What is the management for a patient with severe swelling and erythema of the bilateral scrotum and decreased urine output?

Management of Severe Bilateral Scrotal Swelling, Erythema, and Decreased Urine Output

This presentation is highly concerning for Fournier's gangrene, a life-threatening necrotizing soft tissue infection requiring immediate surgical intervention, broad-spectrum antibiotics, and hemodynamic resuscitation. 1

Immediate Assessment and Stabilization

Clinical Recognition

• Fournier's gangrene should be suspected when severe scrotal swelling and erythema are accompanied by systemic signs including decreased urine output, which suggests evolving sepsis and potential acute kidney injury 1
• Key diagnostic features include cutaneous erythema, subcutaneous crepitations, patches of gangrene, foul smell, purulence, and tenderness to palpation 1
• The decreased urine output indicates either urinary retention from severe perineal involvement or evolving septic shock with acute kidney injury 1

Urgent Diagnostic Workup

• Obtain blood cultures immediately before initiating antibiotics, along with complete blood count, comprehensive metabolic panel, lactate, and coagulation studies 1, 2
• Calculate the Fournier's Gangrene Severity Index (FGSI) using temperature, heart rate, respiratory rate, sodium, potassium, creatinine, leukocytes, hematocrit, and bicarbonate—a score >9 predicts high mortality 1
• Imaging with CT scan is recommended to confirm clinical suspicion and identify the extent of soft-tissue involvement, particularly in perirectal and retroperitoneal planes 1
• Conventional radiology or ultrasound may show subcutaneous gas, but CT provides superior anatomical detail 1
• Address the decreased urine output by placing a urinary catheter to monitor output, assess for urinary retention, and prevent urethral stricture formation 1

Emergency Surgical Management

Timing and Approach

• Surgical debridement must be performed as soon as possible—early and aggressive debridement improves survival and is the cornerstone of treatment 1
• The initial operation should include complete debridement of all necrotic tissue, continuing into healthy-appearing tissue 1
• Obtain cultures of infected fluid and tissues during initial debridement to guide subsequent antibiotic tailoring 1

Surgical Technique

• Remove all visible necrotic tissue radically during the first procedure 1
• Plan repeat surgical revisions every 12-24 hours based on patient condition, continuing until the patient is free of necrotic tissue 1
• Testicular involvement is rare due to separate blood supply—perform orchiectomy only if strictly necessary and preferably after urologic consultation 1

Fecal and Urinary Diversion

• Consider fecal diversion (colostomy or rectal diversion device) in cases with significant fecal contamination, anal sphincter involvement, or fecal incontinence 1
• A multidisciplinary approach is essential—postpone the decision regarding stoma creation for at least 48 hours if possible to allow inflammation to subside and enable proper assessment 1
• Urinary catheterization provides adequate diversion in most cases; suprapubic cystostomy is reserved for urethral disruption or stricture 1

Antibiotic Therapy

Empiric Regimen

• Initiate broad-spectrum antibiotics immediately after obtaining cultures, targeting polymicrobial infection including aerobic and anaerobic bacteria 1, 2
• Recommended empiric regimen: combination therapy with a carbapenem (e.g., meropenem 1g IV every 8 hours) or piperacillin-tazobactam (4.5g IV every 6 hours) PLUS vancomycin (15-20 mg/kg IV every 8-12 hours) to cover gram-positive, gram-negative, and anaerobic organisms 1, 2
• Alternative: third-generation cephalosporin plus metronidazole plus vancomycin 1

Antibiotic Adjustment

• De-escalate or escalate antibiotics after culture results are available, typically within 48-72 hours 2
• Continue antibiotics until clinical improvement is evident and necrotic tissue is completely debrided 1

Hemodynamic Support

Resuscitation

• Aggressive fluid resuscitation is essential for patients with sepsis and decreased urine output 1
• Monitor for septic shock using qSOFA criteria: respiratory rate ≥22/min, altered mental status, or systolic blood pressure ≤100 mmHg 1
• Target urine output of at least 0.5 mL/kg/hour as a marker of adequate resuscitation 1

Intensive Care Management

• Patients with FGSI >9, septic shock, or extensive tissue involvement require ICU admission 1
• Early involvement of intensivists is recommended for hemodynamic monitoring and organ support 1

Multidisciplinary Approach

Immediate consultation with general/emergency surgery, urology, and critical care is mandatory 1

• Plastic surgery involvement may be beneficial for wound management and reconstruction 1
• Early urologic consultation is essential to assess for urethral involvement and determine need for urinary diversion 1

Monitoring and Follow-Up

Serial Assessment

• Procalcitonin (PCT) ratio from postoperative day 1 to day 2 can indicate successful surgical eradication—a ratio >1.14 suggests successful source control with 83.3% sensitivity 1
• Failure to improve within 3 days requires reevaluation of diagnosis, adequacy of debridement, and antibiotic coverage 1

Common Pitfalls

• Delaying surgery while awaiting imaging or laboratory results increases mortality—proceed to operating room based on clinical suspicion alone 1
• Inadequate initial debridement leads to persistent sepsis and need for more extensive subsequent procedures 1
• Failure to recognize urethral or sphincter involvement may result in long-term complications 1