
==== Front
J Am Coll Emerg Physicians Open
J Am Coll Emerg Physicians Open
10.1002/(ISSN)2688-1152
EMP2
Journal of the American College of Emergency Physicians Open
2688-1152
John Wiley and Sons Inc. Hoboken

10.1002/emp2.13289
EMP213289
Images in Emergency Medicine
Images in Emergency Medicine
Man with scrotal pain and swelling
ALLEN et al.
Allen Christopher W. MD https://orcid.org/0000-0002-2838-8444
1 cwallen008@gmail.com

Liao Christina MD 1
Hill Christy RDMS 1
Batchelor Timothy J. MD 1
Ashenburg Nicholas G. MD 1
1 Department of Emergency Medicine, Division of Emergency Ultrasound Stanford University Palo Alto California USA
* Correspondence
Christopher W. Allen, Department of Emergency Medicine, Division of Emergency Ultrasound, Stanford University, 900 Welch Road, Suite 350, Palo Alto, CA 94305, USA.
Email: cwallen008@gmail.com

05 9 2024
10 2024
5 5 10.1002/emp2.v5.5 e1328907 8 2024
13 8 2024
© 2024 The Author(s). Journal of the American College of Emergency Physicians Open published by Wiley Periodicals LLC on behalf of American College of Emergency Physicians.
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc-nd/4.0/ License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.

source-schema-version-number2.0
cover-dateOctober 2024
details-of-publishers-convertorConverter:WILEY_ML3GV2_TO_JATSPMC version:6.4.8 mode:remove_FC converted:05.09.2024
Allen CW , Liao C , Hill C , Batchelor TJ , Ashenburg NG . Man with scrotal pain and swelling. JACEP Open. 2024;5 :e13289. 10.1002/emp2.13289
==== Body
pmc1 PRESENTATION

A 45‐year‐old male with type 2 diabetes presented to the emergency department (ED) with 1 week of testicular swelling. Despite receiving multiple antibiotics for cellulitis at another ED 3 days prior, he experienced increasing pain, swelling, fever, diaphoresis, and perineal desquamation accompanied by serosanguinous discharge. Initial vital signs were stable. Physical examination revealed scrotal swelling and erythema, two draining perianal lesions, and significant tenderness to touch without crepitus. Laboratory findings included leukocytosis, hyponatremia, hyperglycemia, and elevated inflammatory markers. Point‐of‐care‐ultrasound (POCUS) performed in the ED confirmed scrotal edema (Figure 1, Video S1) and a phlegmonous perineal area concerning for abscess formation without subcutaneous emphysema (SE) (Figure 2, Video S2). Computed tomography (CT) imaging corroborated POCUS findings.

FIGURE 1 Point‐of‐care‐ultrasound (POCUS) image of scrotum with testes, revealing scrotal edema and bilateral hydrocele.

FIGURE 2 Point‐of‐care‐ultrasound (POCUS) image of perineum, with heterogeneous area of phlegmon and early abscess formation.

Given failed outpatient antibiotics, markedly elevated inflammatory markers, and POCUS findings, necrotizing soft tissue infection was suspected. The patient received intravenous broad‐spectrum antibiotics and underwent surgical debridement.

2 DISCUSSION

Fournier gangrene (FG) is a necrotizing infection of the perineum that can rapidly extend to surrounding structures. 1 , 2 , 3 Mortality with treatment ranges from 22% to 40%. 2 , 3 , 4 , 5 Risk factors include obesity, alcoholism, diabetes, male gender, and so on. 1 SE is regarded as a classic imaging finding. Yet in one systematic review of diagnostic POCUS in necrotizing fasciitis, SE was the least sensitive (6.3%) compared to fluid accumulation (85.4%), thickened fascia (66.7%), and cobblestoning (16.7%). 6 In this case, POCUS, in conjunction with clinical and laboratory findings, was a valuable component in diagnosis of FG, identifying a soft tissue region indicative of evolving infection requiring surgical intervention.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

Supporting information

Video 1. POCUS of scrotum with testes revealing scrotal edema and bilateral hydrocele.

Video 2. POCUS of perineum with heterogeneous area of phlegmon and early abscess formation.
==== Refs
REFERENCES

1 Lewis GD , Majeed M , Olang CA , et al. Fournier's gangrene diagnosis and treatment: a systematic review. Cureus. 2021;13 (10 ):e18948. doi:10.7759/cureus.18948 34815897
2 Laucks SS 2nd . Fournier's gangrene. Surg Clin North Am. 1994;74 (6 ):1339‐1352. doi:10.1016/s0039-6109(16)46485-6 7985069
3 Stephens BJ , Lathrop JC , Rice WT , Gruenberg JC . Fournier's gangrene: historic (1764‐1978) versus contemporary (1979‐1988) differences in etiology and clinical importance. Am Surg. 1993;59 (3 ):149‐154.8476151
4 Noegroho BS , Adi K , Mustafa A , Haq RS , Wijayanti Z , Liarto J . The role of quick sepsis‐related organ failure assessment score as simple scoring system to predict Fournier gangrene mortality and the correlation with Fournier's gangrene severity index: analysis of 69 patients. Asian J Urol. 2023;10 (2 ):201‐207. doi:10.1016/j.ajur.2021.11.003 36942123
5 Yeniyol CO , Suelozgen T , Arslan M , Ayder AR . Fournier's gangrene: experience with 25 patients and use of Fournier's gangrene severity index score. Urology. 2004;64 (2 ):218‐222. doi:10.1016/j.urology.2004.03.049 15302463
6 Marks A , Patel D , Sundaram T , Johnson J , Gottlieb M . Ultrasound for the diagnosis of necrotizing fasciitis: a systematic review of the literature. Am J Emerg Med. 2023;65 :31‐35. doi:10.1016/j.ajem.2022.12.037 36580698
