Urogenital abscess with a complex etiology: a case report

Scrotal abscesses requiring hospitalization are uncommon, with progression to sepsis being even rarer. A feared complication of a scrotal abscess is Fournier gangrene, an uncommon type of necrotizing fasciitis that starts in the scrotum or perineum. Fournier gangrene is associated with a mortality rate of about 40% and accounts for less than 0.02% of all hospital admissions. The patient in this report was hospitalized for a complex scrotal abscess and, during repeat incision and drainage (I&D), was found to have Fournier gangrene.

The patient was a 49-year-old male who presented with acute left-sided perineal pain. His medical history was significant for severe obesity, uncontrolled diabetes mellitus (DM) type 2, and hypertension (HTN). Physical examination showed no superficial signs of an abscess. Computed tomography (CT) of the abdomen and pelvis was inconclusive. Further workup revealed borderline tachypnea [20 breaths per minute (bpm)], elevated white blood cell count (WBC) (27.60 K/mcL), tachycardia (128 bpm), and a probable source of infection. The patient met septic criteria according to the Systemic Inflammatory Response Syndrome Criteria (SIRS). He was started on intravenous (IV) vancomycin [1,750 mg every 12 hours (q12h) ×2 days to 2,000 mg q12h ×7 days], and IV piperacillin-tazobactam (3.375 mg q8h ×9 days). Clinical decision-making warranted a surgical consult and, thus, immediate I&D. The patient's infection failed to improve. Additional imaging, transfer to a tertiary hospital, and repeat I&D led to more advanced findings. The patient was found to have a scrotal abscess that tracked through the perineum to the ischium. He was diagnosed intraoperatively with Fournier gangrene and was admitted for continued monitoring and IV antibiotics. After discharge and multiple follow-up visits with wound care, the patient made a full recovery.

This case report showcased an uncommon presentation of a male with a urogenital abscess. A patient presenting with a urogenital abscess complicated by sepsis should prompt a clinician to have a high index of suspicion for Fournier gangrene. Broad-spectrum IV antibiotics should be initiated as quickly as possible, and a general surgery consult should be placed for I&D. This case highlights the importance of urgent intervention in reducing mortality secondary to Fournier gangrene as well as maintaining the function of urinary and sex organs.