A 34 year old male with no past medical history presents to the Emergency Department (ED) due to 1 day of left scrotal swelling. He tells you that he’s been having pain, only while walking, and fullness in his left inguinal area, 2 episodes of vomiting, and no fevers or new sexual contacts. On physical exam, he is well appearing and in no acute distress. His heart rate is 130 bpm and the rest of his vital signs are within normal limits. GU exam reveals left sided scrotal swelling and mild erythema with minimal tenderness. Testicle has a normal lie. Abdominal exam is unremarkable. The clinical team suspects an incarcerated inguinal hernia and so a bedside ultrasound is performed. Point of Care Ultrasound (POCUS) reveals normal testicles without signs of torsion. Hyperechoic pockets of air with dirty posterior shadowing are noted.

Outcome

POCUS raised the suspicion of Fournier Gangrene (figures 1 and 2). Laboratory results were remarkable for a WBC count of 35k without other abnormalities. A CT was subsequently performed showing necrotizing soft tissue gas in the left scrotum consistent with Fournier Gangrene. The patient was given broad spectrum intravenous antibiotics, surgery was consulted and the patient was taken to the operating room for emergent debridement.

Discussion

Fournier Gangrene is a polymicrobial necrotizing soft tissue infection of the scrotum (1). It is a surgical emergency requiring emergent debridement. In advanced cases the patient will have clinical signs of sepsis as well as crepitus and severe tenderness of the scrotal tissue. However, early in its course the clinical picture may overlap with more common entities such as epididymitis, orchitis or cellulitis. Crepitus is only felt in 1/3 of patients (2). Bedside ultrasound may be useful screening tool in the assessment of acute scrotal pathologies. In this case, where the clinical picture suggested an alternate diagnosis, bedside ultrasound led the clinicians to consider the less likely but most emergent diagnosis of Fournier Gangrene. This early diagnosis led to early surgical management and, likely, to a better outcome. Literature on bedside ultrasound for the diagnosis of Fournier Gangrene is limited to a few case reports (3-7). However, ultrasound has been reported to have a sensitivity of 88% and specificity of 93% for necrotizing fasciitis in limbs (8).

Conclusion

Limited evidence suggests that bedside ultrasound may be a useful screening tool for acute scrotal emergencies. This case shows how it can help the clinician discover an alternate diagnosis that was not suggested on history and physical exam.