painful-scrotal-swelling-censored-350Case: A 48 year old male with a history of alcoholism presents with one day of painful scrotal swelling. What is the most important next step in management? Please read below for uncensored image. 


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Consult Surgery for Fournier’s Gangrene


There are few urologic emergencies that are more important to quickly recognize than Fournier’s gangrene. A necrotizing infection of the perineum, Fournier’s is usually caused by a polymicrobial infection. The condition is life-threatening with a mortality rate up to 22% despite aggressive therapy. 1

The infection has a predilection for diabetic, alcoholic, and immunocompromised patients. It commonly starts as a cellulitis of the perineum or perianal region accompanied by significant pain and swelling. Systemic signs are common, often “out of proportion” to the local extent of disease. Crepitus can develop due to gas forming organisms. It can quickly spread to involve the scrotum, penis, and abdominal wall before progressing to extensive necrosis, sepsis with multiple organ failure, and death. 2

Emergency physicians should immediately consult a surgeon and start broad spectrum antibiotics. 3


Master Clinician Bedside Pearls

Dr Anton Helman, CCFP(EM)FCFP
Assistant Professor
University of Toronto
Founder & Host of EM Cases podcast

Kessler C, Bauml J. Non-Traumatic Urologic Emergencies in Men: A Clinical Review. West J Emerg Med. 2009;10(4):281-287. [PMC]
Thwaini A, Khan A, Malik A, et al. Fournier’s gangrene and its emergency management. Postgrad Med J. 2006;82(970):516-519. [PubMed]
Shyam D, Rapsang A. Fournier’s gangrene. Surgeon. 2013;11(4):222-232. [PubMed]
Jeff Riddell, MD

Jeff Riddell, MD

Assistant Professor of Clinical Emergency Medicine
Co-Director, Medical Education Fellowship
LA County + USC Emergency Medicine Residency, Department of Emergency Medicine
Keck School of Medicine of the University of Southern California