This case highlights the surgical management of a patient requiring emergent intervention and a multidisciplinary approach of reconstructive repair in the acute care setting.
A 43 year-old male from Panama presented to the emergency department with fever, tachycardia, and increasing swelling and drainage from his scrotum. His medical history was limited. He had not sought medical care in many years. Over the past three decades his scrotal swelling had gradually worsened. He relied on a walker for ambulation and his mother attended to most of his daily needs. He had no prior urologic history and only previous surgery was a diaphragmatic hernia repair as a child.
On examination, there was massive scrotal edema with displacement past the level of his knees. The scrotal skin was thickened and there were two open wounds with foul smelling, purulent fluid located at the bottom of the left hemi-scrotum. His right lower extremity had extensive edema and skin thickening of the upper leg. His white blood cell count was 24.4 WBC/L with 89% granulocytes. He was anemic with hemoglobin of 8.6 g/dL. He was febrile to 102.2F with a pulse of 137 bpm, concerning for sepsis.
Computed tomography (CT) scan of the abdomen and pelvis revealed a massive left inguinal hernia containing non-inflamed colon and its associated mesentery, a large subcutaneous abscess with gas measuring up to 12.8 cm with draining tract to the skin at the anterior inferior aspect of the scrotum. Massive hydrocele was noted in the left hemiscrotum, extensive scrotal wall thickening, soft tissue ulceration at the left posterior aspect of the scrotum, severe left hydronephrosis and hydroureter secondary to the extension of the left ureter into the herniation, and extensive bilateral inguinal adenopathy.
Due to the concern for Fournier's gangrene and patients declining clinical condition, he was taken to the operating room for emergent debridement of infected scrotal skin and subcutaneous tissue.
Intra-operative findings demonstrated a large abscess and sinus tract toward the left inguinal region, with areas of skin and subcutaneous necrosis. Foley catheter placement attempt proved to be difficult due to a buried penis, but was successfully accomplished by a dorsal slit procedure. Initial pathology revealed scrotal skin with extensive deep dermal acute inflammation and liquefactive necrosis.
The next day the patient returned to the operating room for minimal secondary debridement. On hospital day 5, after several days of intravenous antibiotics his wound appeared to be improving but dressing changes and wound vacuum were too painful. A decision was made to proceed with multidisciplinary (urology, general surgery, plastic surgery), definitive treatment.
The hernia repair necessitated a laparotomy to reduce the hernia contents and was augmented with biologic mesh(GORE® BIO-A®). Next, the patient then underwent a scrotectomy, left orchiectomy/hydrocele excision. The hydrocele measured up to 3.35kg and was 30.2 × 24.4 × 13.1 cm in size. On hospital day 8, the patient was taken back to the operating room by the plastic surgery team for a split thickness skin graft for the penis and primary closure of the perineum with advancement flap closures. He was discharged two days later to rehabilitation facility. He was seen four weeks postoperatively and was healing well with satisfactory cosmetic and functional outcomes.