Penile Fournier’s gangrene (FG) is very rare clinical entity, which is also known as penile necrotizing fasciitis or wet gangrene of the penis. It is associated with increased morbidity and mortality and in the majority of the described cases it affects not only penis but also the adjacent organs and tissues (e.g., bladder, muscles, rectum, testis, and scrotum). We report a rare case of a previously healthy 68-year-old male, who presented with acute isolated penile Fournier’s gangrene. Pus culture was identified with pathogens
In 1863 JA Fournier, a French venereologist, described five cases of penis and scrotum gangrene. Since then more than 500 cases have been reported in the literature [
We present an uncommon case of spontaneous, isolated, penile necrotizing fasciitis in a previously healthy patient. Our aim is to underline the significance of early intervention in order to avoid extensive tissue destruction, sepsis, and death.
A 68-year-old male patient presented with a two-day history of a swollen, painless penis, fever (up to 38.7°C), and malodorous discharge from his preputial ring. His medical history included inguinal hernia repair five years ago. The patient denied any recent history of trauma, voiding symptoms, alcohol abuse, and diabetes mellitus or other systemic disease. He had no sexual intercourse during the last nine years, since his wife’s death. Patient’s children confirmed his history’s information.
On admission, his temperature was 38.4°C and the vital signs were stable. Clinical examination revealed edema, tenderness, and diffuse crepitus along the penile shaft. The penile skin was dark-coloured, but there are no other abnormal findings. There was malodorous, thick, purulent discharge from his preputial ring and we could not retract the foreskin (Figure
Swollen and dark-coloured penile shaft and purulent discharge from preputial ring.
White blood cell count was elevated (11.9 × 103/
Preoperative ultrasonography of the penile shaft demonstrating hyperechogenic fluid collection with gas at the middle of the penile shaft, in contact with the right corpus cavernosum and corpus spongiosum (1) and gas in the right corpus cavernosum (2).
Blood, urine, and pus cultures were obtained. Fluid resuscitation and antibiotic treatment with IV clindamycin, piperacillin-tazobactam, and vancomycin were administered, according to the Internal Medicine consultation.
The patient submitted to urgent surgical intervention under general anesthesia. Before the operation, a suprapubic tube and a 20-Fr Foley catheter were inserted. After circumcision and degloving of the penis, it was noticed that although glans appeared normal both cavernosal bodies were replaced by necrotic tissue and pus up to their middle. No blood clots were found but only partial expansion of the inflammation to corpus spongiosum and urethra. Both testicles were normal. Necrotic tissue was debrided to bleeding edges. Glans was still well-vascularised, despite ligation of dorsal arteries of the penis and of cavernosal arteries. However, partial penectomy was performed mainly due to the partial excision of corpus spongiosum and urethra (Figure
Intraoperative photo demonstrating normal, well-vascularised glans (1), corpus spongiosum (2), penile urethra (3), and clamped right cavernosal artery (4). There are two points on penile urethra which were debrided due to infection (arrows).
Postoperatively, the patient remained afebrile. Pus culture suggested
Penis after the closure with skin flaps.
Fournier’s gangrene is a rapid and fulminant polymicrobial infection of the fascia, with secondary necrosis of the subcutaneous tissues [
Both aerobic and anaerobic microorganisms may be implicated in the infection [
Predisposing factors for FG are diabetes mellitus (most common), obesity, cancer, alcohol abuse, advanced age, poor hygiene, malnutrition, heart and peripheral arteries diseases, liver disease, renal failure, HIV infection, and immunodeficiency [
As it was already mentioned previously, glans was well-vascularised intraoperatively despite ligation of dorsal arteries of the penis. The dorsal artery provides most of the blood supply to the glans, which is also supplied by the bulbourethral artery [
Diagnosis is mainly based on history and clinical examination, but the physician should be experienced to suspect this rare pathology [
Treatment consists of rapid and aggressive surgical debridement of the necrotic tissue to bleeding edges (partial or total penectomy) under general or spinal anesthesia, suprapubic catheter insertion, removal of foreign bodies, and fluid resuscitation [
In our opinion, wound care and debridement of necrotic tissues using surgical spoon, under opioid administration, at least twice a day are of paramount importance, prevent progression and need for further debridement under anesthesia, and improve prognosis. Adjuvant hyperbaric oxygen therapy can help in FG’s treatment postoperatively [
Isolated penile FG is a rare disease which can affect men who are healthy and without predisposing factors. Early and aggressive intervention prevents progression of the disease, can be lifesaving, and can improve the quality of life [
The authors declare that there are no conflicts of interest regarding the publication of this paper.