This patient has Fournier's Gangrene. He appears to have good flow to the affected testicle as visualized by both a venous and arterial waveform on spectral doppler which rules out torsion. However, he had gas in the scrotum which id diagnostic for Fournier's. The patient was started on IV antibiotics and was admitted to the hospital. He ultimately underwent a scrotectomy but did not require further perineal debridement.
Fournier's Gangrene
Fournier's gangrene is a type of necotizing fasciitis involving the perineum and genitals, most commonly infecting men, but has been known to affect women and children as well. Risk factors include: diabetes, alcohol abuse, advanced age, renal failure, and immunocompromised states. It is a mixed flora infection of both aerobes and anaerobes. It can result in significant morbidity and mortality, including loss of the testicles and resultant cystomies.
Physical Exam findings: edema to the scrotum; tenderness to palpation of both scrotum and testicles; crepitus (only 64% of patients).
Although CT scan is gold standard for the diagnosis, ultrasound can be done at the bedside to expedite the diagnosis and treatment. It can also confirm the diagnosis in less obvious cases since ultrasound can visualize gas in the tissue prior to the appearance of crepitus.
Ultrasonographic appearance of Fournier's Gangrene: marked tissue thickening; local hyperechoic areas with distal acoustic shadowing with scatter indicative of subcutaneous air; peritesticular fluid; enlarged and hypoechoic epididymis indicating epididymitis.
References: Emergency Ultrasound of the Scrotum: A Review of the Commonest Pathologic Conditions. Demosthenes D, et al. Curr Probl Diagn Radiol. Jan/Feb 2011. Fournier's gangrene and its emergency management. Thwaini A, et al. Postgrad Med J. 2006 Aug;82(970):516-9. Fournier gangrene: rapid diagnosis with bedside ultrasonography. Heiner JD, et al. CJEM. 2010 Nov;12(6):528-9. Emergency diagnosis of Fournier's gangrene with bedside ultrasound. Morrison D, et al. Am J Emerg Med. 2005 Jul;23(4):544-7.