A 58-year-old man with type 2 diabetes presents with rapidly worsening scrotal and perineal pain that began the previous evening. He reports severe pain that seems out of proportion to the visible skin changes and feels weak and nauseated. His medications include an SGLT2 inhibitor. He is tachycardic but afebrile. Examination reveals mild scrotal erythema and edema, exquisite perineal tenderness, a small area of dusky discoloration, and subtle crepitus.
Which of the following is the most appropriate disposition?
- Discharge with oral antibiotics and follow-up in 48 hours
- Obtain outpatient scrotal ultrasonography and refer to urology if abnormal
- Treat for epididymo-orchitis with antibiotics, scrotal elevation, and NSAIDs
- Immediately transfer to an emergency department for surgical evaluation and treatment
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Correct answer: d. Immediately transfer to an emergency department for surgical evaluation and treatment.
Rationale: Severe pain out of proportion to examination findings, rapidly progressive symptoms, dusky skin changes, and crepitus in a patient with diabetes strongly suggest Fournier gangrene, a necrotizing soft-tissue infection. Diabetes and SGLT2 inhibitor use are additional risk factors. Early skin findings may appear deceptively mild, so absence of fever or extensive necrosis should not reassure the clinician. Fournier gangrene requires emergent surgical evaluation, broad-spectrum intravenous antibiotics, resuscitation as needed, and operative debridement; outpatient imaging or treatment should not delay definitive care.
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Tracey Davidoff, MD, FACP, FCUCM, has practiced Urgent Care Medicine for more than 15 years. She is Board Certified in Internal Medicine. Dr. Davidoff is a member of the Board of Directors of the Urgent Care Association and serves as Co-Editor-in-Chief of the College of Urgent Care Medicine’s “Urgent Caring” publication. She is also the Vice President of the Southeast Regional Urgent Care Association and a member of the editorial board of the Journal of Urgent Care Medicine. At EB Medicine, Dr Davidoff is Editor-In-Chief of Evidence-Based Urgent Care, and co-host of the Urgentology podcast.
