OBJECTIVES To evaluate, in a population of patients with very high risk of diabetes, the natural history of Fournier's gangrene (FG) and to characterize the differences in presentation and outcome. METHODS Patients with FG were identified during a 6-year period at two tertiary care institutions in San Antonio, Texas. The impact of diabetes on presentation and outcome were evaluated and compared with previous series. RESULTS We identified 26 patients with FG, of whom 20 (76.9%) had diabetes. Diabetes was the most common risk factor identified and was associated with a younger age. The average hospital stay was not affected by the diagnosis of diabetes. Of 26 patients treated for FG, 3 (11%) died, 1 of whom had diabetes. Although the extent of debridement required was greater among diabetics, the average number of debridements required was not increased (2.55 in diabetic and 2.4 in nondiabetic patients). CONCLUSIONS Although diabetes is a risk factor for FG, the outcome is not affected by this diagnosis.