NECROTIZING INFECTION OF SCROTUM* M . BISWAS, M .B .B.S C . GODEC, M .D . G . IRELAND, M .D . A . CASS, M .B .B .S . From the Department of Surgery, Hennepin County Medical Center, Minneapolis, and Department of Urology, St . Paul-Ramsey Medical Center, St . Paul, Minnesota
ABSTRACT - Necrotizing infection of the scrotum (Fournier gangrene) rapidly spreads to adjacent skin with fever and toxemia and is life-threatening . Subcutaneous gas and a foul-smelling wet discharge from the skin are usually present . The infection is not cured with antibiotic therapy alone and requires immediate extensive debridement of all necrotic tissue . Repeated debridement each several days under general anesthesia is necessary until healthy granulation is present in the wound. Reconstruction with skin flaps or skin grafts shortens hospitalization and prevents the dense scar tissue and immobility of the testes that can occur with spontaneous epithelization .
Since Fournier first described the explosive onset of rapidly progressing gangrene of the scrotum in healthy men in 1884, the management of this necrotizing infection has become confused . Some managed this infection with delayed or no debridement' -9 while others used immediate extensive debridement of all necrotic tissue .'"' We report our experience with immediate debridement of necrotizing infection of the scrotum . Material and Methods This study involved 13 men, with an age range from thirty-three to ninety years (Table I) . Associated conditions were present in 7 patients : general debilitating disease in 3, lower urinary tract pathology in 2, and both in 2 patients . Predisposing causes were present in 8 patients : trauma to the urethra or scrotum in 4 and anoscrotal infections in 4 . 'Supported by Minneapolis Medical Research Foundation, Inc ., Hennepin County Medical Center, and Medical Education and Research Foundation, St . Paul-Ramsey Medical Center .
576
The time interval from the onset of swelling of the scrotum to debridement was two to seven days (average four days) . The inflammatory swelling involved the scrotum in 100 per cent, penis in 62 per cent, perineum in 85 per cent, abdominal wall in 54 per cent, and the upper thigh in 31 per cent (Fig . 1A, B, C) . Subcutaneous gas was present in 8 men (Fig . 2). Fever was present in 11 men, and 9 were acutely ill with toxemia . The organisms grown from the original wound cultures are listed in Table I . Ten patients had mixed infections . The most common organisms were : Streptococcus 19 per cent, Staphylococcus 16 per cent, Enterobacteriaceae 13 per cent, Bacteroides 10 per cent, Escherichia coli 10 percent, and Clostridium perfringens 10 per cent . All patients were treated with penicillin . A second antibiotic was used in 7 patients (gentamicin 4, kanamycin 1, cephalothin [Keflin] 2) and a third antibiotic in 3 patients (gentamicin I, cephalothin 1, clindamycin [Cleocin] 1) . Immediate debridement of all necrotic tissue was performed in 12 of the 13 patients ; I patient had a delayed debridement after two days of hospitalization . Repeated debridement each
UROLOGY / DECEMBER 1979 / VOLUMF %IV, NUMBER 6
FIGURE 1 . (A) Scrotal infection with gangrenous area (Case 6) . (B) Penile and scrotal infection (Case 4) . (C) Gangrene with scrotal infection (Case 8) . (D) Granulating wound after repeated debridement of necrotic tissue (Case 4).
several days under general anesthetic was used, when necessary, to remove all necrotic tissue until a clean granulating wound was present (Fig. ID) . Two deaths occurred (15 per cent) from sepsis and renal failure . Reconstructive surgery was performed in 7 of the 11 survivors while in 4 wounds were allowed to close by granulation . Comment When comparing reports on Fournier gangrene of the scrotum, it is important that the same disease process is present in each report . The generally accepted description of Fournier gangrene of scrotum is a necrotizing infection
UROLOGY
/
DECEMBER 1979
/
FIGURE 2 . Subcutaneous gas seen on radiograph of scrotum (Case 8).
VOLUME XIV, NUMBER 6
577
TABLE I .
Features of 13 cases of necrotizing infection of scrotum
Case Inflammatory Swelling of Duration Fever No . Age Scrotum Penis Perineum Abdomen Thigh (Days) Gas* (° F .) Toxic 1
56
+
-
+
4
+
101
2
33
+
-
+
4
+
101
3
49
+
+
-
-
4
75
+
+
+
+
5
78
+
+
+
-
6
36
+
+
+
7
62
+
+
+
8
43
+
+
+
9
38
+
-
+
10
77
+
-
11
71
12
52
+
+
+
+
13
90
+
+
+
+
+
+
7
102
+
-
Kick in scrotum
+
+
Inflated Foley catheter pulled out
+
+ +
+
99 .4
Predisposing Cause
+
-
103
+
Hairpin into urethra
3
-
100
7
+
101
-
Incision and drainage of scrotal abscess 9 days before
5
+
101
+
2
+
-
+
+
100
2
+
100.4
+
Ischial decubitus ulcers (bilateral)
2
-
102
+
Inflated Foley catheter pulled out 3 days before
Scrotal boil 14 days before Prolapsed hemorrhoids 4 days before
*Subcutaneous .
of the scrotum spreading rapidly to the adjacent skin, accompanied by fever and toxemia, and life-threatening in nature . Subcutaneous gas and a foul-smelling wet discharge from the skin are usually present . The infection may be caused by anaerobic organisms (Streptococcus, Bacteroides, Clostridia) and/or aerobic organisms (Streptococcus, E . coli, Staphylococcus, Enterobacter ., Klebsiella, Proteus) . It can occur with an explosive onset or with an insidious onset in debilitated men (alcoholism, diabetes) with poor hygienic conditions . Predisposing causes are local trauma to urogenital region or anorectal infections which 578
may provide anaerobic conditions allowing for the proliferation of anaerobic organisms with resultant necrotizing infection . The portal of entry for some organisms (e .g., Streptococcus) is rarely demonstrable . Localized or unilateral gangrene of the scrotum secondary to abscess of the testicle following epididymo-orchitis should be excluded when comparing reports . Three reports described Foumier gangrene of the scrotum as a self-limited condition and used delayed debridement in their management," ,' however, all three recommended immediate extensive debridement of necrotic tissue .
UROLOGY
/
DECEMBER 1979
I VOLUME XIV, NUMBER 6
TABLE I .
Associated Condition
Organism Cultured
Urethral stricture
Alcoholic
Staphylococcus, Streptococcus Streptococcus Diptheria, Bacteroides E . coli, Staphyloloccus, Cl . perfringens Streptococcus
Cancer of prostate, Enterobacter . uremia, sepsis, CI bleeding Alcoholic, hepatorenal failure, ascites Diabetes mellitus
Streptococcus, Staphylococcus Staphylococcus ; Bacteroides Streptococcus, Staphylococcus Bacteroides Streptococcus, E . coli, Cl . perfringens Cl . perfringens
Antibiotics Given Kanamycin, ampicillin Clindamycin, penicillin, cephalothin Ampicillin Penicillin, gentamicin Cephalothin, carbenicillin, gentamicin Penicillin, gentamicin Penicillin, gentamicin, clindamicin Penicillin, gentamicin
Immediate Surgical Debridement
Penicillin
immediate and repeated extensive debridement of all necrotic tissue rather than the effect of antibiotics alone was believed to result in rapid local and general improvement with reduced toxemia and to account for reduced mortality' 1 a .5,13,14 Almost all reports state that the testicles are not involved in the gangrenous process because of their separate blood supply and that orchiectomy is not necessary . However when therapy is delayed, hesitant or inadequate extension of the necrotic process increases and may involve the genitals . In our study orchiectomy was performed as part of the immediate debridement
Reconstruction
Yes with suprapubic cystoscopy Yes with colostomy
No
Delayed, debridement after 2 days
No
Yes Yes with suprapubic cystoscopy ; colostomy (delayed penectomy) Yes Yes
Ampicillin, cephalothin
E . coli, EnteroCephalothin, bacter.,anaerobic penicillin Streptococcus Penicillin Atonic bladder, Pseudomonas Proteus, fractured spine (bilateral ischial Klebsiella, decubitis ulcers) Enterobacter . Diabetes mellitus, Proteus, Methicillin vesical calculi, Klebsiella, (Staphcillin), urethral Enterobacter . gentamicin stricture, uremia
UROLOGY /
(continued)
No
Yes with skin flaps No
No Yes with skin grafts
Yes
Yes with skin grafts
Yes with orchiectomy, colostomy Yes with penectomy, orchiectomy, suprapubic cystoscopy, herniorrhapy (bilateral)
Yes ; sepsis, renal failure
Yes with skin grafts
Yes
Yes with orchiectomy Yes with orchiectomy
Death and Cause
Yes ; hepatorenal failure
Yes Yes with skin closure Yes with skin flaps No
in 4 patients (pathology showed the testes to be normal in 3 and necrotic in 1) . Penectomy was performed as part of the immediate debridement in 1 patient (normal on pathology) and as part of repeated debridement in 1 patient (penis necrotic on pathology) . Rapid epithelization occurs after healthy granulation appears in the wound . Some believe that scarring and immobility of the testes occur when the wound is allowed to heal by spontaneous epithelization ." 7 This occurred in one of our patients . Reconstruction with skin flaps or skin grafts prevents this complication and shortens hospitalization .
DECEMBER 1979 / VOLUME XIV, NUMBER 6
579
Department of Urology St . Paul-Ramsey Medical Center St . Paul, Minnesota 55101 (DR. CASS) References 1 . Haury B, et al : Streptococcal cellulitis of the scrotum and penis with secondary skin gangrene, Surg . Gynecol . Obstet . 141 : 35 (1975) . 2 . Rudolph R, Soloway M, DePalma RG, and Persky L : Fourniers syndrome : synergistic gangrene of the scrotum, Am . J . Surg. 129: 391 (1975) . 3. Singh S, Lynfield YL, and Gruber H : Fournier's gangrene of the scrotum, Int . J . Dcrmatol . 14 : 508 (1975). 4. Moustafa MFH : Gangrene of the scrotum : an analysis of ten cases, Br . J . Plastic Surg . 20 : 90 (1967) . 5 . Burpee JF, and Edwards P : Foumie~'s gangrene, J . Uml . 107 : 812 (1972) . 6 . Thomas JF : Fournier's gangrene of the penis and the scrotum, ibid . 75 : 719 (1956) .
58 0
7 . Campbell JC : Fournier's gangrene, Br . J . Urol . 27 : 106 (1955) . 8 . Pande 5K, and Mewara PC : Fournier's gangrene : a report of 5 cases, Br . J . Surg . 63 : 479 (1976) . 9 . McDonald OF, Hulet WH, and Cowan JW : Scrotal gangrene treated with oxygen under high pressure, J . Urol . 113 : 364 (1975) . 10 . Mansfield OT : Spontaneous gangrene of the scrotum (Foumier's gangrene) . Br . J . Surg . 33 : 275 (1945) . 11 . Gerber MP, and Peterson NE : Scrotal gangrene, Urology 1 : 466 (1973) . 12. Flanigan RC, Kursh ED, McDougal WS, and Persky L : Synergistic gangrene of the scrotum and penis secondary to colorectal disease, J . Urol . 119 :369 (1978). 13. Cunningham BL, Nivatvongs S, and Shons AR : Fournier's syndrome following anorectal examination and mucosal biopsy . Dis . Colon Rectum 22 : 51 (1979). 14. Himal HS, McLean APH, and Duff JH : Gas gangrene of the scrotum and perineum, Surg . Gynecul . Obstet . 139 : 176 (1974) . 15. Rubrick MP, and Hitchcock CR : Necrotizing anorectal and perineal infections, Surgery 86 : 655 (1979) .
UROLOGY / DECEMBER 1979 / VOLUME XIV . NUMBER 6
ABSTRACT - Necrotizing infection of the scrotum (Fournier gangrene) rapidly spreads to adjacent skin with fever and toxemia and is life-threatening . Subcutaneous gas and a foul-smelling wet discharge from the skin are usually present . The infection is not cured with antibiotic therapy alone and requires immediate extensive debridement of all necrotic tissue . Repeated debridement each several days under general anesthesia is necessary until healthy granulation is present in the wound. Reconstruction with skin flaps or skin grafts shortens hospitalization and prevents the dense scar tissue and immobility of the testes that can occur with spontaneous epithelization .
Since Fournier first described the explosive onset of rapidly progressing gangrene of the scrotum in healthy men in 1884, the management of this necrotizing infection has become confused . Some managed this infection with delayed or no debridement' -9 while others used immediate extensive debridement of all necrotic tissue .'"' We report our experience with immediate debridement of necrotizing infection of the scrotum . Material and Methods This study involved 13 men, with an age range from thirty-three to ninety years (Table I) . Associated conditions were present in 7 patients : general debilitating disease in 3, lower urinary tract pathology in 2, and both in 2 patients . Predisposing causes were present in 8 patients : trauma to the urethra or scrotum in 4 and anoscrotal infections in 4 . 'Supported by Minneapolis Medical Research Foundation, Inc ., Hennepin County Medical Center, and Medical Education and Research Foundation, St . Paul-Ramsey Medical Center .
576
The time interval from the onset of swelling of the scrotum to debridement was two to seven days (average four days) . The inflammatory swelling involved the scrotum in 100 per cent, penis in 62 per cent, perineum in 85 per cent, abdominal wall in 54 per cent, and the upper thigh in 31 per cent (Fig . 1A, B, C) . Subcutaneous gas was present in 8 men (Fig . 2). Fever was present in 11 men, and 9 were acutely ill with toxemia . The organisms grown from the original wound cultures are listed in Table I . Ten patients had mixed infections . The most common organisms were : Streptococcus 19 per cent, Staphylococcus 16 per cent, Enterobacteriaceae 13 per cent, Bacteroides 10 per cent, Escherichia coli 10 percent, and Clostridium perfringens 10 per cent . All patients were treated with penicillin . A second antibiotic was used in 7 patients (gentamicin 4, kanamycin 1, cephalothin [Keflin] 2) and a third antibiotic in 3 patients (gentamicin I, cephalothin 1, clindamycin [Cleocin] 1) . Immediate debridement of all necrotic tissue was performed in 12 of the 13 patients ; I patient had a delayed debridement after two days of hospitalization . Repeated debridement each
UROLOGY / DECEMBER 1979 / VOLUMF %IV, NUMBER 6
FIGURE 1 . (A) Scrotal infection with gangrenous area (Case 6) . (B) Penile and scrotal infection (Case 4) . (C) Gangrene with scrotal infection (Case 8) . (D) Granulating wound after repeated debridement of necrotic tissue (Case 4).
several days under general anesthetic was used, when necessary, to remove all necrotic tissue until a clean granulating wound was present (Fig. ID) . Two deaths occurred (15 per cent) from sepsis and renal failure . Reconstructive surgery was performed in 7 of the 11 survivors while in 4 wounds were allowed to close by granulation . Comment When comparing reports on Fournier gangrene of the scrotum, it is important that the same disease process is present in each report . The generally accepted description of Fournier gangrene of scrotum is a necrotizing infection
UROLOGY
/
DECEMBER 1979
/
FIGURE 2 . Subcutaneous gas seen on radiograph of scrotum (Case 8).
VOLUME XIV, NUMBER 6
577
TABLE I .
Features of 13 cases of necrotizing infection of scrotum
Case Inflammatory Swelling of Duration Fever No . Age Scrotum Penis Perineum Abdomen Thigh (Days) Gas* (° F .) Toxic 1
56
+
-
+
4
+
101
2
33
+
-
+
4
+
101
3
49
+
+
-
-
4
75
+
+
+
+
5
78
+
+
+
-
6
36
+
+
+
7
62
+
+
+
8
43
+
+
+
9
38
+
-
+
10
77
+
-
11
71
12
52
+
+
+
+
13
90
+
+
+
+
+
+
7
102
+
-
Kick in scrotum
+
+
Inflated Foley catheter pulled out
+
+ +
+
99 .4
Predisposing Cause
+
-
103
+
Hairpin into urethra
3
-
100
7
+
101
-
Incision and drainage of scrotal abscess 9 days before
5
+
101
+
2
+
-
+
+
100
2
+
100.4
+
Ischial decubitus ulcers (bilateral)
2
-
102
+
Inflated Foley catheter pulled out 3 days before
Scrotal boil 14 days before Prolapsed hemorrhoids 4 days before
*Subcutaneous .
of the scrotum spreading rapidly to the adjacent skin, accompanied by fever and toxemia, and life-threatening in nature . Subcutaneous gas and a foul-smelling wet discharge from the skin are usually present . The infection may be caused by anaerobic organisms (Streptococcus, Bacteroides, Clostridia) and/or aerobic organisms (Streptococcus, E . coli, Staphylococcus, Enterobacter ., Klebsiella, Proteus) . It can occur with an explosive onset or with an insidious onset in debilitated men (alcoholism, diabetes) with poor hygienic conditions . Predisposing causes are local trauma to urogenital region or anorectal infections which 578
may provide anaerobic conditions allowing for the proliferation of anaerobic organisms with resultant necrotizing infection . The portal of entry for some organisms (e .g., Streptococcus) is rarely demonstrable . Localized or unilateral gangrene of the scrotum secondary to abscess of the testicle following epididymo-orchitis should be excluded when comparing reports . Three reports described Foumier gangrene of the scrotum as a self-limited condition and used delayed debridement in their management," ,' however, all three recommended immediate extensive debridement of necrotic tissue .
UROLOGY
/
DECEMBER 1979
I VOLUME XIV, NUMBER 6
TABLE I .
Associated Condition
Organism Cultured
Urethral stricture
Alcoholic
Staphylococcus, Streptococcus Streptococcus Diptheria, Bacteroides E . coli, Staphyloloccus, Cl . perfringens Streptococcus
Cancer of prostate, Enterobacter . uremia, sepsis, CI bleeding Alcoholic, hepatorenal failure, ascites Diabetes mellitus
Streptococcus, Staphylococcus Staphylococcus ; Bacteroides Streptococcus, Staphylococcus Bacteroides Streptococcus, E . coli, Cl . perfringens Cl . perfringens
Antibiotics Given Kanamycin, ampicillin Clindamycin, penicillin, cephalothin Ampicillin Penicillin, gentamicin Cephalothin, carbenicillin, gentamicin Penicillin, gentamicin Penicillin, gentamicin, clindamicin Penicillin, gentamicin
Immediate Surgical Debridement
Penicillin
immediate and repeated extensive debridement of all necrotic tissue rather than the effect of antibiotics alone was believed to result in rapid local and general improvement with reduced toxemia and to account for reduced mortality' 1 a .5,13,14 Almost all reports state that the testicles are not involved in the gangrenous process because of their separate blood supply and that orchiectomy is not necessary . However when therapy is delayed, hesitant or inadequate extension of the necrotic process increases and may involve the genitals . In our study orchiectomy was performed as part of the immediate debridement
Reconstruction
Yes with suprapubic cystoscopy Yes with colostomy
No
Delayed, debridement after 2 days
No
Yes Yes with suprapubic cystoscopy ; colostomy (delayed penectomy) Yes Yes
Ampicillin, cephalothin
E . coli, EnteroCephalothin, bacter.,anaerobic penicillin Streptococcus Penicillin Atonic bladder, Pseudomonas Proteus, fractured spine (bilateral ischial Klebsiella, decubitis ulcers) Enterobacter . Diabetes mellitus, Proteus, Methicillin vesical calculi, Klebsiella, (Staphcillin), urethral Enterobacter . gentamicin stricture, uremia
UROLOGY /
(continued)
No
Yes with skin flaps No
No Yes with skin grafts
Yes
Yes with skin grafts
Yes with orchiectomy, colostomy Yes with penectomy, orchiectomy, suprapubic cystoscopy, herniorrhapy (bilateral)
Yes ; sepsis, renal failure
Yes with skin grafts
Yes
Yes with orchiectomy Yes with orchiectomy
Death and Cause
Yes ; hepatorenal failure
Yes Yes with skin closure Yes with skin flaps No
in 4 patients (pathology showed the testes to be normal in 3 and necrotic in 1) . Penectomy was performed as part of the immediate debridement in 1 patient (normal on pathology) and as part of repeated debridement in 1 patient (penis necrotic on pathology) . Rapid epithelization occurs after healthy granulation appears in the wound . Some believe that scarring and immobility of the testes occur when the wound is allowed to heal by spontaneous epithelization ." 7 This occurred in one of our patients . Reconstruction with skin flaps or skin grafts prevents this complication and shortens hospitalization .
DECEMBER 1979 / VOLUME XIV, NUMBER 6
579
Department of Urology St . Paul-Ramsey Medical Center St . Paul, Minnesota 55101 (DR. CASS) References 1 . Haury B, et al : Streptococcal cellulitis of the scrotum and penis with secondary skin gangrene, Surg . Gynecol . Obstet . 141 : 35 (1975) . 2 . Rudolph R, Soloway M, DePalma RG, and Persky L : Fourniers syndrome : synergistic gangrene of the scrotum, Am . J . Surg. 129: 391 (1975) . 3. Singh S, Lynfield YL, and Gruber H : Fournier's gangrene of the scrotum, Int . J . Dcrmatol . 14 : 508 (1975). 4. Moustafa MFH : Gangrene of the scrotum : an analysis of ten cases, Br . J . Plastic Surg . 20 : 90 (1967) . 5 . Burpee JF, and Edwards P : Foumie~'s gangrene, J . Uml . 107 : 812 (1972) . 6 . Thomas JF : Fournier's gangrene of the penis and the scrotum, ibid . 75 : 719 (1956) .
58 0
7 . Campbell JC : Fournier's gangrene, Br . J . Urol . 27 : 106 (1955) . 8 . Pande 5K, and Mewara PC : Fournier's gangrene : a report of 5 cases, Br . J . Surg . 63 : 479 (1976) . 9 . McDonald OF, Hulet WH, and Cowan JW : Scrotal gangrene treated with oxygen under high pressure, J . Urol . 113 : 364 (1975) . 10 . Mansfield OT : Spontaneous gangrene of the scrotum (Foumier's gangrene) . Br . J . Surg . 33 : 275 (1945) . 11 . Gerber MP, and Peterson NE : Scrotal gangrene, Urology 1 : 466 (1973) . 12. Flanigan RC, Kursh ED, McDougal WS, and Persky L : Synergistic gangrene of the scrotum and penis secondary to colorectal disease, J . Urol . 119 :369 (1978). 13. Cunningham BL, Nivatvongs S, and Shons AR : Fournier's syndrome following anorectal examination and mucosal biopsy . Dis . Colon Rectum 22 : 51 (1979). 14. Himal HS, McLean APH, and Duff JH : Gas gangrene of the scrotum and perineum, Surg . Gynecul . Obstet . 139 : 176 (1974) . 15. Rubrick MP, and Hitchcock CR : Necrotizing anorectal and perineal infections, Surgery 86 : 655 (1979) .
UROLOGY / DECEMBER 1979 / VOLUME XIV . NUMBER 6
