what do you know about: Fournier’s gangrene

Fournier’s gangrene is an aggressive and rapidly spreading infection of soft tissue, or necrotizing fasciitis, that involves the deep and superficial fascia of the perineum.1 The rate of fascial necrosis in Fournier’s gangrene is reported to be 2 to 3 cm/h.1 Thrombosis of subcutaneous and cutaneous blood vessels produces gangrene, but the fascial necrosis is usually more extensive than the visible gangrene suggests.2 Classic findings are necrosis of the superficial and deep fascial planes, fibrinoid coagulation of the nutrient arterioles, polymorphonuclear cell infiltration, and positive microorganism culture of involved tissues.KEY POINTS
■ Fournier’s gangrene was originally thought to be an idiopathic gangrene of the genitalia;
however, a specific etiology is found in approximately 95% of cases. Anorectal abscesses,
genitourinary infections, and traumatic injuries are the most common causes.

■ Typically, fluctuance, soft-tissue crepitance, localized tenderness, or occult wounds in the
genitalia, perineum, and anorectal area should alert the examiner to the possibility of
Fournier’s gangrene. A CBC, comprehensive metabolic panel, coagulation profile, and blood
cultures should be obtained.

■ Once the diagnosis is established, emergent surgical excision of all necrotic tissue must be
performed. Given the potential fulminant nature of this necrotizing process, repeat debridement
procedures are usually needed to completely eradicate the infection.

TABLE 1. Common predisposing comorbidities
  • Cirrhosis
  • Diabetes mellitus
  • High-risk behaviors (alcohol or IV drug abuse)
  • Immunosuppression
  • Malignancies
  • Malnutrition
  • Morbid obesity
  • Vascular disease of the pelvis


TABLE 2. Risk factors for Fournier’s gangrene
  • Circumcision
  • Episiotomy
  • Extravasations of urine (periurethrally or through cutaneous fistula)
  • Hernioplasty
  • Hysterectomy
  • Local trauma or instrumentation to the perineum
  • Paraphimosis
  • Septic abortion
  • Urethral stricture caused by sexually transmitted diseases


TABLE 3. Signs and symptoms of Fournier’s gangrene
  • Crepitant skin (“spongy” to the touch)
  • Dead and discolored (gray-black) tissue; pus weeping from injury
  • Fever and lethargy
  • Increasing genital pain and erythema or severe genital pain accompanied
  • by tenderness and swelling of the penis and scrotum

TREATMENT

In patients who present with systemic toxicity manifesting as
hypoperfusion and/or organ failure, aggressive resuscitation
to return normal organ perfusion and function must take
precedence.25 Antibiotics with broad-spectrum coverage
against staphylococci, streptococci, Enterobacteriaceae species,
and anaerobes should be administered. If initial tissue stains
show fungi, an antifungal should be included in the regimen.
Empiric antibiotic regimens should be adjusted when the
infective organisms are identified.

Once the diagnosis is established, emergent surgical excision
of all necrotic tissue is required. The skin should be
opened wide to expose the full extent of underlying fascial
and subcutaneous tissue necrosis. Given the potential fulminant
nature of this necrotizing process, repeat debridement
procedures are usually needed to eradicate the infection. If
perineal involvement is extensive, fecal diversion should be
performed to eliminate potential contamination of the
wounds; urinary diversion is accomplished via a urethral
catheter. Hyperbaric oxygen (HBO) therapy has a theoretical
role in treating Fournier’s gangrene, but results of this therapy
are mixed.26 HBO therapy increases tissue-oxygen tension,
leukocyte activation, oxygen free-radical production,
capillary angiogenesis, fibroblast proliferation, and vasoconstriction
and decreases anaerobe multiplication.27

Prompt antibiotic administration and surgical debridement (with or
without HBO) are the cornerstones of therapy.28

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