From the Plastic Unit, Department of Surgery, Faculty of Medicine, Alexandria, U.A.R.

Transcription

1 GANGRENE OF THE SCROTUM: AN ANALYSIS OF TEN CASES By M. F. H. MOUSTAFA, M.B., B.Ch., M.Ch. From the Plastic Unit, Department of Surgery, Faculty of Medicine, Alexandria, U.A.R. THE scrotum is a pendulous purse-like bag of skin and fascia in which the testes are found. Its skin is more delicate and darker than the surrounding region and quite distensible. Its vascular supply is through scrotal branches of both the internal and external pudendal vessels, the cremesteric branch of the inferior epigastric artery and a twig from the testicular artery. The penis is richly supplied with blood, derived directly from the internal pudendal artery except for a small portion of skin on the under surface which receives blood indirectly from its scrotal branch. Gangrene of the scrotum, penis, or frequently of both, is relatively uncommon and the condition is either primary or secondary. Primary gangrene designates a gangrenous condition arising without a known antecedent trauma or disease It was first described by Fournier in 1883 and sporadic cases have been reported since that time by Randall (1921), Gibson (I93O), Mansfield (I946), Campbell (I955) and Thomas (1956). Although Fournier's gangrene has been reported in all age-groups from infancy to senility, the greatest number of cases occur between the ages of 2o and 5 years. The most striking characteristic of this condition is that it usually occurs suddenly in patients already in good health and progresses rapidly to the gangrenous state. The ~etiology of Fournier's gangrene, although still not definite, appears to be the result of an obliterative endarteritis caused by the spread of the infecting organisms in the subcutaneous tissue, which subsequently causes an isch~emic necrosis of the overlying skin. Earlier theories of fulminating erysipelas or gas gangrene have been discarded (Dunaif, 1964). Secondary gangrene may occur as a complication of some systemic diseases, e.g. infectious diseases or diabetes, or it may occur as a complication of a local condition, e.g. trauma, infection or extravasation of urine. ANALYSIS OF CASES Ten cases are reported in this series, five of which were of idiopathic origin, the remaining cases were secondary to local perineal lesions. Case I.--A labourer, 38 years old, was admitted with complete loss of the skin of the scrotum and the penis. The testes were completely naked, and hung downwards separately with intervening slough (Figs. I and 2). The condition started four days before admission with burning pain and swelling in the scrotum and penis. Three days later the skin changed rapidly in colour, became black and the slough separated leaving the penis and the testes bare. The patient was treated by general antibiotics and daily local dressings. On the fifth day after admission, a white slough on the tunica began to separate and for fear of testicular affection, rapid surgical interference was decided upon. A flap was rotated from each thigh to cover the testes and the perineum. The penis with an indwelling catheter was embedded in the anterior abdominal wall under a rectangular flap (Fig. 3). Two weeks later, the penis was detached and the abdominal flap was wrapped around it. The thigh flaps were detached, remodelled and sutured around the testes. A new scrotum was created which had a satisfactory shape and texture, and the testes could move freely inside it. Erection and penile sensation are normal (Fig. 4). 90

2 GANGRENE OF THE SCROTUM 91 FIG. I FIG. 2 FIG. 3 FIG. 4 FIG. X Complete sloughing of the skin of the scrotum and penis. Only a small strip of skin proximal to the coronal sulcus is saved. FIG. 2 The under surface of the penis is completely naked with absence of an isthmus of skin usually spared at the peno-scrotal junction. FIG. B A flap is rotated from each thigh to cover the testes and the perineum. The penis is seen embedded subcutaneously'in the anterior abdominal wall. FIG. 4 A near-normal scrotum and penis is shown.

3 92 BRITISH JOURNAL OF PLASTIC SURGERY Case 2.--A farmer, 4o years old, was admitted with a tender swollen scrotum and penis. The condition started acutely three days earlier in the from of severe burning pain and itching sensation. Two days after admission, black areas began to appear which sloughed leaving raw areas affecting the whole length of the penis and the lower half of the anterior surface of the scrotum (Fig. 5). As soon as the granulation tissue appeared to be healthy a split skin graft was applied to the penis by the tie-on technique (Fig. 6). Case 3.--An employee, 57 years old, was admitted in a very bad condition, dehydrated and nearly comatose. Four days after resuscitation, gangrene of the scrotum started to appear. Healing of the scrotum left a contracted scrotum with adherence of the testes to the scar (Fig. 7). FIG. 5 FIG. 6 FIG. 5.--Showing the raw area left after sloughing of the gangrenous skin. FIG. &---The penis is covered by skin graft and the scrotal wound is progressively healing. Case 4.--A farmer, 49 years old, presented with a post-gangrenous loss of skin of the fundus of the scrotum and the under surface of the penis. In the centre of the penile wound the urethra was seen simulating an acquired hypospadias (Fig. 8). Suprapubic cystotomy was done, but unfortunately the patient refused to stay in hospital. Case 5..--A farmer, 55 years old, was admitted with a post-gangrenous healing raw area on the penoscrotal junction. In its centre, a urethral fistula was discharging urine. Under conservative treatment the wound healed completely leaving dense white scar (Fig. 9)- The patient was transferred to the urological department for repair of the urethra. Case 6.--A clerk, 35 years old, was admitted with a huge peri-anal abscess, which ended in gangrene of the posterior surface of the scrotum and perineum (Fig. IO). Under proper dressing, the raw area closed satisfactorily. Case 7.--A farmer, 59 years old, suffering from bilharzial hepatosplenomegaly with ascites, was admitted with an irreducible right inguinal hernia. A huge post-operative hmmatoma was complicated by gangrene of the right side of tile scrotum. Case 8.--A diabetic labourer, 52 years old, who was operated upon for piles, developed

4 GANGRENE OF THE SCROTUM 93 FIG. 7 FIG.8 FIG. 7.--Showing contractionofthe left chamber of the scrotum. FIG. 8.--Gangrene of the under surface of the penis extending deeply to destroy the floor of the proximal penile urethra. FIG. 9.--Healing of peno-scrotal wound by dense scarring. Note how the penis is contracted and adherent to the scrotum. Fro. 9

5 94 BRITISH JOURNAL OF PLASTIC SURGERY severe secondary infection of the wound. Three days later, cedema of the scrotum which terminated in gangrene of its base was noticed. Case 9.--A shop-worker, 5o years old, was operated upon for a huge strangulated inguinal hernia. Superficial gangrene of the skin of the scrotum became manifest on the fifth postoperative day. Case Io.--A retired man, 75 years old, was operated upon for a left hydrocele. Severe secondar~ infection occurred and gangrene of the anterior wall of the scrotum resulted. It is noticed in this series that the age of the patients ranges between 35 and 75 years with an average of 49 years. The clinical features of the disease, though fairly uniform, vary according to the type. In primary gangrene, Cases I-5, the disease affects middle-aged men in apparent good health. Sudden unexplained rapidly progressive intense oedema of the scrotum, tenderness and pain of variable degrees are experienced. Hyperpyrexia, rapid pulse and chills are present and the patient appears to be acutely ill. Gangrene of either the skin of the penis or scrotum, in whole or in part, becomes evident in 2-4 days after the onset of the symptoms. The condition is confined to the genitalia. The process seems to be self-limiting ; spontaneous sloughing occurs m 4-7 days, leaving a granulating surface. Culture from the scrotal wounds revealed the presence of one or two of the following micro-organisms; Pseudomonas pyocyanea, Gram-positive aerobic micrococci, Gram-positive diphtheroid bacilli and Bacillus coli. In the last five cases, gangrene occurred secondary to a primary lesion either in the scrotum or the perineum. The local manifestations follow nearly the same lines as in idiopathic gangrene. It is noticed FIG. io that the occurrence of secondary gangrene Incised peri-anal infection with gangrene of the perineum and under surface of the scrotum. does not affect the general condition of the patient. The handling of a case of gangrene of the scrotum falls into two distinctive steps : I. Treatment of the local lesion and concomitant systemic management. Early and adequate debridement of necrotic tissues is essential together with the use of the proper antibiotic locally and systemically. Daily dressing starting with a potassium permanganate bath then cleaning with Eusol and hydrogen peroxide and finally applying chloramphenicol cream is the routine followed.

6 GANGRENE OF THE SCROTUM 95 Supportive measures in the form of blood or plasma transfusion and fluids are given when necessary. z. Repair of the scrotal and penile defects. When the defect is limited to partial skin loss of the scrotum, the case is treated conservatively. Healing is achieved with deformity of the scrotum in all cases. If the defect is partial, scrotal skin associated with partial or complete penile affection, the scrotal wound is treated conservatively but the penile skin loss is replaced by split skin graft. In cases of complete denudation of the scrotal and penile skin, rotation of bilateral thigh flaps and embedding of the penis subcutaneously in the anterior abdominal wall is the method of choice. D ISCUSSION Although the scrotum and the penis are richly supplied with blood from different sources and free anastomoses occur between these arteries, these sources may be insufficient in certain circumstances to the extent that gangrene may occur. It is known that the laxity of the areolar tissues helps the spread of the infection. As a result of all these factors, any inflammatory process will be manifested by severe oedema which may be the precipitating factor in initiating gangrene by occluding the arterioles. It was originally reported by Fournier (~g84) that the gangrene is confined to the skin, but it was noticed in our series that the process extended to affect deeper structures ; the tunica vaginalis in Case ~ and the urethra in Cases 4 and 5. This seems to depend on the degree of affection of the branches of the pudendal arteries. The speed of epithelialisation in scrotal wounds was so encouraging that operative interference was not necessary in many cases. Despite this fact, prolonged hospitalisation, morbidity and cicatrisation could be satisfactorily minimised by operative intervention. In managing our cases, partial scrotal skin loss was treated conservatively. All cases were followed by a deformed scrotum and one case by adherence of the testes to the skin. This could be prevented by early undermining with secondary suture In cases of penile skin loss with the presence of an island of skin at the root of the penis: split skin grafting by the tie-on technique is advised. The importance of this island of skin is to anchor the proximal row of sutures used in the tie-on of the graft. In complete loss of the skin of the scrotum and the penis rotation of bilateral thigh flaps and embedding of the penis subcutaneously is advised. This method proved to be satisfactory as it provides a near normal scrotum and penis from the functional and cosmetic points of view. As a general rule, all losses of penile skin must be replaced by skin grafts as this affords the best physiological cover to the venis. SUMMARY Ten cases of gangrene of the scrotum are described, five primary cases and five secondary. The pathology, bacteriology and management are discussed. Comparative impairment in the venous return due to laxity and dependency of the scrotum may be a precipitating factor in the occurrence of gangrene. It is noticed in this series that the process of gangrene does not limit itself to the skin, as was previously described, but may extend deeply to affect the underlying structures.

7 96 BRITISH JOURNAL OF PLASTIC SURGERY A scheme for the management of the various degrees of gangrene of the scrotum and/or the penis is proposed. Emphasis is laid upon the technique of plastic reconstruction of the scrotum by flaps from the thigh, a technique which could be used in the treatment of cases of lymphoedema of the scrotum. REFERENCES CAMPBELL, J. C. (1955). Br. ft. Urol., 27, lo6. DUNAIF, C. B. (1964). Plastic reconstr. Surg., 33, 84. FOURNIER, J. A. (1883). Mdd. prat., Paris, 4, 589. FOURNIER~ J. A. (1884). Sere. todd., 4, 69. GIBSON, T. E. (193o). ft. Urol., z3, 125. MANSFIELD, O. T. (1946). Br. ft. Surg., 33, 275. RANDALL, A. (1921). J. Urol. 4, 219. THOMAS, J. F. (1956). J. Urol., 75, 719