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Fournier Gangrene – Perigenital Necrotizing Fasciitis
Review literature: (Nomikos, 1998) (Papachristodoulou et al., 1997).
Definition of Fournier Gangrene
Fournier gangrene is a form of necrotizing fasciitis of the genital and perineal region.
Etiology (Causes) of Fournier Gangrene
The origin of the mixed infection with aerobe and anaerobe bacteria is the skin, the urinary tract or the rectum. There is probably a synergy between anaerobic (Bacteroides, Fusobacterium, Clostridium ...) and aerobic bacteria (E. coli, Enterococci, Klebsiella ...).
- Diabetes mellitus
- Trauma or surgery of the perigenital region
- Urethral extravasation of urine
- Urethral injury
- Rectal injury
Signs and Symptoms of Fournier Gangrene
- Local swelling, redness, tumor, crepitus (gas formation).
- In progredient disease, dark hemorrhagic necrotic areas develop [fig. Fournier gangrene of the scrotum].
- Fever, signs of sepsis
Diagnostic Workup in Fournier 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 gangrene is suspected. Trapped air is a sign or marker for the extend of the Fournier gangrene.
Treatment of Fournier Gangrene
Fournier gangrene is a urologic emergency. Timely diagnosis with immediate initiation of antibiotics, early management of sepsis, and prompt radical excision of the necrosis can significantly improve the prognosis.
Antibiosis must cover a broad spectrum of gram-negative, gram-positive, aerobic and anaerobic bacteria. Due to the severe infection, antibiotics must be prescribed in the highest possible dosage. The calculated initial therapy must be adjusted after receiving the antibiogram and resistance testing. The following options are useful:
- Carbapenems (imipenem, meropenem or ertapenem).
- Piperacillin/tazobactam and vancomycin
- Cephalosporin (third generation) and metronidazole
- Aminopenicillin, gentamicin and metronidazole
Wound swab culture and radical resection of gangrenous tissue until healthy tissue is reached [fig. Surgical treatment of Fournier gangrene]. 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 gangrene is the rectum, a colostomy is mandatory. Colostomy is also sometimes necessary in cases of extensive gangrene for wound care reasons.
Surgical reconstruction of large defects with skin grafts or flaps.
Prognosis of Fournier Gangrene
Mortality of Fournier gangrene is around 20%. Risk factors of increased mortality are diabetes mellitus, alcoholism and colorectal origin of Fournier gangrene (often delayed diagnosis and extensive infection).
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ReferencesNomikos 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,
Fournier’s gangrene: still highly lethal.
In: Langenbecks Arch Chir
382 (1997), Nr. 1, S. 15–8
Deutsche Version: Fournier-Gangrän