FOURNIERS GANGRENE
Category: Urology
Abstract : Fournier's gangrene A necrotizing fascitis of the genitalia and perineum primarily affecting males and causing necrosis and subsequent gangrene of infected tissues. Culture of infected tissue reveals a combination of aerobic (E. coli, enterococcus, Klebsiella) and anaerobic organisms (Bacteroides, Clostridium, microaerophilic streptococci), which are believed to grow in a synergistic fashion. C
Fournier's gangrene
A necrotizing fascitis of the genitalia and perineum primarily affecting males and causing necrosis and subsequent gangrene of infected tissues. Culture of infected tissue reveals a combination of aerobic (E. coli, enterococcus, Klebsiella) and anaerobic organisms (Bacteroides, Clostridium, microaerophilic streptococci), which are believed to grow in a synergistic fashion.
Conditions which predispose to the development of Fournier's gangrene include diabetes, local trauma to the genitalia and perineum (e.g. zipper injuries to the foreskin, periurethral extravasation of urine following traumatic catheterization or instrumentation of the urethra), and surgical procedures such as circumcision.
Presentation
This is often dramatic. A previously well patient may become systemically unwell over a very short time course (hours) following a seemingly trivial injury to the external genitalia. A fever is usually present, the patient looks very unwell, they may have marked pain in the affected tissues, and the developing sepsis may alter their mental state. The genitalia and perineum are oedematous and on palpation of the affected area, tenderness and crepitus may be present indicating the presence of subcutaneous gas produced by gas-forming organisms. As the infection advances, blisters (bullae) appear in the skin and, within a matter of hours, areas of necrosis may develop which spread to involve adjacent tissues (e.g. the lower abdominal wall). The condition advances rapidly†hence its alternative name of spontaneous fulminant gangrene of the genitalia.
Diagnosis
The diagnosis is a clinical one, and is based on awareness of the condition and a low index of suspicion.
Treatment
Do not delay. While intravenous access is obtained, blood taken for culture, intravenous fluids started, and oxygen administered, broad spectrum antibiotics are given to cover both gram-positive and negative aerobes and anaerobes (e.g. ampicillin, gentamicin, and metronidazole or clindamycin). Make arrangements to transfer the patient to the operating room as quickly as possible so that debridement of necrotic tissue (skin, subcutaneous fat) can be carried out. Extensive areas of tissue may have to be removed, but it is unusual for the testes or deeper penile tissues to be involved, and these can usually be spared. A suprapubic catheter is inserted to divert urine and allow monitoring of urine output.
Where facilities allow, consider treatment with hyperbaric oxygen therapy. There is some evidence that this may be beneficial. Repeated debridements to remove residual necrotic tissue are not infrequently required.
Mortality is in the order of 20 - 30%. There is debate about whether diabetes increases the mortality rate.
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