Penoscrotal Reconstruction Using Groin and Bilateral Superomedial Thigh Flaps: A Case of Penile Vaselinoma Causing Fournier's Gangrene

Augmentation of the penis by localized injection of petroleum jelly can have severe, destructive consequences.1, 2 However, in Korea, these injections are still performed by non-medical personnel, and urologists are frequently confronted with the complications associated with the injection of petroleum jelly.3, 4

Fournier's gangrene is a form of necrotizing fasciitis occurring around the male external genitalia.5 It often has a rapidly fulminating course which results in gangrenous destruction of the genitalia accompanied by systemic inflammatory response syndromes, including sepsis. For the management of rapidly progressive Fournier's gangrene, immediate and aggressive debridement is essential, along with intravenous antibiotic therapy. Wide surgical debridement can result in major scrotal, penile, perineal, and lower abdominal skin loss. Therefore, it is important to know how to reconstruct the skin defect after the wound has completely healed.

Recently, we had a 42-year-old man with penile vaselinoma causing Fournier's gangrene. This was treated successfully with aggressive surgical debridement, followed by penoscrotal reconstruction using groin and bilateral superomedial thigh flaps. To our knowledge, there have been no reported cases of Fournier's gangrene originating from penile vaselinoma. Here, we present a case of Fournier's gangrene associated with a previous penile injection of petroleum jelly.

A 42-year-old man presented with painful penile and scrotal swelling with dark purple discoloration that had developed 3 days prior to the hospital visit. In the emergency room, his initial systolic and diastolic blood pressures were 70mm Hg and 40mm Hg, respectively. His pulse rate was 88bpm, and the measured body temperature was 38.8℃. In addition, initial blood tests showed marked leukocytosis and elevated creatinine level. The WBC count was more than 30,000/mm³, and the serum creatinine level was 5.0mg/dL. Septic shock was suggested. After the rapid infusion of normal saline, the blood pressure was restored and normalized. However, the penile and scrotal swelling was aggravated, and necrotic changes developed. This condition spread bilaterally to the inguinal area and lower abdomen, as well as the perineum. He did not have a history of recent trauma or systemic disease, such as diabetes mellitus; however, 2 years before presentation, he had undergone a subcutaneous injection of petroleum jelly for penile augmentation. For the treatment of Fournier's gangrene, broad-spectrum antibiotics were administrated intravenously, and 12 hours after arrival at the emergency room, the patient underwent extensive emergent surgical debridement of the necrotic skin and fascia of the scrotum and perineum. In the penis, all of the tissues above Buck's fascia were removed, along with a previous vaselinoma. Thereafter, additional procedures for debridement of the perineum and scrotum were conducted on two more occasions (Fig. 1).

Fig. 1
External genitalia of the patient before penoscrotal reconstruction, showing the penile and scrotal skin defects after extensive debridement of necrotic tissue.

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After the wound had completely healed, we performed penoscrotal reconstruction to compensate for the skin loss from the previous extensive debridement. We used a left-side groin flap for the penile skin loss and bilateral superomedial thigh flaps for the scrotal skin loss (Fig. 2). In the left groin area, we marked and removed a flap measuring 15 × 6cm. The elliptic flap, including the superficial circumflex iliac artery in the pedicle, was elevated subfascially from a lateral to a medial aspect. The flap was then transposed and wrapped around the penile shaft. At the same time, denuded scrotal contents were covered with rectangular (5 × 7cm) bilateral superomedial thigh flaps (Fig. 3). Three weeks after the penoscrotal reconstruction, separation of the groin flap was performed. The final postoperative appearance was very good (Fig. 4). Also, penile bulkiness and erectile function were satisfactory. The patient was followed up postoperatively for 14 months with no specific complications.

Fig. 2
Anatomic illustration of the left-side groin flap and bilateral superomedial thigh flaps for penoscrotal reconstruction. The feeding vessel for the groin flap is the superficial circumflex iliac artery (SCIA), which arises from the femoral artery. The superomedial thigh flap is a flap with ample blood supply derived from three main sources: the deep external pudendal artery, the medial femoral circumflex artery, and the anterior branch of the obturator artery.

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Fig. 3
Intraoperative view immediately after flap application to the penoscrotal defect. The separation of the groin flap was performed 3 weeks after the penoscrotal reconstruction.

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Fig. 4
The final postoperative appearance after penoscrotal reconstruction was quite satisfactory. Penile bulkiness and erectile function were also satisfactory.

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Although there is no evidence that penis augmentation by the injection of mineral oil improves sexual function, the technique has often been used for the purpose of facilitating erection and enhancing sexual image.4 These injections can cause disastrous side effects, such as infection, ulceration, migration, and embolism, and may even be carcinogenic.1-3 This report reveals that penile injection of petroleum jelly can also predispose to Fournier's gangrene, a life-threatening, fulminating infection. Considering the detrimental effects, procedures for penile enlargement by the injection of mineral oil should be strongly condemned and discarded.

Many surgical methods have been described for scrotal and penile reconstruction following Fournier's gangrene, and each method has its own merits and demerits.6-13 In this case, we used a left-side pedicled groin flap for penile reconstruction and bilateral superomedial thigh flaps for scrotal reconstruction, simultaneously. The use of the groin flap, a non-hair bearing flap, is a relatively simple method for the reconstruction of various areas of the body.6 If careful attention is paid to the superficial circumflex iliac vessels when elevating the flap, it is very safe and effective. When it was used to treat the penile skin loss of our patient, it appeared that the increase in penis mass improved postoperative patient satisfaction. On the other hand, the use of bilateral superomedial thigh flaps is a reliable method of covering large scrotal defects in Fournier's gangrene.8, 9 These flaps are robust flaps with a reliable blood supply and provide almost normal sensation. Although they are excellent tools for penoscrotal reconstruction, superomedial thigh flaps have some disadvantages, such as narrow width and inadequate bulk. Recently, Ellabban et al. reported that a single stage muscle flap technique to reconstruct major scrotal defects following Fournier's gangrene is an excellent option.13 Being muscle flaps, the rectus abdominis muscle flap and the gracilis flap have the ability to survive in an infected environment and represent a useful choice for reconstruction in the contaminated perineum.

Penoscrotal reconstruction using groin and bilateral superomedial thigh flaps was successful in this case, in both cosmetic and functional terms. Therefore, we propose the concurrent use of groin and bilateral superomedial thigh flaps as a method for the reconstruction of extensive soft-tissue defects of the penoscrotal region.