Case Presentation Aug 2008 Carrie Fitzgerald GCH URO-1

HPI 63 yo caucasian male admitted with acute mental status change, wife noted confusion at home; did not know his name, no unsteady gait, + lethargy. + RUQ pain, no fever, chills, N/V, + diarrhea. No GU sxs. H/O ETOH abuse but not current, family concern after 24 hours  ER Initial work-up/tx Sepsis and encephalopathy; Intra-abdominal anterior wall abscess on CT scan ( ) WBC 25.7 bands 12, H/H 11.2/32.2, AlkP 281, Cr 1.22 Nh4 109 Bedside I and D, ICU pressors, IVF resuscitation, antibiotics

PMHx/PSHx Cirrhosis secondary to etoh abuse on sandostatin Lupus Crohn’s disease on Entocort, prednisone; chronic Gi bleed CAD s/p MI 2006 Afib on coumadin and sotalol Legally blind secondary to retinal detachment Back pain with compression fractures thoracic spine GERD esopahgeal stricture Anemia of chronic disease PSHx AICD, left inquinal hernia repair, r retinal detachment repair, appendectomy age 10

Physical exam VS T 94.7 P 102 R 18 BP 103/ lbs 5’9” Morbidly obese Anasarca, with skin breakdwn Groin, upper thigh bullous edema Abdominal striae, RLQ pain, Fluctuant necrotic lesion on scrotum (8cm-6cm) RLQ induration, erythema around inguinal abscess s/p I and D, no granulation tissue, no adenopathy

Laboratory findings WBC 24.6 H/H 12.7 Plt 73 Na 141 K 5.2 Cl 111 bicarb 18.5 BUN 44 Cr 2.26 Alb 1.7 PT 17.8 INR 1.72 PTT 38 Cx s/p bedside extra abdominal abscess I and D Corynebacterium Alpha streptococcous not group D Staphylococcus-coagulase negative

Imaging CT scan Hosp day #1 CT scan Hosp day #2 Scrotal U/S

Impression Fourniers gangrene vs scrotal abscess R inguinal extra-abdominal abscess with eneterocutaneous fistula secondary to Crohn’s disease Anterior abdominal wall abscess secondary to Crohn’s diease Multiple enteroenetric fistulas secondary to Crohn’s disease Adrenal insufficiency

Procedure Emergent scrotal exploration Scrotal debridement R inguinal abscess debridement Drain placement

Post operative diagnosis Fourniers gangrene of the scrotum R inguinal extra-abdominal abscess with eneterocutaneous fistula secondary to Crohn’s disease Cultures pending Hematuria secondary to foley trauma

Fournier’s disease Predisposing factors: DM, adrenal insufficiency, immune system disorders, etoh abuse, morbid obesity 10:1 male, age Local trauma, paraphimosis, periurethral extravasation or urine, perirectal or perianal infections, and surgery such as circumcision or herniorrhaphy, strictures with STD’s

Signs symptoms Crepitant ("spongy" to the touch) skin Swelling, blistering of the penis and scrotum Dead and discolored (gray-black) tissue; pus weeping from injury Foul odor Pain out of proportion Dysuria, urethral discharge, and obstructed voiding Marked systemic toxicity out of proportion to the local finding Sepsis; Altered mental status, tachypnea, tachycardia, and temperature greater than 38.3° C (101° F) or less than 35.6° C (96° F) suggest gram-negative sepsis.

Pathophysiology Infection arising from skin, urethra, rectum (uterus, bartholin glands in females) Bacteria spread along the dartos fascia of the scrotum and penis, Colles' fascia of the perineum, and Scarpa's fascia of the anterior abdominal wall Necrotizing fascitis of the skin and superficial and deep fascia No extension beyond Buck’s facsia that separate muscles and protect nerves and vessels of the genital area. corpora cavernosa, testicles, and urethra are not usually affected. ~ 95% of the cases, a source identified Mixed cultures; E. coli, Klebsiella, enterococci and anaerobes ie Bacteroides, Fusobacterium, Clostridium, microaerophilic streptococci

Treatment Triple antibiotic therapy Intravenous hydration Emergent exploration, debridement to healthy tissue margins May requires re-exploration in 24 hours +/- bariatric oxygen therapy Orchiectomy rarely required Reconstruction ie. myocutaneous flaps Complications 7-75% (16-40%) mortality Sepsis

Complications

References Campbells’ urology 9 th edition EMedicine