A rare infection that rots the penis and scrotum brings nine patients a year to just one of South Africa’s tertiary hospitals.

In the US‚ only one hospital in 100 treats more than five cases a year of Fournier’s gangrene‚ and urologists say the number at Grey’s Hospital in Pietermaritzburg is linked to the high rate of HIV and diabetes.

The infection leads to gangrene in the penis‚ scrotum and perineum‚ and five of the 44 Grey’s patients over five years died.

Even for those who survived‚ the experience was agonising. On average‚ they each needed 1.3 operations to remove dead tissue and 26 days in hospital‚ and 45% needed blood transfusions. Most then required outpatient wound care followed by skin grafts.

The cases are described in the August issue of the South African Medical Journal‚ where the authors say almost half of the patients were HIV-positive and 41% were diabetics.

Urologists Ali Elsaket‚ Suhani Maharajh and James Urry analysed all Grey’s cases of Fournier’s gangrene from 2010 to 2014 and found that most of them began with abscesses in the genital area.

All but one of the men had dead tissue removed from their penis and scrotum‚ and in a third of patients the gangrene had spread to the abdomen.

“Fasciitis extended to the chest wall in one patient and down the thighs in another‚” the doctors said. Both these patients died.

Six of the patients should have been admitted to the intensive care unit for organ support‚ but “owing to severe constraints on ICU bed availability and according to local protocols‚ four patients were refused ICU admission on the basis of being too ill and ultimately died”.

Of the two who were admitted to intensive care‚ one survived. The mean age of all the patients was 51‚ although the HIV-positive patients were 10 years younger.

The urologists said in developing countries such as SA‚ poor socioeconomic conditions‚ limited access to healthcare‚ high HIV rates and a growing number of lifestyle diseases such as diabetes made Fournier’s gangrene “an important clinical condition”.