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Fournier's Gangrene – Perigenital Necrotizing Fasciitis
Review literature: (Nomikos, 1998) (Papachristodoulou et al, 1997).
Definition of Fournier's Gangrene
Fournier's gangrene is a form of necrotizing fasciitis of the genital and perineal region.
Etiology (Causes) of Fournier's Gangrene
The origin of the mixed infection with aerobe and anaerobe bacteria is the skin, the urinary tract or the rectum.
- Diabetes mellitus
- Trauma or surgery of the perigenital region
- Urethral extravasation of urine
- Urethral injury
- Rectal injury
Bacteriology:Fournier's gangrene is caused by a mixed infection. There is probably a synergy between anaerobic (Bacteroides, Fusobacterium, Clostridium ...) and aerobic bacteria (E. coli, Enterococci, Klebsiella ...).
Signs and Symptoms of Fournier's Gangrene
- Local swelling, redness, tumor, crepitus (gas formation).
- In progredient disease, dark hemorrhagic necrotic areas develop [fig. Fournier's gangrene of the scrotum].
- Fever, signs of sepsis
Diagnostic Work-Up in Fournier's Gangrene
- Routine laboratory tests including markers of sepsis
- Blood culture
- Swab of the wound
Ultrasound Imaging of the Scrotum:
Signs of testicular infection? Epididymitis? Trapped air in scrotal tissue?
CT is indicated if a colorectal origin of the fournier's gangrene is suspected. Trapped air is a sign or marker for the extend of the fournier's gangrene.
Treatment of Fournier's Gangrene
Treatment of Fournier's gangrene consists of antibiotic therapy together with surgical debridement.
Antibiotic Therapy for Fournier's Gangrene:
A combination with cephalosporin (third generation), gentamicin and metronidazole i.v. is necessary to treat the mixed infection with aerobe and anaerobe bacteria.
Deep incisions and excisions of gangrenous tissue until healthy tissue is reached [fig. Surgical treatment of Fournier's gangrene]. Necrotic areas should be completely removed (radical surgery). Orchiectomy is rarely necessary. For the period of open wound healing, the testicles can be secured in subcutaneous thigh pockets. After 24–48 h, a second look operation with surgical debridement is necessary to ensure complete removal of necrotic tissue. To speed up wound healing, secondary wound closure is sometimes possible.
If catheter drainage is necessary, a suprapubic catheter should be preferred.
If the origin of Fournier's gangrene is the rectum, a colostomy is necessary.
Surgical reconstruction of removed tissue can be done, if vital wound edges without systemic signs of infection are achieved.
Prognosis of Fournier's Gangrene
Mortality of Fournier's gangrene is around 20%. Risk factors of increased mortality are diabetes mellitus, alcoholism and colorectal origin of Fournier's gangrene (often delayed diagnosis and extensive infection).
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- Nomikos 1998 NOMIKOS, I. N.:
- Necrotizing perineal infections (Fournier’s disease): old remedies
for an old disease.
In: Int J Colorectal Dis
13 (1998), Nr. 1, S. 48–51
- Papachristodoulou u.a. 1997 PAPACHRISTODOULOU, A. J. ; ZOGRAFOS, G. N. ; PAPASTRATIS, G. ; PAPAVASSILIOU, V. ; MARKOPOULOS, C. J. ; MANDREKAS, D. ; GOGAS, J. G.:
- Fournier’s gangrene: still highly lethal.
In: Langenbecks Arch Chir
382 (1997), Nr. 1, S. 15–8
Deutsche Version: Fournier'sche Gangrän