April 23, 2020
Years published: 2004, 2011, 2014, 2017, 2020
NORD gratefully acknowledges Rodolfo L. Bracho-Riquelme, MD, General and Colorectal Surgeon, 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 English language medical literature. This disease occurs worldwide and, although it is recognized more frequently among male adults, has been identified also among women 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 where 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 instrumentation and other contributing 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.
There are many ways for the virulent microorganism to gain access to the host, where the compromised immunological system is unable to prevent the infection from taking hold. The virulence of the resulting disorder is thought to be enhanced by the toxins and enzymes produced by the combination of microorganisms (synergy).
The mean age of presentation 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 among males. It may be that the high male to female ratio in the diagnosis is the result of the lack of recognition of this entity among women by physicians. 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 achieve early differentiation between Fournier gangrene and an acute inflammatory process, such as epididymitis or orchitis. Computed tomography 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. Computerized tomographic (CT) images are preferred because they resolve smaller amounts of soft tissue gases and fluids.
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 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 (thrombembolic phenomena) and may require medication to reduce the risk for thrombosis 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.
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