Penile Fournier’s gangrene

A 70-year-old non-diabetic male presented with fever with chills, pain and swelling of the penis for 4 days. He had a history of penile stricture and was catheterized for urinary retention a week before. No complaints of urethral discharge, abdominal pain, high-risk sexual behaviour or penile trauma. On examination, the penile shaft was tender, swollen with red and inflamed skin with mild oedema of the scrotal skin. Leukocyte counts and CRP were raised.

Ultrasonography of the inguinoscrotal region was performed. It showed oedematous thickening of the skin of the penile shaft. The areolar tissues showed hypoechoic liquified areas with internal debris and moving echoes suggestive of air. Corpora cavernosa and corpora spongiosum appeared normal. Associated skin thickening and scrotal wall oedema were noted. (Figure 1)

A non-contrast CT of the abdomen and pelvis was performed. The penis and scrotum were enlarged with thickened skin. The subcutaneous tissue of the penile shaft showed fluid attenuation areas with multiple air foci. These air foci were seen tracking along the dorsum of the penis up to the lower anterior abdominal wall. Mild bilateral hydrocele was seen. The anorectal and perineal regions appeared unremarkable. No evidence of free intraperitoneal air/fluid or lymphadenopathy was seen. (Figure 2)

Fournier's gangrene is a urological emergency with a high mortality rate. It is polymicrobial necrotizing fasciitis of the genitourinary and perineal region. Males are commonly affected and it usually involves the scrotum, perineum and anterior abdominal wall. [1]

It can be caused by both aerobic and anaerobic bacteria, the most common being E. coli and Bacteroides. Others like Staphylococcus aureus, Proteus, Streptococcus, Klebsiella and Clostridium strains can also be isolated. [2]

Predisposing factors for Fournier’s disease include prior trauma, catheterization, prior operative history, and traumatic sexual intercourse. Certain systemic causes like diabetes mellitus, obesity, alcohol, cancer, chemoradiotherapy, poor hygiene, malnutrition and immunocompromised states also act as predisposing factors. In few cases, no predisposing factors can be demonstrated. [3]

Fournier’s gangrene is usually diagnosed clinically. Most common presenting complaints include local part swelling, tenderness, skin discolouration, pus discharge or discharge per urethra, fever with chills, pain, hyperaemia and crepitus. It is rapidly progressive and may involve the scrotum and ascend to involve anterior abdominal wall. [4]

Various imaging modalities like Ultrasonography and CT can be used to diagnose Fournier’s gangrene. [5]

Computed tomography:  CT plays an important role to determine the aetiology and extent of disease. CT features of Fournier's gangrene include soft tissue inflammation and thickening. Penile involvement causes diffuse skin thickening with associated fluid collection or abscess formation in areolar tissue and may show free air foci. The underlying cause of Fournier’s gangrene, like a perianal abscess, perianal fistulous tract or intra-abdominal and retroperitoneal infectious process can be detected with help of CT. It is an excellent tool for both pre-operative and post-operative assessment.

Ultrasonography: US findings of Fournier’s gangrene include echogenic skin thickening and oedema. Hypoechoic fluid collections can be seen with hyperechoic air foci showing reverberation artefacts.

Multidisciplinary management is advocated. It includes hemodynamic stabilization, intravenous administration of broad-spectrum antimicrobial agents and immediate surgical debridement. Serial necrotic tissue debridement may be needed.

Take home message           

Isolated penile Fournier’s is a rare entity and its awareness is crucial to initiate prompt management.

Written informed patient consent for publication has been obtained.