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Gangrene of the Scrotum

Scrotum Gangrene


Presentation

  • We report on 3 heroin abusers who presented with localized gangrene of the genitalia after injection into the femoral vessels.[ncbi.nlm.nih.gov]
  • Fournier's Gangrene Presenting as Gas-forming Subcutaneous Infection of the Scrotum. Scand J Urol Nephrol. 1983;17(2):245-7. PubMed PMID: 6612244. TY - JOUR T1 - Fournier's gangrene presenting as gas-forming subcutaneous infection of the scrotum.[unboundmedicine.com]
  • Four cases of recreation of the scrotum with meshed split thickness skin grafts (STSG) are presented. The discussion includes a comparison of STSG with other treatment options.[ucdavis.pure.elsevier.com]
  • Clostridia Klebsiella Proteus Presentation Pain is usually severe and out of proportion to clinical signs. As the disease progresses, pain may subside due to necrosis of the nerves. The patient may present in severe septic shock.[aci.health.nsw.gov.au]
Gangrene
  • We report on 3 heroin abusers who presented with localized gangrene of the genitalia after injection into the femoral vessels.[ncbi.nlm.nih.gov]
Chills
  • Chills and sweats appeared with the increasing pain and swelling of the scrotum skin 1 month later. Physical examination showed an enlarged tender scrotum with white discoloration and some necrosis ( Figure 1 ).[academic.oup.com]
  • Swelling and erythema of the region follow pain, and a patient may complain of systemic symptoms such as fever or chills. As gangrene develops, pain may subside as nerve tissue becomes necrotic.[intechopen.com]
Acute Abdomen
  • The disease may present initially as an acute abdomen, but laparotomy should be avoided. Usually an anaerobic Streptococcus is found, acting in synergism with aerobic, frequently gram-negative, bacilli.[ncbi.nlm.nih.gov]
  • Introduction The "acute scrotum" may be viewed as the urologist's equivalent to the general surgeon's "acute abdomen."[auanet.org]
Abdominal Pain
  • Haug Browse recently published Learning/CME Learning/CME View all learning/CME CME Partial Oral versus Intravenous Antibiotic Treatment of Endocarditis Case 4-2019: An 18-Year-Old Man with Abdominal Pain and Hematochezia Bridging the Gap Challenge Yourself[nejm.org]
  • The symptoms of rigor and discomfort in the external genitalia were initially overshadowed by lower abdominal pain and a positive urinalysis.[bjuinternational.com]
Hematochezia
  • Haug Browse recently published Learning/CME Learning/CME View all learning/CME CME Partial Oral versus Intravenous Antibiotic Treatment of Endocarditis Case 4-2019: An 18-Year-Old Man with Abdominal Pain and Hematochezia Bridging the Gap Challenge Yourself[nejm.org]
Hypertension
  • The mortality rate is close to 40% (Verma, 2012). 5 leading predisposing factors: Diabetes Hypertension Chronic Liver Disease Liver Cirrhosis Chronic Renal Insufficiency The infection is usually polymicrobial, with microbes behaving synergistically resulting[aci.health.nsw.gov.au]
  • He had a 15-year history of hypertension, but no sign of diabetes mellitus. His serum creatinine level was 5.6 mg/dl, blood urea nitrogen was 141 mg/dl and he was disoriented due to uraemia. Haemodialysis was immediately started.[academic.oup.com]
  • CASE REPORT Case 1 A 64-year-old man had a history of hypertension, and presented with necrotizing fasciitis without any predisposing factor. He initially underwent surgical debridement and antibiotic therapy.[rbcp.org.br]
  • Lastly, scrotal edema secondary to hypoalbuminemia, portal hypertension and lymphadenopathy are also rare but significant conditions that may occur under the aegis of the acute scrotum.[auanet.org]
Suggestibility
  • This number of cases suggests that there may be an increasing incidence of this entity that has been reported only several times in the past. Pseudomonas was one of the organisms cultured in all cases.[ncbi.nlm.nih.gov]
  • We have been applying a small dressing that has a gel like quality on the dressing side, per wound care suggestion.[allnurses.com]
  • There is also a small left hydrocele with particulate matter within it suggestive of early purulent material within it. The left testis itself is relatively normal in appearance. This suggests a left acute epididymitis involving the epididymal head.[ultrasound-images.com]
  • The very sudden onset of pain and swelling is more typical of torsion, while a more gradual, progressive onset pain (often greater than 24 hours) suggests epididymitis.[auanet.org]
Confusion
  • Such an appearance giving rise to the likeness of an extra testicular mass in this typical location is diagnostic of right epididymitis- and in this case a case of right tuberculous epididymitis. such an ultrasound appearance can often be confused with[ultrasound-images.com]
  • Patients become confused and apathetic.[patient.info]
Scrotal Pain
  • The differential in the setting of acute scrotal pain includes: epididymo-orchitis testicular torsion testicular trauma scrotal cellulitis / abscess Promoted articles (advertising)[radiopaedia.org]
  • Case Study: Scrotal Pain in a Young Man [pdf] This document was amended in July 2016 to reflect literature that was released since the original publication of this content in May 2012.[auanet.org]
  • The major pitfall of radiography in the diagnosis and evaluation of FG is that it does not detect deep fascial gas. 2,15 Contrary to other conditions that can cause acute scrotal pain, the scrotal contents, testes, and epididymides are normal in FG.[uspharmacist.com]
Renal Insufficiency
  • The mortality rate is close to 40% (Verma, 2012). 5 leading predisposing factors: Diabetes Hypertension Chronic Liver Disease Liver Cirrhosis Chronic Renal Insufficiency The infection is usually polymicrobial, with microbes behaving synergistically resulting[aci.health.nsw.gov.au]

Workup

Pseudomonas
  • Pseudomonas was one of the organisms cultured in all cases.[ncbi.nlm.nih.gov]
  • Urine and sputum cultures from our patient revealed MRSA and Pseudomonas aeruginosa, but no anaerobes. We therefore considered this patient an immunocompromised host.[academic.oup.com]
  • E.coli (an aerobic microorganism often found within the digestive tract), bacteroides (anaerobic), streptococcus (anaerobic), enterococcus (aerobic), staphylococcus facultative anaerobes that grow by aerobic respiration), pseudomonas (anaerobic), klebsiella[urologists.org]
  • Other commonly identified microorganisms are Proteus, aerobic and anaerobic Streptococcus, Pseudomonas, Enterococcus, and Clostridium species.[uspharmacist.com]
  • Other common microflora includes Proteus, Staphylococcus, Enterococcus, aerobic and anaerobic Streptococcus, Pseudomonas, Klebsiella, and Clostridium. Incidence of methicillin-resistant Staphylococcus aureus (MRSA) may be increasing 7.[intechopen.com]

Treatment

  • The discussion includes a comparison of STSG with other treatment options. We conclude that STSG are a safe, technically easy treatment option with satisfactory cosmetic and functional results.[ucdavis.pure.elsevier.com]
  • Error in diagnosis and delay in initiating medical treatment were the main causes of the high mortality rate associated with the disease.[ncbi.nlm.nih.gov]
  • A three pronged treatment strategy consisting of antibiotic coverage for aerobes and anaerobes, general supportive measures and surgical debridement is usually applied [ 4 ].[academic.oup.com]
  • The etiology, pathology, bacteriology and treatment of Fournier's gangrene are discussed.[unboundmedicine.com]

Prognosis

  • It is considered a urological emergency with a poor prognosis due to its high mortality rate (ranging 15-50% 3 ).[radiopaedia.org]
  • PROGNOSIS • Delays in diagnosis or treatment increase the mortality rate. o A 24-hour delay in radical debridement increases the mortality rate by 11.5%; o A 6-day delay is associated with a mortality rate of 76%. • Additional factors associated with[slideshare.net]
  • Prognosis of Fournier's Gangrene Mortality of Fournier's gangrene is around 20%. Risk factors of increased mortality are diabetes mellitus, alcoholism and colorectal origin of Fournier's gangrene (often delayed diagnosis and extensive infection).[urology-textbook.com]
  • Prognosis Many factors impact on the prognosis in FG. Early presentation in good functional status together with adequate and prompt treatment lead to a good outcome.[intechopen.com]
  • […] requiring intravenous antibiotics and debridement (surgical removal) of necrotic (dead) tissue. [2] In addition to surgery and antibiotics, hyperbaric oxygen therapy may be useful and acts to inhibit the growth of and kill the anaerobic bacteria. [8] Prognosis[en.wikipedia.org]

Etiology

  • The etiology, pathology, bacteriology and treatment of Fournier's gangrene are discussed.[unboundmedicine.com]
  • Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology.[icd10coded.com]
  • However, we believe this is an oversight because the etiology and pathology of this rare entity is not completely unknown.[ijri.org]
  • Etiology and Predisposing Factors FG is classified as a type I necrotizing fasciitis of polymicrobial etiology.[uspharmacist.com]
  • Fournier stated that there were three characteristic findings of this syndrome: sudden onset in young and healthy males, rapid progression, and absence of a specific etiologic agent 1. The etiology of this disease is controversial.[rbcp.org.br]

Epidemiology

  • "Fournier's gangrene: Population based epidemiology and outcomes". The Journal of Urology. 181 (5): 2120–6. doi : 10.1016/j.juro.2009.01.034. PMC 3042351. PMID 19286224.[en.wikipedia.org]
  • Epidemiology Elderly adults (male and female), immunocompromised (particularly diabetes) or those with depressed mental status Sites Dartos and penile fascia are preferred sites Etiology 50 - 60% of infections have GI or GU source of infection Usually[pathologyoutlines.com]
  • However, understanding of the disease has changed with increasing elucidation on the epidemiology, causative organisms, and pathogenesis.[jcsjournal.org]
  • Epidemiological aspects of Fournier's gangrene at Kenyatta National Hospital, Nairobi. East Afr. Med. J. 75, 586–589 (1998). 9. Czymek, R. et al. New insights into the epidemiology and etiology of Fournier's gangrene: a review of 33 patients.[nature.com]
  • Epidemiology Fournier gangrene is relatively uncommon, but the exact incidence of the disease is unknown.[emedicine.medscape.com]
Sex distribution
Age distribution

Pathophysiology

  • We postulate that the pathophysiology of this entity is related to arterial embolization of particulate matter into the microcirculation of the genitalia, which causes arterial thrombosis leading to localized gangrene.[ncbi.nlm.nih.gov]
  • There are three possible pathophysiological mechanisms: local trauma, which would facilitate the entry of micro-organisms through injured skin; infection of the genitourinary tract, with extension to deep planes; and/or infection of the perineal or retroperitoneal[rbcp.org.br]
  • Symptoms and Pathophysiology The etiology of, and predisposing factors for, FG provide a favorable environment for infection.[uspharmacist.com]
  • Pathophysiology The following are pathognomonic findings of Fournier gangrene upon pathologic evaluation of the involved tissue: Necrosis of the superficial and deep fascial planes, Fibrinoid coagulation of the nutrient arterioles, Polymorphonuclear cell[intechopen.com]
  • Abstract Despite advances in the evaluation, treatment, and pathophysiological understanding of necrotizing soft-tissue infections, Fournier's gangrene remains a life-threatening urological emergency.[nature.com]

Prevention

  • Keeping diabetes under control can help prevent the condition Controlling overweight and obese body conditions can help reduce the risk of this infection Avoiding alcohol: Avoiding the intake of alcohol reduces or prevents the risk of Fournier's Gangrene[dovemed.com]
  • Prevention. To prevent gangrene in an open wound, the wound should be kept as clean as possible.[medical-dictionary.thefreedictionary.com]
  • Can You Prevent It? There are some steps you can take to lower your chances of getting Fournier’s gangrene: If you have diabetes, check your genitals and surrounding areas for wounds or signs of infection, as well as for swelling or drainage.[webmd.com]

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