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Last updated: 1/25/2024
Years published: 2004, 2011, 2014, 2017, 2020, 2024
NORD gratefully acknowledges Rodolfo L. Bracho-Riquelme, MD, General and Colorectal Surgeon, formerly affiliated with Hospital General de Durango, Mexico, for assistance in the preparation of this report.
Fournier gangrene is an acute necrotic infection of the scrotum, penis or perineum. It is characterized by scrotum pain and redness with rapid progression to gangrene and sloughing of tissue. Fournier gangrene is usually secondary to perirectal or periurethral infections associated with local trauma, operative procedures or urinary tract disease.
Since 1950, more than 1,800 cases for study have been reported in the English language medical literature. This disease occurs worldwide and although it is recognized more frequently among male adults, has also been identified in females and children. Treatment usually consists of the surgical removal (debridement) of extensive areas of dead tissue (necrosis, necrotic) and the administration of broad-spectrum intravenous antibiotics. Surgical reconstruction may follow when necessary.
Symptoms include fever, general discomfort (malaise), moderate to severe pain and swelling in the genital and anal areas (perineal) followed by rankness and smell of the affected tissues (fetid suppuration) leading to full blown (fulminating) gangrene. Rubbing the affected area yields the distinct sounds (crepitus) of gas in the wound and of tissues moving against one another (palpable crepitus). In severe cases, the death of tissue can extend to parts of the thighs, through the abdominal wall and up to the chest wall.
This disease is commonly found in conjunction with other disorders (comorbidity), especially those that weaken the immune system. Some disorders that increase the predisposition to Fournier gangrene are diabetes mellitus, profound obesity, cirrhosis, interference with the blood supply to the pelvis and various malignancies.
Portals of entry for the bacteria, fungi, and/or viruses responsible for a particular case of Fournier gangrene are generally colorectal, urogenital or cutaneous in origin. Anorectal abscesses, urinary tract infections, surgical instruments and other factors have all been implicated. Some cases continue to be of unknown cause (idiopathic). Why this process occasionally develops in individuals with common ailments is still not understood.
Debilitating illnesses, such as diabetes, alcoholism, HIV infection and malnutrition seem to increase the susceptibility of a person to Fournier gangrene.
The mean age of diagnosis is about 50 years, but the range of patient ages in reported cases is from eight days to 90 years. Fournier gangrene is diagnosed more frequently in males. It may be that the high male to female ratio is the result of the lack of recognition of this condition in females. It is believed that the male to female proportion may be anywhere from 5:1 to 10:1.
The diagnosis is basically made on clinical findings. Ultrasound evaluation may help differentiate between Fournier gangrene and an acute inflammatory process such as epididymitis or orchitis. Computed tomography (CT) may help to determine the portal of entry and extension of the process but is not indispensable and should not delay surgical treatment.
X-ray studies are useful to confirm the location and extent of gas distribution in the wounds. Ultrasonography is useful to detect gases and/or fluids, but patients with severe pain may not be able to tolerate the pressures on the skin required to obtain an acceptable image. CT images are preferred because they resolve smaller amounts of soft tissue gases and fluids.
Treatment
It is critical to recognize the disorder and to initiate aggressive resuscitation and administration of broad-spectrum intravenous antibiotics as quickly as possible. Such antibiotics must be followed by urgent surgical removal (debridement) of all affected dead (necrotic) skin and subcutaneous tissue involved, with repeated removal of wound margins as necessary. If colorectal or urogenital origin is established, source control is imperative, in accordance with each case. Patients with severe blood infection (sepsis) are at increased risk for developing blood clots and may require medication to reduce the risk for clots. Reconstructive surgery is undertaken once infection is under control.
Colostomy remains controversial as a means of decreasing fecal contamination. Foley catheters generally get rid of urine adequately.
When available, a burn center may be a good location for the treatment of patients with necrotizing soft-tissue surgical infections, including Fournier gangrene.
Information on current clinical trials is posted on the Internet at www.clinicaltrials.gov. All studies receiving U.S. government funding, and some supported by private industry, are posted on this government web site.
For information about clinical trials being conducted at the NIH Clinical Center in Bethesda, MD, contact the NIH Patient Recruitment Office:
Tollfree: (800) 411-1222
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Email: [email protected]
Some current clinical trials also are posted on the following page on the NORD website: https://rarediseases.org/living-with-a-rare-disease/find-clinical-trials/
For information about clinical trials sponsored by private sources, contact: www.centerwatch.com
For information about clinical trials conducted in Europe, contact: https://www.clinicaltrialsregister.eu/
TEXTBOOKS
Corman ML [ed.]. Cormanโs colon and rectal surgery. 6th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2013.
REVIEW ARTICLES
Shyam DC(1), Rapsang AG. Fournierโs gangrene. Surgeon. 2013 Aug;11(4):222-32.
Park H(1), Copeland C, Henry S, Barbul A. Complex wounds and their management. Surg Clin North Am. 2010 Dec;90(6):1181-94.
Mopurgo E, Galandiuk S. Fournierโs gangrene. Surg Clin North Am. 2002;1213-24.
Korhonen K. Hyperbaric oxygen therapy in acute necrotizing infections with a special reference to the effects on tissue gas tensions. Ann Chir Gynaecol Suppl. 2000;214:7-36.
Yagham RJ, Al-Jaberi TM, Bani-Hani I. Fournierโs gangrene: changing face of the disease. Dis Colon Rectum. 2000;43:1300-08.
Eke N. Fournierโs gangrene: a review of 1726 cases. Br J Surg. 2000;87:718-28.
JOURNAL ARTICLES
Korkut M, Icoz G, Dayangac M, et al. Outcome analysis in patients with Fournierโs gangrene: report of 45 cases. Dis Colon Rectum. 2003;46:649-52.
Norton KS, Johnson LW, Perry T, et al. Management of Fournierโs gangrene: an eleven year retrospective analysis of early recognition, diagnosis, and treatment. Am Surg. 2002;68:709-13.
Xeropotamos NS, Nousias VE, Kappas AM. Fournierโs gangrene: diagnostic approach and therapeutic challenge. Eur J Surg. 2002;168:91-95.
Faucher LD, Morris SE, Edelman LS, Phil M, Saffle JR. Burn center management of necrotizing soft-tissue surgical infections in unburned patients. Am J Surg. 2001; 182:563-569.
Fillo J, Cervenakov I, Labas P, et al. Fournierโs gangrene: can aggressive treatment save life. Int Urol Nephrol. 2001;33:533-36.
Nisbet AA, Thompson IM. Impact of diabetes mellitus on the presentation and outcomes of Fournierโs gangrene. Urology. 2000; 60(5):775-779
Corman JM, Moody JA, Aronson WJ. Fournierโs gangrene in a modern surgical setting: improved survival with aggressive management. BJU Int. 1999;84:85-88.
Burciaga-Alvarado A, Bracho-Riquelme RL, Betancourt-Valdivia JC. La Gangrena de Fournier: Serie de casos del Hospital General โCโ de Durango, SSA. Cirugรญa (Durango, Mexico). 1995;4(1):11-17.
INTERNET
Pais VM, Santora T, Rukstalis DB. Fournier Grangrene. Medscape. Last Update May 30, 2023. Available at https://emedicine.medscape.com/article/2028899-overview Accessed Jan 25, 2024.
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