Fourniers Gangrene

Epidemiology

• First described in 1764 by Jean-Alfred Fournier as a gangrene of the penis and scrotum, necrotizing fasciitis of the perineum, genital or perianal area affects both sexes and is a true emergency.
• Failure to recognize the entity, delay in treatment and lack of aggressive medical and surgical therapy are all contributors to the high morbidity and mortality seen with this disease.
• The mortality rate varies by report from 3-45%, and causes of death have included sepsis, coagulopathy, renal failure, diabetic ketoacidosis and multiple organ failure.
• Older age, renal abscesses or hepatic dysfunction, and anorectal infectious source, are associated with higher mortality.
• Although glycosuria is present in over two-thirds of these patients, the presence of diabetes mellitus appears to have no affect on the outcome of the disease and is only associated with approximately 20% of the cases.
• In addition, the chronic use of alcohol has been associated with 25-50% of the cases.

• Although seen in children and women, Fournier’s gangrene is more common in males (10:1) and was originally described as a severe gangrenous infection of the scrotum.
• The most common sources of infectious agents are the local skin (24%), anorectal (21%), and urologic (19%).
• The disease appears to affect the affluent as well as the socioeconomically depressed individuals, and the average age of presentation is older than originally described, in one recent series the mean age of patients was 50 yr.
• The bacteriology of confirmed cases reveals as a rule mixed aerobic and anaerobic organisms including Clostridia, Klebsiella, Staphylococci, coliforms and Staphylcocci species. These organisms work synergistically, with the aerobic bacteria keeping the oxygen tension low enough to allow anaerobic growth.
• Initially a cellulites develops, superficial vessels are thrombosed and gangrene of the superficial skin and subcutaneous fat results.
• While extension of the infection into the muscle layers may lead to myonecrosis, this is not a characteristic of classic Fournier’s gangrene.
• In addition, while the scrotum may often be affected, the underlying testicles, which receive blood from an independent source, are usually not affected.
• If such involvement does occur, it should prompt a search for a retroperitoneal or intra-abdominal source.

Diagnosis

• Clinical presentation of perineal necrotizing fasciitis, while often described as sudden, is more likely insidious over the span of several days.
• Given its location, some patients may present later than usual due to embarrassment.
• In its early stages, the disease presents with pain, erythematic, and scrotal swelling.
• Advanced cases are described as rapidly advancing (up to 1 in/h) woody indurations extending up the anterior abdominal wall, associated with crepitus and purulent, malodorous discharge.
• Diabetes mellitus is a comorbidity in more than two-thirds of these patients.
• Laboratory findings include leukocytosis, anemia, thrombocytopenia and hyperglycemia as mentioned above. Hypocalcemia, caused by chelation of calcium by the bacterial lipases, penile emergencies has been reported as an important diagnostic clue, and hyponatremia may also be present.
• Imaging may reveal free air in the scrotum or dissecting upward through the fascial planes.
• Ultrasound may demonstrate gas in the scrotum, and CT scan may allow definition of the spread of the disease.
• In reality however, none of these imaging studies should delay the institution of therapy once there is suspicion of disease.

Treatment

• Treatment of Fournier’s gangrene is aimed at stabilizing the thermodynamics of the patients and beginning antimicrobial infection as rapidly as possible.
• Appropriate antibiotics include any broad-based regimen.
• Classically, penicillins were given to combat the streptococcal sp., metronidazole for anaerobic organisms and gentamicin or a third generation cephalosporin for coliforms.
• Current recommendations replace this cocktail with medications such as imipenem or meropenem as single agents in the patient with confirmed polymicrobial infection.
• Urologic or surgical consultation is mandatory and should precede any laboratory or imaging results.
• Replacement of fluids, blood transfusion and antibiotics in isolation cannot replace surgical debridment of the infectious nidus.
• Hyperbaric oxygen, recommended by some as an adjunct after the initial debridement, has not been shown to improve outcomes when used in this setting.