160 CHAPTER 5 Infections and inflammatory conditions
Fournier gangrene
Fournier gangrene is a necrotizing fasciitis of the genitalia and perineum primarily affecting males and causing necrosis and subsequent gangrene of infected tissues. Culture of infected tissue reveals a mixed polymicrobial infection with aerobic (E. coli, enterococcus, Klebsiella) and anaerobic organisms (Bacteroides, Clostridium, microaerophilic streptococci), which are believed to grow in a synergistic fashion.
Conditions predisposing to the development of Fournier gangrene include diabetes, local trauma to the genitalia and perineum (e.g., zipper injuries to the foreskin, periurethral extravasation of urine following traumatic catheterization or instrumentation of the urethra), and surgical procedures such as circumcision.
Presentation
This is one of the most dramatic and rapidly progressing infections in medicine. A previously well patient may become critically ill over a very short time course (hours). It may follow a seemingly trivial injury to the external genitalia.
A fever is usually present, the patient looks very ill, with marked pain in the affected tissues, and the developing sepsis may alter the patient’s mental state. The genitalia and perineum are edematous, and on palpation of the affected area, tenderness and crepitus may be present, indicating presence of subcutaneous gas produced by gas-forming organisms.
As the infection advances, blisters (bullae) appear in the skin and, within a matter of hours, areas of necrosis may develop on the genitalia and perineum that spread to involve adjacent tissues (e.g., the lower abdominal wall).
The condition advances rapidly—hence its alternative name of spontaneous fulminant gangrene of the genitalia.
Diagnosis
The diagnosis is a clinical one and is based on awareness of the condition and a high index of suspicion. CT will demonstrate areas of subcutaneous areas of necrosis and gas.
Treatment
Do not delay. While IV access is obtained, blood taken for culture, IV fluids started, and oxygen administered, broad-spectrum antibiotics are given to cover both gram-positive and gram-negative aerobes and anaerobes (e.g., ampicillin, gentamicin, and metronidazole or clindamycin). Monitor for signs of septic shock and manage as noted on p. 156.
Make arrangements to transfer the patient to the operating room emergently so that debridement of necrotic tissue (skin, subcutaneous fat) can be carried out. Extensive areas of tissue may have to be removed, but it is unusual for the testes or deeper penile tissues to be involved, and these can usually be spared.
A suprapubic catheter is inserted to divert urine and allow monitoring of urine output.
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Where facilities allow, consider treatment with hyperbaric oxygen therapy.1 There is some evidence that this may be beneficial. Repeated débridements to remove residual necrotic tissue are usually required with subsequent skin grafting required.
A VAC (vacuum-assisted closure) dressing can be used or wet-to- dry dressing changes are performed 2–3 times a day. Repeat operative debridement every 24–72 hours may be necessary to remove newly necrotic tissue.
Mortality is on the order of 20–30%. There is debate about whether diabetes increases the mortality rate.
Further reading
Chawla SN, Gallop C, Mydlo JH (2003). Fournier’s gangrene: an analysis of repeated surgical debridement. Eur Urol 43:572–575.
Sorensen MD, Broghammer JA, Rivara FP, et al. (2008). Fournier’s gangrene—contemporary popu- lation-based incidence and outcomes analysis: a HCUP database study. J Urol 179(4):13.
1 Mindrup SR, Kealey GP, Fallon B (2005). Hyperbaric oxygen for the treatment of Fournier’s gangrene. J Urol 173:1975–1977.
162 CHAPTER 5 Infections and inflammatory conditions
Epididymitis and orchitis
This is an inflammatory condition of the epididymis, often involving the testis, and caused usually caused by bacterial infection. It has an acute onset and a clinical course lasting <6 weeks. It presents with pain, swelling, and tenderness of the epididymis.
It should be distinguished from chronic epididymitis, where there is longstanding pain in the epididymis but usually no swelling. Untreated, bacterial epididymitis can extend to the testicle, resulting in epididmo-orchitis.
Infection ascends from the urethra or bladder. In men aged <35 years, the infective organism is usually N. gonorrhoeae, C. trachomatis, or coliform bacteria (causing a urethritis that then ascends to infect the epididymis).
In children and older men, the infective organisms are usually coliforms (such as E coli, Pseudomonas, Proteus, and Klebsiella species). Occasionally, Ureaplasma urealyticum, Corynebacterium, or Mycoplasma is the cause.
Mycobacterium tuberculosis (TB) is a rarer cause—the epididymis feels like a beaded cord.
A rare, noninfective cause of epididymitis is the antiarrhythmic drug amiodarone, which causes inflammation and resolves on discontinuation of the drug. Vasculitis, sarcoidosis, and more rare infections (coccidioidomycosis, blastomycosis) can be seen in immunocompromised men.
Differential diagnosis
Torsion of the testicle is the leading differential diagnosis. A preceding history of symptoms suggestive of urethritis, STD or urinary infection (dysuria, frequency, urgency, and suprapubic pain) suggest that epididymitis is the cause of the scrotal pain, but these symptoms may not always be present in epididymitis.
In epididymitis pain, tenderness and swelling may be confined to the epididymis, whereas in torsion, the pain and swelling are localized to the testis. However, there may be overlap in these physical signs.
Where the diagnosis is not clear between torsion or epididymitis, exploration is the safest option. Though radionuclide scanning can differentiate between a torsion and epididymitis, this is not available in many hospitals.
Color Doppler ultrasonography, which provides a visual image of blood flow, can differentiate between a torsion and epididymitis, but its sensitivity for diagnosing torsion is only 80% (i.e., it ‘misses’ the diagnosis in as many as 20% of cases—these 20% have torsion but normal findings on Doppler ultrasonography of the testis). Its sensitivity for diagnosing epididymitis is about 70%.
Again, if in doubt, explore. Complications of acute epididymitis abscess formation, infarction of the testis, chronic pain, and infertility.
Treatment of epididymitis
Culture urine, any urethral discharge, and blood (if the patient appears systemically ill). Urine cultures are often sterile. Management consists of bed rest, analgesia, anti-inflammatories, ice packs and antibiotics. Any form of urethral instrumentation should be avoided.
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•With suspected gonorrhea infection: Ceftriaxone 125 mg IM in a single dose or Cefixime 400 mg orally in a single dose or 400 mg by suspension (200 mg/5 mL) with treatment for chlamydia if chlamydial infection is not ruled out.
•Where C. trachomatis is a possible infecting organism, prescribe a 10–14 day course of tetracycline 500 mg 4 times a day or doxycycline 100mg twice daily.
•For non-STD related epididymitis, prescribe antibiotics empirically (until culture results are available). Typically levofloxin or ofloxacin x 14 days.
•When the patient is systemically ill, IV gentamicin and ampicillin are often used. When afebrile complete a 14 day total antibiotic course based on sensitivities.
Chronic epididymitis
Chronic epididymitis is diagnosed in patients with long-term pain in the epididymis and testicle. It can result from recurrent episodes of acute epididymitis. Clinically, the epididymis is thickened and may be tender. Treatment is with the appropriate antibiotics (guided by cultures), or epididymectomy in severe cases.
Supportive therapy with gabapentin and tricyclic antidepressants has shown to sometimes control symptoms.
Orchitis
Orchitis is inflammation of the testis, although it often occurs with epididymitis (epididymo-orchitis). Causes include mumps; M. tuberculosis; syphilis; autoimmune processes (granulomatous orchitis). The testis is swollen and tense, with edema of connective tissues and inflammatory cell infiltration. Treat the underlying cause.
Mumps orchitis occurs in 30% of infected post-pubertal males. It manifests 3–4 days after the onset of parotitis, and can result in tubular atrophy. 10–30% of cases are bilateral and are associated with infertility.