Sliding Inguinal Hernia in a Case of Fournier's Gangrene: A Rare Case.

Fournier's gangrene and inguinal hernia, both are common diseases. However, inguinal hernia in a case of Fournier's gangrene is rarest of rare cases. Only one such case is reported in literature. We present one such rare case. A 50-year-old man presented with blackish discoloration of scrotum with inguinoscrotal swelling. It was associated with pus discharge and foul smell. There were noassociated co morbidities. The patient was a chronic smoker from 40 years. Serial debridement was done until the wound became healthy and free of infection. After infection control, the patient was operated and hernioplasty was done. Copyright:

Introduction

Fournier's gangrene is a necrotizing fasciitis characterized by a polymicrobial infection of the soft tissues of the perineum, external genitalia and perianal region.[1] It can arise following minor injuries or procedures in the perineal area, such as a bruise, scratch, or opening of a periurethral abscess. Many patients have concurrent illnesses that diminish their defenses, most notably diabetes mellitus and alcoholism. There is a mixed infection of aerobic and anaerobic bacteria in a fulminating inflammation of the subcutaneous tissues which results in an obliterative arteritis of the arterioles to the scrotal skin resulting in gangrene. The condition can spread rapidly to involve the fascia and skin of the penis, perineum, and abdominal wall. Infection spreads rapidly with small necrotic areas of skin which, if untreated, coalesce to involve the entire scrotal and penile coverings, which may then slough, leaving the testes exposed. There may be crepitus and a foul-smelling exudate. The patient typically becomes septic in a short period of time. Fournier's gangrene is a surgical emergency. Initial management involves intravenous fluid resuscitation and early use of broad spectrum intravenous antibiotics. Urgent wide surgical excision of the dead and infected tissue is essential and the extent of the internal necrosis is typically much greater than the external appearances. Supportive care is essential.

Case Report

A 50-year-Gentleman presented with a complaint of blackish discoloration of scrotum from 20 days. The patient initially developed pain and pustule over scrotum which later progressed to involving whole of the scrotum and was associated with foul smell, blackish discoloration, and fever. The patient was diagnosed with Fournier's Gangrene and debridement of scrotum was done [Figure 1a]. The patient had also left inguinal hernia and it was irreducible. The patient was chronic smoker from 40 years. There was no significant past medical or surgical history. On examination, the patient was vitally stable. Irreducible left inguinal hernia with Fournier's gangrene of scrotum was present. Patient's hemoglobin was on the lower side (8.4 g %) and total leukocyte count was raised (31,000/mm3). Serial debridement was done and culture and sensitivity of tissue was sent [Figure 1b]. Broad spectrum antibiotic started early and later, the patient was shifted on antibiotic according to sensitivity test. Dressings were done twice a day to manage the Fournier's Gangrene. Patient's clinical picture and blood parameters improved significantly. Patient was operated for irreducible inguinal hernia after scrotal infection was controlled and debridement with reduction of hernial sac with anatomical repair of hernia (hernioplasy) under general anaesthesia was done. Per-operative findings– Dense adhesions were present between gangrenous testis and caecum. Caecum was the content of the hernial sac. Specimen was sent for histopathological examination [Figure 1c]. The patient improved and discharged. Patient was followed up after 2 weeks and then after 3 months. The patient had no complaints.

Figure 1

Debridement of scrotum. (a) At time of presentation, (b) Postdebridement, (c) Resected specimen

Discussion

Fournier's gangrene was first described by Baurienne in 1764 and is named after a French venereologist, Jean Alfred Fournier following five cases he presented in clinical lectures in 1883.[2] Initially, it was considered as rapidly progressing idiopathic necrotizing soft-tissue infection of scrotum. However, later, it was concluded that it is the infection of perineal and genital region, typically seen in elderly, diabetic, or otherwise immune-compromised and is known to be frequently due to a symbiotic polymicrobial infection. Females can also acquire this infection but there is a male predominance. Sliding hernia is the hernia in which one of the walls of the hernial sac is formed by a viscous. Approximately 3%–5% of all indirect inguinal hernias are sliding hernias. Sigmoid colon being the most common slided organ. Other common slided organs are retroperitoneal appendix, caecum, and urinary bladder. In 1995, Laor et al.[3] developed Fournier's Gangrene Severity Index to predict the prognosis of the patients. The treatment of Fournier's gangrene is radical debridement of the gangrene until no infected tissue is left, supported by broad spectrum antibiotics and followed by skin grafting. The treatment of sliding hernia is surgery. Depending on the setting of treating center, surgeon and the patient, treatment can either be done by open surgeries or by laparoscopic surgeries.

Conclusion

Inguinoscrotal hernia in a case of Fournier's gangrene is extremely rare. No literature states the proper treatment for such condition. Fournier's gangrene should managed first as it is a life-threatening condition if inguinal hernia is uncomplicated. After control of infection, the patient can be taken for surgery to manage the hernia. It can either be done as open surgery using high inguinal approach or can be done laparoscopically. However, in case of complicated inguinal hernia with Fournier's gangrene, further study is needed.

Declaration of patient consent

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Conflicts of interest

There are no conflicts of interest.