Doctors have reported the case of a 43-year-old man who arrived at an emergency department showing signs of fever and increased heart rate – and an unusually massive swelling of the scrotum.
He informed doctors that he had suffered from the scrotal swelling for the last three decades, but had not sought medical treatment. However, it had got to the point where he was unable to get about without using a walker, and relied on his mother for most of his daily needs.
Upon inspection, the doctors found a "massive scrotal edema (enlargement of the scrotal sac) with displacement past the level of his knees". The skin of his scrotal sac had thickened, and two large open wounds were also quite visible, with "foul-smelling, purulent fluid" leaking out of them, the doctors describe in Urology Case Reports.
The man finally went to the ER of a hospital in Panama, and was given a scan of his abdomen and pelvis, revealing a large inguinal hernia; part of his bowel tissue was protruding through his abdominal muscles.
The hernia led to lymphedema (a blockage in the lymphatic system that prevents lymph fluid from draining, causing a buildup of fluid and swelling) of the scrotum, which had gradually worsened. They diagnosed him with Fournier's gangrene, a sometimes life-threatening type of necrotizing fasciitis, or "flesh-eating" infection, that primarily affects the genitals.
Concerned by the risk of sepsis and rotting flesh, he was taken to surgery for emergency debridement (removal of tissue) of his infected scrotal skin. The surgeons found necrosis of fat below his skin, as well as further open wounds. "Catheter placement attempt proved to be difficult due to a buried penis, but was successfully accomplished by a dorsal slit procedure," the authors write.
He returned for surgery the following day to have more infected tissue removed, and was placed on intravenous antibiotics. Five days later, after attempts to replace the wound's dressing were found to be too painful for the patient, the decision was made to remove his scrotum and end his trauma. Surgeons then stitched the scrotal area together using a skin graft made of mesh. The images of his recovery can be seen here, but be warned, they are graphic.
The patient then had surgery to reduce his hernia, and following the operation, was discharged two days later to a rehabilitation facility. A follow-up 4 weeks later found he was "healing well with satisfactory cosmetic and functional outcomes". The doctors were pleased with the approach taken in this case, confident it minimized the trauma experienced by the man.
"With this treatment plan, initial debridement followed by a staged repair on day 3 and day 8, the patient was spared prolonged wound care, painful dressing changes, without sacrificing cosmetic and functional outcomes," the authors concluded.