Diagnosis

• A high index of suspicion is critical
  • A young diabetic patient with scrotal discomfort and systemic toxicity out of proportion with the physical signs with rapidly advancing erythema, edema, bronzing of skin, bleb formation, or a foul-smelling discharge should warn of a fulminant and rapidly progressive process.
  • In advanced presentation, the patient may be septic and hemodynamically unstable
• Urine, tissue, and blood cultures are mandatory
• Serum creatinine, BUN, electrolytes, hematologic and coagulation studies, and arterial blood gas analysis are recommended
• A KUB is recommended
• If indicated, a retrograde urethrogram, cystoscopy, and proctoscopic examinations are done

Medical Management

• Prompt and aggressive therapy is required. This includes rapid assessment and stabilization of the patient and administration of broad-spectrum antibiotics.
• Antibiotics. Triple antibiotic therapy that includes an aminoglycoside and an anaerobic cover is recommended.
  • Gentamicin (3 to 5 mg/kg per day) for gram-negative organisms
  • Clindamicin (600 mg every 4 hours) for adequate anaerobic coverage. Metronidazole can be used alternatively
  • A third-generation cephalosporin such as ceftriaxone should be used. Penicillin G (3 to 5 million U every 6 hours) for Clostridia is also useful. An infectious disease consult and input is often useful

Surgical Management

• A wide excision and debridement of all devitalized tissues is recommended
• A suprapubic catheter may be needed for urinary diversion
• Patient is monitored carefully postoperatively and further debridements are done as needed
  • Often, this leaves large denuded areas between the lower abdomen and upper thighs and may require the testicles to be placed in the upper medial thigh pouches
• Postoperative hyperbaric oxygen therapy has been found to enhance wound healing
• A wide variety of scrotal reconstruction is done once the patient is stable and the wound looks clean and granulating.
• In spite of the current advances, mortality is high and approaches 25 percent

References

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