Case: A 48 year old male with a history of alcoholism presents with one day of painful scrotal swelling. What is the most important next step in management? Please read below for uncensored image.

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Consult Surgery for Fournier’s Gangrene

Explanation

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There are few urologic emergencies that are more important to quickly recognize than Fournier’s gangrene. A necrotizing infection of the perineum, Fournier’s is usually caused by a polymicrobial infection. The condition is life-threatening with a mortality rate up to 22% despite aggressive therapy. 1

The infection has a predilection for diabetic, alcoholic, and immunocompromised patients. It commonly starts as a cellulitis of the perineum or perianal region accompanied by significant pain and swelling. Systemic signs are common, often “out of proportion” to the local extent of disease. Crepitus can develop due to gas forming organisms. It can quickly spread to involve the scrotum, penis, and abdominal wall before progressing to extensive necrosis, sepsis with multiple organ failure, and death. 2

Emergency physicians should immediately consult a surgeon and start broad spectrum antibiotics. 3

Master Clinician Bedside Pearls

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Dr Anton Helman, CCFP(EM)FCFP

Assistant Professor

University of Toronto

Founder & Host of EM Cases podcast

1. West J Emerg Med. 2009;10(4):281-287. PMC] Kessler C, Bauml J. Non-Traumatic Urologic Emergencies in Men: A Clinical Review.. 2009;10(4):281-287. 2. Postgrad Med J. 2006;82(970):516-519. PubMed] Thwaini A, Khan A, Malik A, et al. Fournier’s gangrene and its emergency management.. 2006;82(970):516-519. 3. Surgeon. 2013;11(4):222-232. PubMed] Shyam D, Rapsang A. Fournier’s gangrene.. 2013;11(4):222-232.