Lisa Mathis FNP-BC
Something no one wants to think about during the holiday season is a wound in the perineal area—more painful than the ugly sweater your aunt gives you that you’ll never wear. This is not a common diagnosis, and years ago it was a fairly rare occurrence. However, it has been appearing more and more frequently.
Fournier’s gangrene is a severe, rapidly progressing bacterial infection that causes tissue death (gangrene) in the genital, perianal, or perineal region. It is a true medical emergency that requires immediate treatment, including aggressive surgical debridement of necrotic tissue, broad-spectrum antibiotics, and hemodynamic support. Classic risk factors include diabetes, immunodeficiency, and substance abuse.¹
But now, another risk factor has reared its ugly head—much like the Grinch—and its incidence is rising. With the latest “Four Pillars of Heart Failure” guidelines and the widespread adoption of SGLT2 inhibitors, cases have increased.
SGLT2 inhibitors can contribute to the development of Fournier's gangrene because they increase the amount of glucose excreted in the urine. This creates a warm, moist, sugar-rich environment in the genital and perineal areas—ideal conditions for bacteria to grow. When combined with other risk factors such as diabetes, obesity, immunosuppression, or poor hygiene, this can set the stage for a serious infection. Although the exact mechanism is not fully understood, the rise in urinary glucose is believed to play a major role in fostering these infections.
Because this diagnosis has historically been rare, many healthcare providers may not immediately recognize its early signs or appreciate how rapidly the condition can progress. In addition, patients started on SGLT2 inhibitors are often not counseled on what symptoms to watch for.
Early symptoms can be vague, including malaise, fever, and pain or discomfort in the genital or perineal area. The infection can escalate quickly, leading to swelling, redness, warmth, and increasing tenderness. Classic findings include a “cobblestone” appearance of the skin, subcutaneous gas (crepitus), and dusky or purplish discoloration. As the disease advances, the skin may begin to necrose and slough off.
The FDA and the European Medicines Agency have approved several SGLT-2 inhibitors, including canagliflozin, dapagliflozin, ertugliflozin, and empagliflozin. Because these medications increase urinary glucose excretion, common side effects include glycosuria and polyuria. More recently, the FDA issued warnings regarding rare but serious genital infections associated with the initiation of SGLT-2 inhibitors.²
In this new era of awareness, advanced practice providers must be especially diligent in educating patients when these medications are prescribed. Patients should be advised to call or seek medical attention immediately if they develop any concerning symptoms in the perineal or genital area—and to never ignore new pain, swelling, redness, or discharge. This is a particularly sensitive part of the body, and many individuals may feel embarrassed to report symptoms or undergo an exam. As a result, these infections are often not evaluated until they have become severe, which can be devastating.
Providers should explain the risks in clear, patient-friendly language and emphasize the seriousness of this potential complication, ensuring that patients understand both what to watch for and why prompt evaluation is critical.
When a patient calls reporting a “sore area down there,” do not simply call in an antibiotic. They should be evaluated in person. If you are unable to see them promptly, encourage them to visit urgent care or the emergency department—especially if they have any of the previously mentioned risk factors. Early recognition is essential.
Education remains the most effective tool for both patients and providers. With proper counseling and rapid evaluation, the prognosis can be significantly improved and long-term complications minimized. These medications offer substantial benefits, so patients should not be afraid to take them; they simply need to understand when to seek help.
GLP-1 receptor agonists (GLP-1 RAs) provide additional benefits for patients with heart failure (HF). They can improve symptoms, enhance exercise tolerance, and support weight loss—particularly in individuals with obesity and heart failure with preserved ejection fraction (HFpEF). GLP-1 RAs also improve endothelial function by increasing nitric oxide availability, which promotes vasodilation and reduces cardiac workload.³
Therefore, patient education should strike a balance: clearly explain the potential risks while emphasizing the significant benefits of medication adherence. Simple measures—such as not ignoring new soreness, maintaining good hygiene, keeping the area clean and dry, and working toward gradual weight loss—can help lower the risk of infection.
So let your gift this holiday season be honest, proactive—and sometimes difficult—conversations with your patients. No one wants to see a person facing major surgery, skin grafts, or even loss of life at a time when they should be sipping eggnog and opening presents. A few minutes of education today can prevent a devastating outcome tomorrow.
Wishing you a safe and healthy Holiday Season!
“This holiday season, may we find gratitude in our work, compassion in our service, and hope in the year ahead.”
1-FourniersGangrene:https://www.visualdx.com/visualdx/diagnosis/fournier+gangrene?diagnosisId=51600&moduleId=101
2-Fournier’s Gangrene: A Coexistence or Consanguinity of SGLT-2 Inhibitor Therapy https://pmc.ncbi.nlm.nih.gov/articles/PMC9450557/
3- Use of Semaglutide nijm.org/doi/full/10.1056/NEJMoa2306963#:~:text=Fraction%20and%20Obesity-,Results,greater%20weight%20loss%20than%20placebo