CASE 13993 Published on 24.03.2017

Fournier's gangrene secondary to foreign body self-insertion into the urethra

Section

Uroradiology & genital male imaging

Case Type

Clinical Cases

Authors

Teiga, Eduardo; Radosevic, Aleksandar; Bazan, Fernando; J.A Prat-Matifoll

Hospital Universitario del Mar;
Passeig Maritim
08005 Barcelona, Spain;
Email:eduardo_teiga@hotmail.com

Patient

57 years, male

Categories

Area of Interest Urinary Tract / Bladder ; Imaging Technique CT

Procedure Diagnostic procedure ; Special Focus Infection ;

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Clinical History

A 57-year-old patient presented at the emergency room with a painful scrotal swelling and purulent urethral discharge. The patient was hypotensive. Examination showed extensive subcutaneous emphysema of the lower abdominal soft tissue and genital area. Furthermore, he explained self-insertion of a foreign object into the urethra 3 months before.

Imaging Findings

CT scan depicted soft-tissue thickening and inflammation with a coexisting abscess and subcutaneous emphysema secondary to gas-forming bacteria. The subcutaneous emphysema dissected along fascial planes and extended from the scrotum and perineum to the inguinal regions and abdominal wall. Large oval-shaped laminated calcifications of the self-introduced foreign body 3 months before were also clearly depicted.

Discussion

Fournier gangrene (FG) is a urologic emergency carrying a high mortality rate when inappropriately managed. It is a rapidly progressing, polymicrobial necrotizing fasciitis of the perineal, perianal, and genital regions, with a mortality rate ranging from 15% to 50% [1]. Fascial necrosis rate can be as high as 2–3 cm per hour; early diagnosis is therefore imperative. [2, 3].

The condition is relatively uncommon and usually found in middle-aged men [2], who are 10 times more likely to develop the disease than females [4]. FG's aetiology is identified in the vast majority of cases; 10% remain idiopathic [2]. It is commonly due to a local infection adjacent to a point of entry. Urologic sources include urethral strictures, chronic urinary tract infection, neurogenic bladder, instrumentation and epididymitis [5]. Main predisposing factors are diabetes mellitus, found in up to 40-60% [6] and alcohol abuse [2].

FG's common symptoms include scrotal swelling, pain, hyperaemia, pruritus, crepitus, and fever [7]. A foul-smelling discharge might be present. Symptoms' onset usually occurs over a 2–7 day period [8]. Crepitus is identified in no more than 19%–64% of patients [9]. Systemic findings include leukocytosis, dehydration, tachycardia, thrombocytopenia, anaemia, hypocalcaemia, and hyperglycaemia [10].

Diagnosis is usually made clinically. Nevertheless CT plays a key role in patients in whom the diagnosis is unclear or when the extent of the disease is difficult to assess [11]. Findings include soft-tissue thickening and inflammation. The underlying cause, such as a perianal abscess, a fistulous tract, or an intraabdominal or retroperitoneal infectious process may also be demonstrated at CT [12]. The extent of fascial thickening and fat stranding seen at CT has been found to correlate well with the affected tissue at surgery [4]. CT is also helpful differentiating FG from other less aggressive conditions such as soft-tissue oedema or cellulitis and allows posttreatment follow-up of therapeutic response. Regarding MRI, it gives greater soft tissue detail than CT and is of value in patients who have advanced skin lesion [13].

Treatment is based on intravenous administration of broad-spectrum antibiotics and immediate and complete surgical debridement of the necrotic tissue [14].

In conclusion, FG is a rapidly spreading disease that represents a urologic emergency with a potentially high mortality rate. CT plays an important role in diagnosis and in the evaluation of disease extent for planning appropriate surgical treatment. Early diagnosis and complete surgical debridement of all necrotic tissue have been found to be the most important factors in improving survival [15].

Differential Diagnosis List

Fournier's gangrene

Cellulitis

Scrotal abscess with gas-forming organism

Final Diagnosis

Fournier's gangrene

References

[1] Tahmaz L, Erdemir F, Kibar Y, Cosar A, Yalcyn O. (2006) Fournier’s gangrene: report of thirty-three cases and a review of the literature. Int J Urol 13:960–967 (PMID: 16882063)

[2] Safioleas M, Stamatakos M, Mouzopoulos G, Diab A, Kontzoglou K, Papachristodoulou A. (2006) Fournier’s gangrene: exists and it is still lethal. Int Urol Nephrol 38(3–4):653–657 (PMID: 17160545)

[3] Uppot RN, Levy HM, Patel PH (2003) Case 54: Fournier gangrene. Radiology 226:115–11 (PMID: 12511678)

[4] Grayson DE, Abbott RM, Levy AD, Sherman PM. (2002) Emphysematous infections of the abdomen and pelvis: a pictorial review. RadioGraphics 22:543–561 (PMID: 12006686)

[5] Amendola MA, Casillas J, Joseph R, Galindez O (1994) Fournier’s gangrene: CT findings. Abdom Imaging 19:471–474 (PMID: 7950832)

[6] Yanar H, Taviloglu K, Ertekin C, et al. (2006) Fournier’s gangrene: risk factors and strategies for management. World J Surg 30(9):1750–1754 (PMID: 16927060)

[7] Atakan IH, Kaplan M, Kaya E, Aktoz T, Inci O (2002) A life-threatening infection: Fournier’s gangrene. Int Urol Nephrol 34:387–392 (PMID: 12899235)

[8] Rotondo N (2002) Fournier’s gangrene: an unusual presentation of sepsis. J Emerg Med 23(4):413–414 (PMID: 12480026)

[9] Kane CJ, Nash P, McAninch JW (1996) Ultrasonographic appearance of necrotizing gangrene: aid in early diagnosis. Urology 48:142–144 (PMID: 8693639)

[10] Piedra T, Ruiz E, Gonzalez FJ, Arnaiz J, Lastra P, Lopez-Rasines G (2006) Fournier’s gangrene: a radiologic emergency. Abdom Imaging 31(4):500–502 (PMID: 16947074)

[11] Cameron JL (2004) Current surgical therapy. 8th ed. Philadelphia, Pa: Elsevier Mosby

[12] Rajan DK, Scharer K (1998) Radiology of Fournier’s gangrene. AJR Am J Roentgenol 170:163–168 (PMID: 9423625)

[13] Kickuth R, Adams S, Kirchner J, Pastor J, Simon S, Liermann D (2001) Magnetic resonance imaging in the diagnosis of Fournier's gangrene. Eur Radiol 11: 787-790 (PMID: 11372608)

[14] Thwaini A, Khan A, Malik A, et al (2006) Fournier’s gangrene and its emergency management. Postgrad Med J 82(970):516–519 (PMID: 16891442)

[15] Robin B. Levenson, MD, Ajay K. Singh, MD, and Robert A. Novelline, MD (2008) Fournier Gangrene: Role of Imaging. Radiographics Volume 28, Issue 2 (PMID: 18349455)

Case information

URL:	https://www.eurorad.org/case/13993
DOI:	10.1594/EURORAD/CASE.13993
ISSN:	1563-4086

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This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.

Figure 1

CT - axial

The subcutaneous emphysema (orange arrow) dissected along fascial planes and extended from the scrotum and perineum to the inguinal regions and abdominal wall.

CT scan depicted soft-tissue thickening and inflammation with a coexisting abscess and subcutaneous emphysema secondary to gas-forming bacteria. Note the calcified foreign body in the bladder (red arrowhead)

CT scan depicted soft-tissue thickening and inflammation with a coexisting abscess and subcutaneous emphysema (orange arrow) secondary to gas-forming bacteria.

Figure 2

CT - coronal & sagittal

Large oval-shaped laminated calcifications (red arrowhead) secondary to foreign body self-insertion 3 months before. Note the emphysema in the scrotum (orange arrow).