title: A multistep approach to manage Fournier's gangrene in a patient with unknown type II diabetes: surgery, hyperbaric oxygen, and vacuum-assisted closure therapy: a case report.
abstract: BACKGROUND
  Fournier's gangrene is an infectious necrotizing fasciitis of the perineum and genital regions and has a high mortality rate. It is a synergistic infection caused by a mixture of aerobic and anaerobic organisms and predisposing factors, including diabetes mellitus, alcoholism, malnutrition, and low socioeconomic status. We report a case of Fournier's gangrene in a patient with unknown type II diabetes submitted to 24-hour catheterization 15 days before gangrene onset.
  
  
  METHODS
  The patient, a 60-year-old Caucasian man, presented with a swollen, edematous, emphysematous scrotum with a crepitant skin and a small circle of necrosis. A lack of resistance along the dartos fascia of the scrotum and Scarpa's lower abdominal wall fascia combined with the presence of gas and pus during the first surgical debridement also supported the diagnosis of Fournier's gangrene. On the basis of the microbiological culture, the patient was given multiple antibiotic therapy, combined hypoglycemic treatment, hyperbaric oxygen therapy, and several surgical debridements. After five days the infection was not completely controlled and a vacuum-assisted closure device therapy was started.
  
  
  CONCLUSIONS
  This report describes the successful multistep approach of an immediate surgical debridement combined with hyperbaric oxygen and negative pressure wound therapy. The vacuum-assisted closure is a well-known method used to treat complex wounds. In this case study, vacuum-assisted closure treatment was effective and the patient did not require reconstructive surgery. Our report shows that bladder catheterization, a minimally invasive maneuver, may also cause severe infective consequences in high-risk patients, such as patients with diabetes.
authors.affiliation: Department of Medico-Surgical Sciences and Biotechnologies, Urology Unit, ICOT, Faculty of Pharmacy and Medicine, Sapienza University of Rome, Via Franco Faggiana 1668, Latina, 04100, Italy. antonioluigi.pastore@uniroma1.it.
authors.forename: Antonio Luigi
authors.initials: AL
authors.lastname: Pastore
authors.forename: Giovanni
authors.initials: G
authors.lastname: Palleschi
authors.forename: Andrea
authors.initials: A
authors.lastname: Ripoli
authors.forename: Luigi
authors.initials: L
authors.lastname: Silvestri
authors.forename: Antonino
authors.initials: A
authors.lastname: Leto
authors.forename: Domenico
authors.initials: D
authors.lastname: Autieri
authors.forename: Cristina
authors.initials: C
authors.lastname: Maggioni
authors.forename: Davide
authors.initials: D
authors.lastname: Moschese
authors.forename: Vincenzo
authors.initials: V
authors.lastname: Petrozza
authors.forename: Antonio
authors.initials: A
authors.lastname: Carbone