The presentation is often dramatic. A previously well patient may become systemically unwell over a very short time course (hours) following a seemingly trivial injury to the external genitalia. A fever is usually present. The patient looks very unwell, may have marked pain in the affected tissues, and the developing sepsis may alter their mental status. The genitalia and perineum
4. OTHER INFECTIVE UROLOGICAL EMERGENCIES 51
are oedematous; on palpation of the affected area there is tenderness, and crepitus may be present, indicating the 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, which 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.
Though blood tests may be abnormal (e.g., elevated white count), the diagnosis is a clinical one, and is based on awareness of the condition, and a low index of suspicion.
Do not delay. While intravenous access is obtained, blood is taken for culture, intravenous fluids are started and oxygen administered, and broad-spectrum antibiotics are given to cover both gram-positive and -negative aerobes and anaerobes, e.g., ampi-cillin, gentamicin, and metronidazole or clindamycin. Make arrangements to transfer the patient to the operating room as quickly as possible 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.
Where facilities allow, consider treatment with hyperbaric oxygen therapy. There is some evidence that this may be beneficial (Pizzorno et al. 1997). Repeated debridements to remove residual necrotic tissue are not infrequently required.