clinical case

1. Clinical Case Discussion
On Scrotal Lesion

2. History
A 45YR old male from Barabanki presented in the
emergency with
Chief complaints- Swelling in the scrotum for about one
and half month

3. History of Present illness- Patient was apparently well one and half month
back .There is a history of sustaining injury from the handle of bicycle in
the scrotum following which swelling and pain started .Initially the swelling
is of mildly enlarge in size and gradually the size is increased . He received
treatment from the local doctor and swelling started to decrease . At
present the swelling is irreducible in standing and supine position.
It is also associated with dull aching pain localized to scrotum and from
past 15 days the nature of pain has became throbbing , continuous, and
relieved on taking medication .
It is also associated with fever which was felt by the patient but not
recorded .It is not associated with chills and rigor and gets relieved on
taking medicine.
History continued

4. After 15 days there was development of multiple abscesses
and crusting for which debridement and dressing is done by
village doctor . There is a history of narrowing of stream of
urine but there is no incomplete sense of evacuation.
Presently he has pain and fever with scrotal swelling
associated wound is present .
There is no history of loss of weight ,loss of appetite ,nausea
,vomiting, haemoptysis ,cough and cold, burning and painful
micturition.
History of present illness continued

5. Past History- There is no history suggestive of Hypertension ,Type 2
Diabetes Mellitus and any respiratory problem .
 He was operated for hydrocele (left side) 15yrs back.
Family history- There is no family history suggestive of Hypertension ,Type 2
Diabetes Mellitus ,Tuberculosis .
Personal history-
 Mixed diet .
 Alcoholic –drinking alcohol from past 20years .
 Tobacco chewing from past 20yrs (3-4 packets /day)
 Bowel and bladder movement is normal.
Allergy history- There is no known history of allergy to any drug and food .
History continued

6. An average built male person
 Weight -65kg
 Height-180cm
 Basal Metabolic Index-23.1kg/ mt square
 Temperature -101.2degree F
 Blood Pressure-134/82mm of Hg (left arm )
 Pulse Rate-102/min ,regular in rate and rhythm and normal in volume
and character
 Respiratory Rate -22/min
 SpO2-99% at RA
No pallor , icterus , cyanosis, clubbing , edema , dehydration and
generalized lymphadenopathy (only inguinal lymph nodes are palpable
bilaterally )
General Examination

7. Central Nervous System- conscious ;oriented to time ,place and person.
Chest examination-
 Bilateral equal air entry
 Normal vesicular breath sound
 No added sound
Cardio Vascular System-
 S1 S2 heard
 No murmur
Per Abdomen-
 Soft , non tender ,no distension
 No organomegaly
 Bowel sound heard
Systemic Examination

8. Local Examination
On Inspection
 Penis
 Edematous
 Meatus is not visible
 Skin over the penis is thickened.
 Scrotum-
 Scotum is enlarged (approx- 12X8cm)
 Skin is blackish in color and hardened .
 Foul smell present .
 Ulcer present which is (approx -10X3cm) with approx 0.5cm depth
 Margin irregular
 Sloping edge
 Floor has yellow slough
 Line of demarcation is present.

9.  Thigh
 Bilateral inner thigh has annular lesion
extending till the mid thigh.
 Central is clear and peripherally white scales
are visible.

10. On Palpation
 Penis –
 Retraction of prepucial skin is difficult
 Meatal opening is seen but can’t be exposed fully
 Scrotum-
 No local rise in temperature.
 Swelling (12x10cm) in size .
 Consistency –hard .
 Non tender.
 Skin is blackish and hardened and adherent to the swelling

11.  Ulcer is present over the swelling (11x4cm) and
depth of 1cm.
 Edge –sloping.
 Base –firm .
 Floor has yellow slough .
 Bleeding is not present.
Bilateral inguinal lymph nodes are palpable
 Multiple ,1cm in size,
 Round and
 Firm in consistency
 mobile in both the directions
 Non matted ,arranged horizontally
 Free from skin
Per Rectal examination- no any significant finding

12. Provisional Diagnosis-
On the basis of the following points –
History of injury and alcoholism
Foul smell
Painless ulcer, discoloration of skin
Do not bleed on touch
Necrotic areas
Fournier’s Gangrene

13. Investigation
 Complete blood count
 Renal function test
 Liver function test
 Serum electrolyte
 Random blood sugar
 Pus culture and sensitivity
 Coagulation profile
 Chest X ray PA view
 Ultrasonography of the scrotum

14. After complete Evaluation
Final diagnosis
Fournier’s Gangrene

15. Jean Alfred Fournier

16. Layers of scrotum
1.Skin
2.Dartos
3.External spermatic fascia
4.Cremasteric fascia
5.Internal spermatic fascia
6.Parietal layer of tunica vaginalis

17. Blood Supply
From superficial external pudendal, deep external
pudendal and internal pudendal arteries.
Nerve Supply
 Anterior 1/3rd portion by ilioinguinal nerve and genital
branch of genitofemoral nerve.
 Posterior 2/3rd portion by posterior scrotal branch of
pudendal nerve and perineal branch of posterior
femoral cutaneous nerve.
 Dartos is supplied by sympathetic nerve.

18. characterised by a polymicrobial infection of
the soft tissues of the perineum, external genitalia and
perianal region. It is a form of necrotising fasciitis.
Fournier’s Gangrene

19.  Etiology -an obvious cause is usually absent
 Polymicrobial (mixed infection )
 Minor injuries or procedures in the perineal area, such as a
bruise, scratch, urethral dilatation
 Treatment of haemorrhoids or opening of a periurethral
abscess.
 Diabetes mellitus
 Alcoholism.

20. Clinical features
 sudden pain in the scrotum
associated with prostration, pallor
and pyrexia.
 Cellulitis spreads rapidly (within
hours) with small necrotic areas of
skin which, if untreated, coalesce to
involve the entire scrotal and penile
coverings,
which may then slough, leaving the
testes exposed but healthy.

21.  crepitus and a foul-smelling exudate.
 sepsis

22. Ultrasound of scrotum

23. Treatment
 It is a surgical emergency.
 Initial management –
 intravenous fluid resuscitation and
 Early broad spectrum intravenous antibiotics.
 Extensive debridement is needed urgently.
 Along with debridement, surgical procedures may include complex
closure, suprapubic tube placement, and fecal diversion.
 If the patient survives the acute episode, skin grafting is often
necessary.

24. Once the infection is eradicated,
healthy granulation tissue develops;
this signifies the time to proceed to
reconstruction.
Options for reconstruction include the
following:
•Primary closure of the skin, if possible
•Local skin flap coverage
•Split-thickness skin grafts
•Muscular flaps, which are used to fill a
cavity (eg, ischiorectal space)
Shameful exposure of testis

26. Summary
 Fournier’s gangrene requires early and aggressive treatment
if the patient is to survive .
 Treatment involves urgent surgical debridement of necrotic
tissue in combination with early use of intravenous broad
spectrum antibiotics

27. On time reporting to a surgeon reduces the mortality rate