Fournier’s gangrene after male circumcision: A case report

Abstract

Necrotizing soft tissue infection (NSTI) is a rare, life-threatening emergency. Fournier’s gangrene (FG), a type of NSTI affecting the perineal, genital, or perianal region, requires prompt and aggressive treatment and has a multifactorial aetiology. However, cases of FG in patients without predisposing factors, as a complication of an elective procedure, are seldom reported. In this report, a 32-year-old patient without prior medical history presented with a NSTI after elective circumcision. Patient was successfully treated with multiple surgical debridement’s, antibiotic therapy and hemodynamic support. Healthcare providers must remain vigilant, as FG has significant morbidity and mortality and early intervention is crucial.

1 Introduction

Fournier’s gangrene (FG), first described by Jean Alfred Fournier in 1883, is a rare but potentially life-threatening necrotizing soft tissue infection (NSTI) of the genital, perineal, or perianal regions and demands immediate medical attention due to its aggressive nature. This disease has a reported overall mortality rate of 20–40 %, reaching 70–80 %, particularly if the patient presents with a septic profile. Therefore, it remains a challenging condition for healthcare providers globally FG predominantly affects adult males, with a peak incidence between the ages of 50 and 60 years. However, it can also occur in women and children, with a male to female ratio of 10:1.

The precise aetiology of FG often involves a polymicrobial infection, with a mixture of aerobic and anaerobic bacteria contributing to its pathogenesis. The infection typically arises from a primary source, such as perineal trauma, urinary tract infections, or genital surgeries, facilitating bacterial infiltration into the subcutaneous tissues and subsequent necrosis. Furthermore, immunocompromised states, diabetes mellitus, obesity, and other comorbidities predispose individuals to this condition. ^, ^, Few cases of FG in adults after circumcision have been published.

Understanding the definition, epidemiology, and causes of FG is paramount for early recognition and prompt initiation of aggressive treatment, which often involves surgical debridement and broad-spectrum antibiotic therapy. Failure to intervene swiftly can lead to rapid progression, systemic complications, and high mortality rates, underscoring the urgency of effective management strategies.

In this paper, we describe a case of FG that occurred in a 32-year-old male after voluntary circumcision due to phimosis. The patient had no previous medical history and no predisposing factors for the development of FG.

2 Case presentation

A 32-year-old male patient presented at the Emergency Department two days after circumcision in another clinic, with unbearable pain and swelling of the penis. Progressive pain and swelling of the penis developed one day after planned circumcision performed for phimosis. No signs of infection were observed at the time of the initial procedure. At the ED patient had a temperature of 38.1 °C, a heart rate of 126 per minute and a blood pressure of 102/68 mmHg. Inspection of the penis showed evident swelling and erythema with purple discoloration of the entire penis ( Fig. 1 A and B ). The scrotum, perineum and inguinal region showed no involvement. The patient had an elevated white blood cell count (12.0∗10ˆ9/l), C-reactive protein (160 mg/l) and sedimentation rate (25 mm/h). Initially the patient was treated with intravenous antibiotics, namely amoxicillin/clavulanic acid. However, due to increased pain, swelling, blistering, progression to the scrotum and a suspicion of a NSTI, the antibiotic treatment was directly altered. The patient received Meropenem and Clindamycin with an additional single dose of Tobramycin.

Five hours after initial presentation at the emergency department, the patient underwent surgical debridement in the operating room, during which the necrotic ventral skin of the penis and part of the scrotum were removed ( Fig. 2 A and B ). Fascia inspection through a suprapubic incision revealed no involvement. Following the procedure, the patient remained intubated and was admitted to the intensive care unit. Subsequently, the patient developed septic shock, requiring fluid resuscitation and high doses of vasopressors. In addition to antibiotics, intravenous immunoglobulin therapy were continued for three days. Due to hemodynamic instability and progressing necrosis, manifested by purple discoloration of the wound edges, repeated surgical debridement was performed in the operating room 8 h after the first surgical debridement. A negative pressure therapy device was placed for the prepubic wound ( Fig. 3 ).