What is the best course of action for a patient with suspected Fournier's gangrene when a CT (Computed Tomography) or MRI (Magnetic Resonance Imaging) of the pelvis is not available due to insurance constraints?

Use Bedside Ultrasound and Proceed to Surgery Based on Clinical Findings

When CT or MRI is unavailable for suspected Fournier's gangrene, perform bedside ultrasound immediately and do not delay surgical intervention if clinical findings are suggestive—imaging is not mandatory and should never postpone surgery in this life-threatening emergency. 1

Immediate Bedside Ultrasound as Primary Alternative

Ultrasound is the recommended alternative when CT is not available or feasible and offers multiple critical advantages for Fournier's gangrene diagnosis: 1

• Can be performed immediately at the patient's bedside without requiring transport to radiology 1
• Requires no radiation or intravenous contrast, making it safe in patients with renal failure 1
• Detects key diagnostic features including subcutaneous gas (the hallmark finding), marked scrotal skin thickening, soft tissue inflammation, collections/abscesses, and paratesticular fluid 1, 2
• Demonstrates paratesticular fluid before clinical crepitus develops, providing earlier detection than physical examination alone 1, 2
• Gas in tissue is highly specific (94%) for necrotizing infection and appears in nearly half of all Fournier's gangrene cases 2

Critical Decision Algorithm

Follow this structured approach based on clinical presentation: 3, 4

1. Hemodynamically Unstable OR Obvious Clinical Findings → Proceed Directly to Operating Room

• Do not obtain any imaging—go straight to surgery 1, 3
• Obvious clinical findings include: visible necrosis, crepitus on palpation, black eschar, extensive ecchymosis, or frank septic shock 5, 6, 7
• Time to surgery is the most critical determinant of outcome in a disease with 20-30% mortality 3, 8

2. Hemodynamically Stable with Equivocal Clinical Findings → Bedside Ultrasound

• Perform point-of-care ultrasound immediately to look for subcutaneous gas, fluid collections, and scrotal abnormalities 1, 4
• If ultrasound shows gas or collections, proceed to surgery without further imaging 2, 4
• If ultrasound is negative but clinical suspicion remains high, do not rule out Fournier's gangrene—proceed to surgery based on clinical judgment 6

3. Stable with Low Clinical Suspicion → Consider Alternative Diagnoses

• If ultrasound is negative and clinical findings suggest simple cellulitis (no systemic toxicity, no crepitus, normal labs), consider outpatient antibiotics with close follow-up 6
• However, misdiagnosis is common and can be fatal—maintain a low threshold for surgical consultation 6

Common Pitfalls to Avoid

Never delay surgery waiting for insurance approval of advanced imaging when Fournier's gangrene is clinically suspected: 1, 3

• Imaging is not mandatory in treating emergent cases with clinical or hemodynamic impairment 1
• The disease progresses rapidly over 2-7 days, and delayed treatment dramatically increases mortality 5, 8
• Early aggressive surgical debridement improves survival and reduces the number of required surgical revisions 1

Do not be falsely reassured by negative ultrasound if clinical suspicion is high: 6, 9

• Subcutaneous gas (the hallmark finding) is not present in all cases 9
• Fournier's gangrene can masquerade as simple cellulitis in early stages 6

Concurrent Management While Arranging Surgery

Initiate these interventions immediately while preparing for operative debridement: 5, 8

• Broad-spectrum antibiotics covering gram-positive, gram-negative, and anaerobic organisms 5, 8
• Aggressive fluid resuscitation and hemodynamic stabilization 5, 8
• Correct electrolyte imbalances and metabolic derangements 5
• Urgent surgical consultation—this is a surgical emergency requiring debridement as soon as possible 1

Why CT Would Be Preferred (But Is Not Essential)

While CT has superior diagnostic performance (90% sensitivity, 93.3% specificity) and better evaluates disease extent and fascial plane involvement, the lack of CT should not prevent you from making the diagnosis clinically and proceeding to surgery: 1, 3, 9

• CT is most useful for stable patients with equivocal findings where it can identify the underlying source 1, 3
• However, clinical diagnosis alone is sufficient to proceed to surgery in obvious cases 5, 9