Fournier’s gangrene was described by Jean Alfred Fournier in 1883. Alfred, a French dermatologist and venereologist, described this acute-onset as a rapidly progressing perineal disease in previously healthy young men [1]. This condition is a rare, life-threatening bacterial necrotizing infection of the perineum. The main risk factors for Fournier’s gangrene are diabetes, obesity, immunosuppression (such as HIV), alcoholism, smoking, male sex, and the use of cytotoxic drugs [2]. Although many of the associated comorbid risk factors are common diseases, FG is rare. The published literature on its incidence in men and women is quite limited. Therefore, analysis from the US Inpatient Database of 593 civilian hospitals in 13 states in 2001 and 21 states in 2004 report that Fournier’s gangrene occurs in 1.6 of every 100,000 males per year, primarily between 50 and 79 years (3.3 of every 100,000). Nevertheless, the small number of Fournier’s gangrene cases in women precludes any meaningful incidence analysis [3,4]. The infection is usually polymicrobial due to an aerobic and an anaerobic bacteria. Traditionally, the diagnosis of this entity was made by clinical examination. Thus, the most common symptoms are scrotal edema, local pain, hyperemia, pruritus, crepitus (between 19% and 64% of cases), fever, and the presence of foul-smelling secretions. Due to a progressive increase in imaging studies, the diagnosis of this entity has become more common, computed tomography (CT) of the abdomen and pelvis being the most appropriate scan. It accurately evaluates the extent of the necrosis, including the possible dissemination to the retroperitoneum [5]. The treatment is aggressive combining surgical debridement and broad-spectrum antibiotics. Reported mortality rates range from 3% to 45%, especially associated with comorbidities such as those previously mentioned [6].

In August 2018, the US Food and Drug Administration (FDA) issued a warning that Sodium glucose co-transporter 2 inhibitors (SGLT2i) may cause FG [7]. The underlying physiopathological mechanisms are not fully clear, but there appears to be greater endothelial damage at the microvascular level. Later, in January 2019, the Spanish Society of Gynecology & Obstetrics (SEGO), the European Medicines Agency (EMA) and the Spanish Agency for Medicines and Health Products (AEMPS) published a statement mentioning the risk of FG in women treated with SGLT 2 inhibitors [8]. SGLT2i are relatively new antihyperglycemic agents that have become popular in the treatment of diabetes due to their favorable cardiac and renal outcomes. The EMA in 2012 and the FDA in 2013 approved these drugs for patients with type 2 diabetes (T2DM) as an adjunct to diet and exercise to improve glycemic control; including canagliflozin, dapagliflozin, empagliflozin, and ertugliflozin [7,9]. The SGLT2 cotransporter is located almost exclusively in the kidney and it is responsible for the reabsorption of 90% filtered glucose by the glomerulus. Thus, its inhibition improves insulin resistance and decreases glycosylated hemoglobin (HbA1c) values. By inhibiting the reabsorption of glucose and sodium from the renal tubule, SGLT2i stimulates glycosuria and natriuresis, reducing blood glucose, body weight and blood pressure [9]. Nevertheless, this mechanism is independent of insulin, and therefore it makes an interesting drug in combined therapies [10]. The most common adverse reactions are mild genital and urinary tract infections [1]. In contrast, there are studies where the risk of serious and non-serious UTI events among patients treated with SGLT-2 inhibitors was similar to that of those treated with other antidiabetics [11]. Additionally, more serious and life-threatening side effects have been found including ketoacidosis, acute kidney injury, increased amputation rates, and Fournier’s gangrene [8,9,10].

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