Don't say the 'F' word please

I'm talking about Fournier's gangrene, also known as necrotizing fasciitis of the male genitalia. The popular press likes to give the friendly moniker "flesh eating bacteria" to describe this horrible infection.
This 'F' word is guaranteed to put the fear of God in any urologist. It's an extremely aggressive, rapidly spreading infection that can become life-threatening in a matter of hours. It's very different from the regular garden variety scrotal cellulitis, which is commmon. This rare infection usually starts in the scrotal region and can spread to the whole perineum, upper thigh and lower abdominal area. The patients are very very sick, and the only treatment is prompt surgical debridment, which is a nice way of saying you have to cut off all the infected skin and underlying tissue.

The first time I encountered a patient with Fournier's gangrene was at the VA hospital, when I was the intern rotating through the urology service. I was called by the ER to see a diabetic gentleman who was described just as "having a scrotal infection". As soon as I entered the ER, there was an unmistakable smell of decay and rot permeating through the entire area. I didn't know at the time that this was what Fournier's smelled like. I just knew it was the most unpleasant gag-inducing odor I have ever smelled. To this day, I haven't smelled anything else like it. Little did I know it was emanating from my patient until I entered his room, and was pulled off his covers.

The sight was almost indescribable. The scrotum itself was swollen and black, and the rest of his perineum and buttocks were bright red and extremely indurated. I immediately called my Chief Resident, and we promptly took him to the OR for an emergent debridment. I will go into the gory details of the surgery, but suffice it to say that this is one of the most inelegant procedure we perform. Usually the testes are not affected and we can save them, but the whole scrotum and part of the penile skin had to be taken off. The smell was overwhelming and several of us had to leave the room periodically.

After days in the ICU, weeks of antibiotics and reconstructive skin grafting several months later, the patient recovered and eventually did well. But I will never forget my very first brush with Fournier's. Since then, I've dealt with 6 or 7 other patients with the condition, and it's the same unpleasant story.

However, I've noticed that a few of my non-urology colleagues will throw around the word "Fournier" routinely when they see a patient with plain scrotal cellulitis. I've rushed to the ER twice now over the past 6 months for a "rule out Fournier's", which turns out to be nothing more than plain cellulitis. In fact, just last friday, I rushed out of clinic to see a gentleman who underwent a scrotal ultrasound, and the radiologist called it "Fournier's". I went to the Radiology department expecting to see a very sick patient, and found a man comfortably waiting in the radiology reception area, and upon exam, just found some mild scrotal induration. Sure the patient had an infection, but certainly no Fournier's gangrene. Just because a patient is diabetic and has a scrotal infection does not make it automatically Fournier's.

So I am begging my medical colleagues to use this 'F' word judiciously. Once you actually see a patient with Fournier's there is no need to "rule it out", because it is usually quite obvious. Just remember that everytime you use that word in my presence, you are aging me prematurally.