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

Pathogen Origin:

The origin of the mixed infection with aerobe and anaerobe bacteria is the skin, the urinary tract or the rectum.

Risk factors:

Diabetes mellitus
Trauma or surgery of the perigenital region
Urethral extravasation of urine
Urethral injury
Paraphimosis
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

Blood tests:

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 Abdomen/Pelvis

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.

Surgical Debridement:

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.

Fournier's gangrene: necrotic infection of the scrotal skin with dark hemorrhagic areas (upper left). Despite complete excision of the necrotic tissue, the testicles could be preserved. (upper right). Antiseptic dressing of the wound (lower left and right).

Suprapubic catheter:

If catheter drainage is necessary, a suprapubic catheter should be preferred.

Colostomy:

If the origin of Fournier's gangrene is the rectum, a colostomy is necessary.

Surgical Reconstruction:

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).

Mumps orchitis

Index

Testicular torsion

Index: 1–9 A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

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References

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

Last update

Dr. med. Dirk Manski
man...@urologielehrbuch.de