Skip to main content
  1. BAUS Home
  2. Training & Trainees
  3. Urology SHO
  4. Testicular & Scrotal
  5. Scrotal Cellulitis & Fournier's gangrene

Please note: This page is intended for healthcare professionals only. It is designed as a general educational guide and does not replace local guidance, senior clinical advice, or individual clinical judgement. Patients should not use this page as medical advice and should seek advice from an appropriate healthcare professional.

Scrotal Cellulitis & Fournier's Gangrene

Scrotal cellulitis is a superficial infection of the scrotal skin and subcutaneous tissues.
Important to differentiate from Fournier's gangrene (necrotising infection) which is a surgical emergency.

Immediate priorities

Fournier's gangrene is a life-threatening surgical emergency. If suspected, escalate immediately, start broad-spectrum IV antibiotics, resuscitate, and keep the patient NBM for emergency theatre.

Do not wait for imaging if the diagnosis is clinically obvious.

Scrotal cellulitis is usually more superficial and may respond to antibiotics, but carefully examine for abscess, necrosis, bullae, crepitus, rapid progression, or systemic toxicity.

Scrotal Skin Cellulitis

Usually responds well to antibiotics but requires careful assessment to exclude deeper infection.

Management

  1. Treat as per local Microbiology guidance for skin and soft tissue infections
  2. Carefully assess for abscess formation → if present, may require incision & drainage → keep patient NBM
  3. Thoroughly examine entire scrotum for signs of necrotic skin, bullae, or crepitus
  4. Mark the borders of erythema with a pen to monitor progression or improvement
  5. Provide supportive care: adequate analgesia, scrotal support/elevation, keep well hydrated

If ANY signs of necrosis, bullae, crepitus, or rapid progression → suspect Fournier's gangrene → inform Urology SpR immediately

 

⚠️Fournier's Gangrene

LIFE-THREATENING SURGICAL EMERGENCY – ACT FAST

This is necrotising fasciitis of the perineal and genital skin. Delay in diagnosis and treatment significantly increases mortality. Do not wait for imaging if clinically obvious.

Background

  • Necrotising fasciitis involves the perineum, penis, and scrotum; usually spares the testicles due to different blood supply
  • Rapidly progressive, often polymicrobial infection (aerobic & anaerobic bacteria)
  • Pain is typically severe and out of proportion to visible findings (especially in early stages)
  • Usually associated with risk factors such as long-term catheter, previous/ recent instrumentation of urinary tract and immunocompromised state.
  • Requires immediate surgical debridement to save life and tissue

Clinical Features

  • Severe scrotal/perineal pain
  • Skin discolouration (dusky, grey, black patches)
  • Bullae or blistering
  • Crepitus (subcutaneous gas)
  • Foul-smelling discharge (smells like rotting flesh)
  • Systemic toxicity (fever, tachycardia, hypotension, confusion)

Management

  1. Immediate Actions
    1. URGENT Urology/General Surgery SpR review NOW
    2. Start broad-spectrum IV antibiotics immediately (do not wait for imaging or lab results)
    3. Keep patient NBM for emergency theatre (booked as Cat 1)
    4. IV fluid resuscitation
    5. Catheterisation (discuss with SpR)
    6. Bloods: FBC, CRP, U&Es, lactate, blood cultures, clotting, Group & Save
    7. Involve Critical Outreach / ICU team promptly
  2. Imaging
    1. CT pelvis/perineum if diagnosis unclear and patient stable

    Do NOT delay theatre if clinical diagnosis is obvious

  3. Definitive Treatment
    1. Emergency surgical debridement in theatre
      • Often requires multiple returns to theatre for further debridement
      • May need diverting colostomy if perianal involvement
    2. HDU/ITU care post-operatively
 

When to Escalate / Red Flags

  1. ANY suspicion of Fournier's gangrene → immediate senior review + broad-spectrum IV antibiotics + resuscitation
    • Rapid progression of erythema, swelling, or skin changes
    • Crepitus or palpable gas in the tissues
    • Skin necrosis, bullae, grey/black patches, or skin breakdown
  2. Severe pain out of proportion to examination findings
  3. Systemic toxicity: fever >38.5°C, hypotension, tachycardia, confusion
  4. Immunocompromised patient or poorly controlled diabetes
  5. Scrotal abscess identified requiring surgical drainage
  6. Cellulitis rapidly progressing despite 24–48 hours of appropriate antibiotics

References

  1. European Association of Urology. EAU Guidelines on Urological Infections. Arnhem: EAU Guidelines Office; 2026. Available from: https://uroweb.org/guidelines/urological-infections
  2. Singh A, Ahmed K, Aydin A, Khan MS, Dasgupta P. Fournier's gangrene. A clinical review. Arch Ital Urol Androl. 2016;88(3):157-164. Published 2016 Oct 5. doi:10.4081/aiua.2016.3.157