Fournier's gangrene is a rapidly progressive necrotizing soft tissue infection of the perineal and genital regions associated with significant morbidity and mortality. Patients with poorly controlled diabetes mellitus are at particularly high risk for severe disease and complications. We present the case of a 57-year-old Hispanic male with uncontrolled type 2 diabetes mellitus (hemoglobin A1c of 12.2%), hypertension, and alcohol use disorder who presented with a two-week history of worsening scrotal pain and swelling. Computed tomography demonstrated extensive subcutaneous emphysema involving the perineum, scrotum, penis, bilateral inguinal canals, and anterior abdominal wall. The patient underwent multiple operative debridements, end colostomy creation, and prolonged antimicrobial therapy for polymicrobial bacteremia and severe sepsis. His hospital course was further complicated by bilateral abdominal wall fluid and gas collections concerning for abscess formation, requiring image-guided drainage and subsequent readmission for persistent collections. After a cumulative hospital stay of approximately seven weeks, he was ultimately discharged in stable condition. This case highlights the aggressive nature of Fournier's gangrene and the importance of early surgical intervention, repeated source control, and close follow-up for persistent or delayed infectious complications.

Fistula-in-ano rarely extends anteriorly into the penile shaft and scrotal structures, and when it does, the anorectal origin of disease may not be clinically apparent, particularly in patients presenting predominantly with scrotal swelling. We report a 27-year-old male who had a 6-month history of perianal pain radiating to the perineum and scrotum, along with a gradually increasing left scrotal swelling. The patient was referred to us for magnetic resonance imaging (MRI) fistulography, which revealed an internal opening at the 1 o'clock position abutting the external anal sphincter, with a continuous fistulous tract extending anteriorly through the left obturator internus region, then along the inferolateral corpus spongiosum for approximately 66 mm, reaching the penoscrotal junction and scrotal base. A well-defined pericorpus spongiosum abscess measuring 11 mm × 8 mm × 13 mm (craniocaudal × anteroposterior × transverse) in the penile shaft showed diffusion restriction on diffusion-weighted imaging, confirming purulent content. The case illustrates how MRI fistulography, through systematic multiplanar tract mapping and diffusion-weighted imaging, enables accurate delineation of complex fistulous tract extension and characterization of associated collections, preventing dangerous underestimation of disease extent in atypically presenting perianal fistulas.

Background and Clinical Significance: Malignant priapism is a rare manifestation of advanced malignancy caused by malignant infiltration of the corpora cavernosa. We report a case of persistent and refractory priapism associated with penile carcinoma and extensive metastatic disease, with a suspected pulmonary primary. Case Presentation: An 81-year-old man with a history of prostate cancer treated by radical prostatectomy and persistently undetectable PSA levels developed persistent low-flow priapism. Despite aspiration and irrigation, followed by distal and proximal shunting procedures, the condition recurred with progressive corporal induration and severe pain. Cavernous biopsy was initially interpreted as moderately differentiated squamous carcinoma, while total penectomy performed for refractory pain showed poorly differentiated carcinoma with morphological adenosquamous features. CT and PET/CT demonstrated a pulmonary mass and widespread metastatic disease, although bronchoscopy was non-diagnostic and no histological confirmation of the pulmonary lesion was obtained. A focused review of the literature identified 32 published cases of malignant priapism; bladder cancer was the most frequently reported primary malignancy (37.5%), followed by prostate cancer (18.8%) and renal cell carcinoma (9.4%), while penectomy was performed in 34.4% of cases. Conclusions: Persistent or recurrent priapism associated with corporal induration, progressive or atypical pain, failure of conventional treatment, or discordant imaging findings should raise suspicion of malignant infiltration and prompt consideration of repeat imaging and tissue sampling. In the present case, carcinoma involving the penile structures was histologically confirmed, whereas pulmonary origin remained a clinicoradiological suspicion; penectomy provided immediate pain relief in the setting of extensive refractory local disease.

BACKGROUND Chronic pelvic pain (CPP) is a prevalent, multifactorial condition with neuropathic, visceral, myofascial, and psychogenic components; a subset of patients remain refractory to multimodal pharmacotherapy and conventional interventional procedures. Pulsed radiofrequency (PRF) of the dorsal root ganglia (DRG) is a minimally invasive neuromodulatory technique that can attenuate pathological nociceptive transmission while preserving neural integrity. We describe 3 patients with severe, treatment-refractory CPP of predominantly neuropathic origin who underwent sacral DRG PRF as rescue therapy. CASE REPORT Case 1 was a 46-year-old man with a 7-year history of neuropathic penile pain following circumcision. Case 2 was a 54-year-old woman with an 11-year history of urethral burning pain and urgency after anal sphincterotomy. Case 3 was a 39-year-old woman with an 18-year history of CPP related to interstitial cystitis, vulvodynia, and pelvic floor myofascial dysfunction. All 3 had failed extensive pharmacological, nerve block, and neuromodulation therapies. Bilateral PRF of the S2-S4 DRG produced reductions in pain intensity (Numeric Rating Scale, NRS) of 55.6-62.5% at 3 months, partially sustained at 6 months (42.9-50.0%), with parallel improvements in neuropathic pain scores, quality of life, and reduced analgesic use, without procedure-related complications. CONCLUSIONS In these 3 refractory CPP cases, sacral DRG PRF was associated with clinically meaningful, although partially attenuating, symptomatic improvement. Given the small, uncontrolled sample, these findings represent preliminary clinical observations suggesting possible benefit in carefully selected patients and should be regarded as hypothesis-generating rather than evidence of established clinical effectiveness.

A 2-year-old male entire Samoyed presented with 2 weeks of suspected lumbar pain, following an episode of compulsive hypersexual behavior towards other dogs. Computed tomography revealed a lobulated, enlarged left corpus cavernosum with a central non-enhancing, hypoattenuating region (-20 to 40 HU) and rim enhancement, surrounding ischiocavernosus muscle swelling, and left-sided bulbus penis hyperenhancement. Ultrasound showed an enlarged heterogeneous hyperechoic left corpus cavernosum. Ultrasound-guided needle aspiration for cytology, interpreted by a board-certified clinical pathologist, revealed mesenchymal proliferation and mild macrophagic inflammation, supporting a diagnosis of cavernositis. The dog was treated with anti-inflammatories and antibiotics with clinical resolution at a 4-week follow-up.

Penile metastasis from other primary sites is rare. A 78-year-old man was referred for an 18F-FDG PET/CT scan for evaluation of perineal pain on a background of previous cystoprostatectomy 4 years previously for infiltrating urothelial carcinoma of the bladder. The scan demonstrated a hypermetabolic focus at the ventral aspect of the proximal penile shaft with urethral and percutaneous histopathological confirmation of penile metastasis from primary high-grade urothelial carcinoma. The patient subsequently underwent urethrectomy.