Medical Bytes Thailand Number 105 I Have Seen Some Strange Medical Managements in My Time but This One was a Real Doozy

The following is a guest opinion article from Doc Martyn. His opinions and advice are entirely his own and may not necessarily be those of The Pattaya News Company Limited. His contact information can be found at the end of the article.

We also note the following medical bytes contains some sensitive subject matter that may bother extremely sensitive readers.

1. When James, not his real name, came to see me on January 21st, 2024, he told me the following, quite extraordinary, story:

One evening,whilst in Japan, James enjoyed a sushi dinner, although he thought the sticky rice was inadequately cooked. The following day he was constipated. He laboured on the toilet to release the blockage. The force required was “extraordinary” and the straining caused him pain in the right side of his lower abdomen.

The following day the right side of his scrotum was swollen. The swelling reduced somewhat, then after socialising the swelling returned with a vengeance. His right testicle increased to “the size of a large chicken egg!” and it ached. He sought an opinion from Dr Kira, a Japanese GP with a special interest in Urology. Dr Kira treated him for epididymitis, an infection of the testicular appendage, with 10 days of Levofloxacin, a broad-spectrum fluoroquinolone antibiotic.

After 4 days, the skin on his scrotum was “scaly and itchy”. He returned to see Dr Kira for review. Dr Kira prescribed a moisturiser.

2. Four days later, James woke with blood on his sheets and a 5cm flap of skin hanging from his scrotum. He purchased adult diapers and attended Dr Kira’s office the following day, Monday 4^th December.

Dr Kira removed the flap of dead skin and cleaned the wound, and used the word necrosis (the death of tissue due to disease), as he cut away the diseased flesh. He called the treatment ‘snippy snippy’,which was repeated over the next 2 weeks. The procedures were performed with surgical scissors and/or a scalpel, but without an anaesthetic!!

Dr Kira remained troubled by James’s presentation and referred him to a colleague who was a specialist Urologist, with the recommendation that James be admitted. The surgeon recommended removal of his right testicle and the right side of his scrotum.

Politely, James refused admission and the surgical management.

3. James has an agile intellect. He researched Levofloxacin, one of the side effects of which is epidermal necrolysis (shedding of the upper layers of the skin). James ceased Levofloxacin. The necrolysis settled.

4. As I listened to this story, and because Dr Kira had used the term necrosis, I became concerned that James had Fournier’s gangrene, a very serious illness with a 40% fatality rate. Fourier’s gangrene, a necrotising fasciitis (see MBT 97, legless in Thailand), is gangrene of the scrotal sac. It is an uncommon illness; 1.6 per 100,000 men in America, per year. Most of its victims are overweight and have poorly controlled diabetics. To preserve life, surgical excision of the scrotum should be performed with priority.

But James was 172cm tall and weighed 78 kg. He was not a diabetic.

Fournier’s gangrene progresses rapidly. James had endured ‘snippy snippy’ for over 2 weeks. If he had Fournier’s gangrene, he would be dead already.

5. This was a crazy story, but the diagnosis was simple: After examining his healing scrotum, see photo 5, I told him that the excessive straining to release his constipation had caused an inguinal hernia with swelling of his right testicle.

James was a little surprised, stating that he had previously self-assessed for a hernia, which he could not find. I reassured him that I made the diagnosis from his story, explaining that the right sided lower abdominal pain, caused by his straining, was, in fact, the rupture of his internal inguinal ring, see photo 6. When I examined his inguinal canal, in which there was a cough impulse, the diagnosis was confirmed. I showed James how to examine himself correctly. He could feel the difference between the right and left sides.

His previous self-examination technique was for a direct inguinal hernia, not an indirect inguinal hernia.

James was delighted with the diagnosis: He was not going to lose his right testicle and scrotum. Everything would be fine, and if his nascent inguinal hernia did not heal itself, a simple operation would return him to normal, except, of course, for the ‘snippy snippy’ manicuring of his scrotum.

6. The question? How did two Japanese doctors trained in Urology fail James in such a profound manner?

Answer: For the following reasons they did not fail him!

-The medical language difference; Japanese vs English.

-Fournier’s gangrene is a rare, potentially fatal disease. Urgent surgical removal of the infected tissue is paramount, which is what they were intending to do.

-The two Japanese doctors had obviously read about Fournier’s gangrene, but they had never managed a case. They were informed but they were not knowledgeable. Knowledge arises from experience.

-Such serious pathology is rarely seen in small provincial hospitals.

-As a surgical intern I worked in the second largest hospital in the UK. Within the first month of my employment, I was involved in the treatment of a Fournier’s case. I developed the knowledge to correctly diagnose and manage Fournier’s. 45 years since, I have not seen another case.

-Finally, although slightly misguided, jointly the two doctors were attempting to save James’s life and, as physicians, that is our job.

7. Throughout this ordeal, James’s fortitude was admirable. To endure ‘snippy snippy’ without local anaesthetic was unbelievable.

Finally, his facility to challenge the surgeon saved his right testicle.

8. Snippy, snippy; “I have seen some strange medical managements in my time but this one was a real doozy”.

Addendum: Over the past 6 years, as a retired medic living in Buriram I offered second opinions on any medical issue. I recently moved to Pattaya. As in this case, if you reside outside of Pattaya, telephone consultations are provided. For assistance; please contact me, Doc Martyn, on Facebook or call Dao on 095 414 8145.