Clinical Presentation

The diagnosis of Fournier's gangrene is made on clinical grounds. It is usually preceded by prodromal symptoms such as fever, prostration, nausea and vomiting, perineal discomfort, and poor glucose control in diabetics, for a period ranging from 2 to 9 days (Bahlmann et al. 1983; Paty and Smith 1992; Benizri et al. 1996; Edi-no et al. 2005).

Genital and perineal discomfort worsens, leading to pain, itching, burning sensation, erythema, swelling, and eventual skin necrosis. There may be a purulent discharge with a feculent odor. The pain may subside as neural damage develops (Corman et al. 1999). Crepitus may be difficult to elicit, due to pain on palpation, but is present in up to 50%-60% of cases (Corman et al. 1999; Benizri et al. 1996).

Clinical signs such as an elevated temperature, tachycardia, tachypnea, ileus, poor glucose control, and vascular collapse maybe found, but are not very consistent, especially with underlying immunosuppressive disorders.

The diagnosis is sometimes delayed due to morbid obesity, poor communication (stroke, dementia), or inadequate physical examination. In Africa, patients may first seek help from a traditional healer, thereby delaying proper medical attention (Attah 1992).

Once there is necrosis of the skin, the underlying fascia has already undergone extensive necrosis. This explains the frequent finding of systemic symptoms, which are out of proportion to the visible pathology.

Other symptoms and signs depend on the origin of the infection. A history of lower urinary tract symptoms may indicate a urethral stricture. Preceding ano-rectal symptoms such as pain, fissures, or hemorrhoids may indicate an anorectal origin of Fournier's gangrene.

It is essential that the attending doctor have a high index of suspicion in patients presenting with perineal discomfort accompanied by systemic symptoms. A missed or delayed diagnosis may have catastrophic effects.

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