What is the best course of action for an adult patient with a recent history of urological surgery, presenting with complete swelling and drainage around the suprapubic area?

Immediate Surgical Evaluation for Fournier's Gangrene

This patient requires immediate surgical consultation and emergency debridement if Fournier's gangrene is suspected, as this necrotizing infection carries high mortality and demands surgical intervention as soon as possible. 1

Critical First Step: Rule Out Fournier's Gangrene

The combination of suprapubic swelling with active drainage following urological surgery is highly concerning for necrotizing soft tissue infection. You must immediately assess for:

• Fever, systemic toxicity, or septic appearance 2
• Crepitus on palpation of the suprapubic area, perineum, or genitals 2
• Skin discoloration (erythema, dusky appearance, or necrosis) 2
• Foul-smelling discharge from the drainage site 2

If ANY of these signs are present, this is Fournier's gangrene until proven otherwise and requires emergency surgical debridement within hours, not days. 1

Immediate Management Algorithm

If Fournier's Gangrene is Suspected:

1. Start broad-spectrum antibiotics immediately covering gram-positive, gram-negative, aerobic/anaerobic organisms, plus anti-MRSA coverage 2

2. Obtain emergency surgical consultation (general surgery, urology, intensivist) for debridement as soon as possible 1, 2

3. Plan serial surgical revisions every 12-24 hours until all necrotic tissue is removed 1, 2

4. Consider suprapubic cystostomy if there is extensive penile/perineal involvement, urethral damage, or periurethral abscess 1, 2

If Fournier's Gangrene is NOT Present:

Evaluate for other post-surgical complications:

• Urethral injury: Look for blood at meatus, inability to void, perineal/genital ecchymosis, or recent catheterization trauma 2

  • Perform retrograde urethrography (95.9% diagnostic accuracy) before catheter manipulation 3, 2
  • Place suprapubic catheter if complete disruption or failed catheterization 3, 2

• Bladder trauma: Assess for gross hematuria with recent pelvic trauma or penetrating injury 2

  • Obtain CT cystogram or conventional cystogram 2
  • Intraperitoneal rupture requires mandatory open surgical repair 2
  • Extraperitoneal rupture can be managed conservatively with catheter drainage 2

• Simple wound infection or seroma: If no signs of necrotizing infection, urethral injury, or bladder trauma, manage with local wound care and antibiotics if indicated 4

Common Pitfalls to Avoid

Do not delay surgical consultation if you suspect Fournier's gangrene. Early aggressive debridement improves survival and reduces the number of required surgical revisions. 1 Mortality increases dramatically with delayed treatment. 1

Do not assume simple wound infection in a post-urological surgery patient with suprapubic swelling and drainage. The suprapubic area's proximity to the urinary tract and potential for fecal contamination creates high risk for necrotizing infection. 1

Do not attempt urethral catheterization without imaging if urethral injury is suspected. This can convert a partial injury into complete disruption. 3, 2