bacteria, are the main microorganisms associated with Fournier’s gangrene.

Leslie SW, Rad J, Foreman J. Fournier Gangrene. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Updated June 5, 2023.

 

 

 

Symptoms and risk factors

 

Fournier’s gangrene is one of the rare urological cases that requires immediate surgical intervention and antibiotic treatment.

Leslie SW, Rad J, Foreman J. Fournier Gangrene. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Updated June 5, 2023.

It often presents with tissue death and general signs of sepsis like fever, chills, and high heart rate. “The infection typically starts as a red spot or 'pimple' on the scrotum, perineum, or penis and can spread rapidly, causing redness and swelling of the scrotal skin,” Dr. Krzastek explains. 

 

The more the infection spreads, the more the redness deepens, and blisters appear.

Zhang KF, Shi CX, Chen SY, et al. Progress in multidisciplinary treatment of Fournier's gangrene. Infect Drug Resist. 2022;15:6869–6880.

“When the involved skin dies, it can turn black,” she says. 

 

Risk factors can include advanced age, immunosuppression, vascular disease, diabetes, malnutrition, liver cirrhosis, alcoholism, and poor personal hygiene, according to Dr. Krzastek. These factors can also predispose a patient to worse clinical outcomes.

Fournier’s gangrene typically occurs in men and is found most often in those aged 50 to 79. But it can occur in women or infants.

 

She highlights the importance of good personal hygiene and tight control of other medical conditions, such as diabetes, hypertension, and obesity, to reduce the risk of Fournier’s gangrene. 

 

Diagnosis tips

 

Diagnosing Fournier's gangrene early can be tricky because the initial symptoms are subtle and may be similar to other conditions like scrotal swelling and cellulitis. It is even more challenging to diagnose Fournier’s gangrene when patients present without known risk.

Zhang KF, Shi CX, Chen SY, et al. Progress in multidisciplinary treatment of Fournier's gangrene. Infect Drug Resist. 2022;15:6869–6880.

 

 

The condition is diagnosed by a surgeon’s physical exam, but the diagnosis may be aided by imaging or lab findings, according to Dr. Krzastek. 

Imaging tests may help rule out other conditions, such as epididymitis or orchitis. A CT scan, for instance, can help show how the infection started and how far it has spread. But it can be omitted to avoid delaying surgery.

Fournier Gangrene. National Organization for Rare Disorders (NORD). January 25, 2024.

 

 

Treatment options

 

“​​The treatment of Fournier’s gangrene requires emergent IV antibiotics and removal of the affected skin and tissues,” says Dr. Krzastek. Several antibiotic regimens are  recommended. Carbapenems given through an IV include imipenem or meropenem, 1 g IV every 6-8 hours, and ertapenem, 1 g IV every 24 hours. Another option is piperacillin-tazobactam, given through an IV every 6-8 hours, along with IV clindamycin (every 8 hours) and IV vancomycin (every 8-12 hours).

Surgery involves removing all dead and dying tissue. Patients with sepsis who are at higher risk for blood clots may need medications to prevent them. Patients should also be given fluids for rehydration and appropriate medications for blood sugar control if they have been diagnosed with diabetes.