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Case Reports in Emergency Medicine

[WARNING: Extremely graphic text]

We had never come across a report of “gangrene of the genitals” until a seeing a current television ad campaign seeking victims of the condition among patients who have taken Jardiance, the heavily promoted drug used to treat type 2 diabetes. It turns out that Jardiance is not the only possible cause of this difficult condition (difficult to go through, difficult to read about). Also in his post, tips for both men and women to maintain genital health and sensation at any age. – Editor 

Case Report [explanatory notes added – Ed.]

Fournier’s Gangrene due to Masturbation in an Otherwise Healthy Male Results in 22-Day Hospitalization

Abstract

Fournier’s gangrene is a rare and often fulminant [severe and sudden in onset] necrotizing fasciitis [tissue death] of the perineum and genital region frequently due to a synergistic polymicrobial infection [which are more severe than infections with individual microorganisms].

This truly emergent [arising suddenly and unexpectedly, calling for quick judgment and prompt action] condition is typically seen in elderly, diabetic, or otherwise immune-compromised individuals.

Here, we report an unusual case of Fournier’s gangrene due to excessive masturbation in an otherwise healthy 29-year-old male who presented to the emergency department complaining of two days of fever, vomiting, and diffuse myalgias [generalized pain].

Upon further questioning, he also endorsed severe scrotal pain and swelling and frequent masturbation with soap as a lubricant resulting in recurrent penile erythema [superficial reddening of the skin] and minor skin abrasions.

Have you or a loved one experienced similar symptoms after taking Jardiance? See FDA Warns of Serious Genital Infection With Diabetes Meds below. 

Examination of the patient’s perineum was consistent with Fournier’s gangrene and included significant erythema, edema [abnormal accumulation of fluid], and calor [heat, one of the four classic signs of inflammation] of the penis and scrotum with a large malodorous eschar [ulcer with foul odor due to tissue degradation].

He was given intravenous antibiotics and immunoglobulin and promptly underwent three surgical debridements of the scrotum and penis with split-thickness skin grafting.

Complications from excessive masturbation are exceedingly rare, but as this case illustrates, they can be life threatening. (Story continues below … ) 

OTHER GENITAL HEALTH COVERAGE ON HEADLINE HEALTH: 

Case Presentation | Outcome

An otherwise healthy 29-year-old male presented to the emergency department (ED) after being evaluated at an outside urgent care clinic for two days of fever, vomiting, and diffuse myalgias.

Upon further questioning, he also endorsed severe scrotal pain and swelling and frequent masturbation with soap as a lubricant.

He reported that past episodes of masturbation often resulted in recurrent penile erythema and abrasions which had worsened over the previous three days since his last masturbation episode. He denied any recent travel, notable lapses in personal hygiene, or any other preceding genitourinary injury or symptoms. 3 Natural Alternatives To Lube; [DO NOT USE SOAP]

The patient appeared alert but ill and in pain, with rigors [a sudden feeling of cold with shivering accompanied by a rise in temperature, often with copious sweating, especially at the onset or height of a fever] and a rectal temperature of 104.3°F.

His initial blood pressure was 87/50 mmHg, heart rate was 124 beats/min, and respiratory rate was 24 breaths/min with an oxygen saturation of 100% on room air.

His physical exam was remarkable for significant erythema, edema, and calor of the penis and scrotum extending to the region of the pubis symphysis but sparing the glans (Figure 1).

A large malodorous eschar was noted to the ventral surface of the penis. Aggressive intravenous (IV) fluid resuscitation with normal saline was begun and, with a provisional clinical diagnosis of Fournier’s gangrene, IV clindamycin, and ampicillin/sulbactam, was administered, and surgery was consulted.

His initial ED labs were remarkable for a white blood cell count of 12,000/mm3 and a lactate of 2.2 mEq/L.

Figure 1: [Graphic medical image – NSFW] Appearance of the patient’s perineum upon emergency department presentation. 

The patient was taken to the operating room where cystoscopy [endoscopy of the urinary bladder via the urethra] and anoscopy [examination using scope inserted into the anus] were found to be normal with no sign of gangrenous extension or source of infection from the bladder or rectum.

He underwent three separate surgical debridements of the scrotum and penis as well as penoscrotal split-thickness skin grafting [a skin graft including the epidermis and part of the dermis].

Intravenous immunoglobulin (IVIG) was added to his treatment regimen and blood cultures identified strains of Staphylococcus aureus and Streptococcus pyogenes. On hospital day 22, he was discharged home.

Discussion 

In the late 1800s, the Parisian dermatologist and venereologist Professor Jean-Alfred Fournier used the term “fulminant gangrene” of the penis and scrotum to describe a sudden onset of rapidly progressing idiopathic scrotal gangrene in young men [6]. Today, this rare and often fulminant necrotizing fasciitis of the perineum and genital region is typically seen in elderly, diabetic, or otherwise immune-compromised individuals (with a male predominance) and is known to be frequently due to a synergistic polymicrobial infection [1–5].

The nidus of infection is typically urogenital or anorectal, but cutaneous sources of infection have been reported, with poor personal hygiene acting as an apparent contributing element of infection occurrence [1–5].

Reported mortality rates range from 3% to 45%, affected by factors such as underlying comorbidities, the source of infection, and the presence of severe illness or sepsis upon initial evaluation and treatment [1–5].

Consultation for early surgical debridement and initiation of broad-spectrum IV antibiotics to cover Gram-positive, Gam-negative, and anaerobic bacteria is critical, and the addition of other adjunctive therapies such as IVIG and hyperbaric oxygen therapy may be considered [1–5, 7–9].

While the occurrence of Fournier’s gangrene in an otherwise healthy young adult is unanticipated in modern times, frequent masturbation as the underlying cause of this condition is even more unexpected.

An extensive review of the current medical literature rarely reveals past reports of Fournier’s gangrene or necrotizing fasciitis of the penis or scrotum directly resulting from masturbation.

More frequently, occasional reports exist of male patients with other medical and surgical genital complications due to masturbation, autoerotic, and other sexual activities. Past published complications include direct bacterial inoculation or fat embolism after penile injection, and urethral tears and lodged foreign bodies in the bladder after urethral self-instrumentation for erotic stimulation [10–12].

Reports of penile incarceration injury after placement of constricting rings and ring-like devices exist and can rarely lead to Fournier’s gangrene or penile necrosis [13–16].

In a classic account, Fournier himself did report that gangrene “could be seen as a consequence of pulling of the skin of the penis” and “as a result of violent twisting of the penis during erection” but also that he had never seen gangrene as a result of “excessive masturbation” [6].

Nearly 130 years later, complications from excessive masturbation have proven to be exceedingly rare, but, as this case illustrates, they can be life threatening.

Disclaimer: The views expressed herein are solely those of the authors and do not represent the official views of the Department of Defense or Army Medical Department.

References: Jason D. Heiner,1 Katisha D. Eng,2 Todd A. Bialowas,1 and Diane Devita2
1Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, San Antonio, TX 78234, USA
2Department of Emergency Medicine, Madigan Army Medical Center, Fort Lewis, Tacoma, WA 98431, USA

Received 18 February 2012; Accepted 22 March 2012

Academic Editors: H. David, A. K. Exadaktylos, K. Imanaka, W. Mauritz, and F. Natale

Copyright © 2012 Jason D. Heiner et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Volume 2012, Article ID 154025, 3 pages
http://dx.doi.org/10.1155/2012/154025

MORE SEXUAL HEALTH COVERAGE ON HEADLINE HEALTH 

FDA Warns of Serious Genital Infection With Diabetes Meds

By Miriam E. Tucker, Aug. 30, 2018

WebMD – The FDA is warning about rare cases of necrotizing fasciitis — sometimes called “flesh-eating bacteria” — of the genitals and genital area in patients taking type 2 diabetes drugs known as SGLT2 inhibitors.

The new warning will be added to the prescribing information and the patient medication guides for all types of the drugs and drug combinations approved to treat type 2 diabetes. They include:

  • Canagliflozin (Invokana, Invokamet, Invokamet XR)
  • Dapagliflozin (Farxiga, Xigduo XR, Qtern)
  • Empagliflozin (Jardiance, Glyxambi, Synjardy, Synjardy XR)
  • Ertugliflozin (Steglatro, Segluromet, Steglujan)

Necrotizing fasciitis of the genital area, also called Fournier’s gangrene, is a life-threatening bacterial infection of the tissues under the skin surrounding the muscles, nerves, fat, and blood vessel in the genital area. It is estimated to happen to about 1.6 of 100,000 men annually in the United States, most often among those ages 50 to 79.

But from March 2013 to May 2018, the FDA received reports of 12 cases of Fournier’s gangrene among patients taking SGLT2 inhibitors, of whom five were women and seven were men. The condition has rarely been reported among women. The patients ranged from 38 to 78 years old.

The condition developed an average of 9.2 months after the patients starting taking the drug. (Though the development time ranged from 7 days to 25 months.) Patients stopped taking the drug in most cases.

Multiple Surgeries, One Death

Reports included all SGLT2 drugs except ertugliflozin, but it “would be expected to have the same risk for this rare and serious infection as other SGLT2 inhibitors,” the FDA said in a statement … Read more.