para>Fournier gangrene is a urologic emergency with a high rate of morbidity and mortality if not diagnosed and managed promptly.
Epidemiology
Incidence
- Most common in the 5th and 6th decades of life but can occur in all age groups.
- Male > female 10:1 (1)
- Estimated of incidence of 1 in 7,500 (2)
Etiology and Pathophysiology
- Etiology
- Often polymicrobial (83%) (3)
- Common organisms include
- Bacteroides (43.9%)
- Escherichia coli (36.6%)
- Prevotella (34.1%)
- Other organisms isolated include Staphylococcus, Streptococcus, Candida
- Pathophysiology
- Infection, typically polymicrobial, occurs in the genitals or perineum.
- Develops into a synergistic necrotizing fasciitis
- Leads to thrombosis of adjacent subcutaneous vessels resulting in gangrene
- Left untreated, it progresses to sepsis and death.
Risk Factors
- Alcohol abuse
- Diabetes
- Extremes of age <10 years old or >50 years old
- Intravenous (IV) drug abuse
- Recent genital or perineal trauma or infection
- Recent penile, perineal, or perirectal surgery
- Immunocompromised state
- Chronic renal failure
- Chronic liver disease
- Peripheral vascular disease
General Prevention
- Routine hygiene
- Modification of risk factors
Commonly Associated Conditions
- Perirectal abscess
- Urethral strictures
- Testicular Infections (epididymitis, orchitis)
- Skin infections (hidradenitis, folliculitis, cellulitis)
- Sepsis
Diagnosis
History
- History of mild trauma or localized infection in perineum, genitals, rectum
- Progressive fullness, discomfort, and/or pain
- May report rapidly progressing skin necrosis
- Development of systemic symptoms: fever, chills, nausea, vomiting
Physical Exam
- Crepitus (64%) (4)[B]
- Cellulitis
- Edema
- Induration
- Erythema
- Ecchymosis
- Purulent drainage
- Fever
- Tachycardia and hypotension
- Necrosis
Differential Diagnosis
- Cellulitis or other soft tissue infection
- Soft tissue edema
- Testicular torsion
- Epididymitis
- Orchitis
- Incarcerated or strangulated hernia
Diagnostic Tests & Interpretation
Initial Tests (lab, imaging)
- Labs
- CBC: leukocytosis, anemia
- Serum chemistry: electrolyte abnormality, renal impairment, hyperglycemia
- Acute phase reactants: elevated ESR, C-reactive protein (CRP)
- Coagulation profile: coagulopathy
- Urinalysis: concomitant infection, glucosuria
- Wound cultures: gram stain, anaerobic and aerobic cultures
- Blood and urine cultures
- Imaging
- Radiograph of pelvis
- Ultrasound soft tissue of perineum
- CT scan of pelvis
- MRI of pelvis
Follow-up tests & special considerations
- Acute phase reactants can be helpful as a way to measure response to treatment.
- Cultures should be followed up to guide antibiotic treatment.
Diagnostic Procedures/Other
Frozen section biopsy specimens (1)
Test Interpretation
- Radiograph-subcutaneous gas is identified in up to 89% of patients, limited ability to identify deep fascial gas (1,4)[B].
- Ultrasound-Marked thickening of scrotal skin with discrete focal regions of high-amplitude echoes, with posterior acoustic shadowing indicative of subcutaneous gas is pathognomic of Fournier gangrene (4)[B].
- CT scan of pelvis-may demonstrate asymmetric fascial thickening, fluid collections, subcutaneous emphysema, and the primary source of infection (1)[B]
- MRI of pelvis-can accurately detect the extent of fascial involvement and inflammation associated with Fournier gangrene. Can be used as an early diagnostic tool and for operative planning (1)[B].
Treatment
General Measures
- Patients should be placed on cardiac monitoring and observed for any clinical worsening.
- Aggressive fluid resuscitation with isotonic solutions should be performed as needed to treat fluid loss and potentially sepsis.
- Vasopressors should be used as needed.
- Correction of electrolyte abnormalities
Medication
First Line
Broad-spectrum antibiotics covering aerobic and anaerobic organisms, adequate MRSA coverage (3)[B]
- Piperacillin-tazobactam, clindamycin, and vancomycin
- Meropenem, clindamycin, and vancomycin
Second Line
- Consider treatment for fungal infection in immunocompromised or diabetic patients (3)[B].
- Amphotericin B
- Change antibiotics once cultures and sensitivities available.
Issues for Referral
Patients with suspected Fournier gangrene should be referred emergently to urology.
Alert
Initiate emergent urology referral once you clinically suspect Fournier gangrene; do not wait until after diagnostic results return.
Additional Therapies
Treatment of underlying conditions
Surgery/Other Procedures
The mainstay of treatment is extensive surgical debridement of devitalized tissue and questionably affected tissue.
Complementary & Alternative Therapies
- Hyperbaric oxygen therapy-combined with wound care, it enhances tissue growth and viability (1)[B].
- Wound vacuum assisted closure-improved patient comfort and mobility (5)[B]
- Lyophilized collagenase-enzymatic debridement (1)[B]
- Honey-local application may accelerate wound healing (6)[B].
Inpatient Considerations
Admission Criteria/Initial Stabilization
Hemodynamically stable patients should be taken to the operating room emergently. Resuscitate all unstable patients in a critical care setting (emergency department and/or intensive care unit) prior to surgery.
IV Fluids
Administer IV fluids to maintain adequate urine output.
Nursing
- Patients will need localized wound care following surgical debridement.
- Monitor the area surrounding the surgical site for signs of infection.
- Monitor patient for hemodynamic changes suggestive of sepsis.
Discharge Criteria
- With the approval of urology, the patient can be discharged once medically stable.
- Patients will likely require assistance with local wound care.
- Given the severity of illness, patients may require placement in a skilled nursing facility or nursing home.
Ongoing Care
Follow-up Recommendations
- Urology follow-up for postoperative care
- Wound care follow-up for wound care
- Primary care follow-up for medical conditions
- Depending on comorbidities, may need further specialist follow-up.
Patient Monitoring
- Monitored for signs of infection
- Monitor blood glucose of diabetics.
Diet
General diet unless patient has other comorbidities such as diabetes or renal dysfunction.
Patient Education
- Wound care education
- Patient education regarding comorbid diagnoses
Prognosis
- Overall poor prognosis 15-45% reported mortality (2).
- Chronic renal failure (up to 50% mortality)
- Anorectal source of infection (up to 75% mortality)
- Several prognostic indices available: Fournier's Gangrene Severity Index, Laboratory Risk Indicator for Necrotizing Fasciitis, affected area calculation/extension of necrosis (1)
Complications
- Loss of testes
- Colostomy
- Cystostomy
- Sexual impairment
- Deconditioning from prolonged hospitalization
- Sequelae from sepsis: renal failure, acute respiratory distress syndrome (ARDS)
References
1.Shyam DC, Rapsang AG. Fournier's gangrene. Surgeon. 2013; 11(4): 222-232.
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2.Jeong HJ, Park SC, Seo IY, et al. Prognostic factors in Fournier gangrene. Int J Urol. 2005;12(12):1041-1044.
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3.Bjurlin MA, O'Grady T, Kim DY, et al. Causative pathogens, antibiotic sensitivity, resistance patterns, and severity in a contemporary series of Fournier's gangrene. Urology. 2013;81(4):752-758.
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4.Morrison D, Blaivas M, Lyon M. Emergency diagnosis of Fournier's gangrene with bedside ultrasound. Am J Emerg Med. 2005;23(4):544-547.
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5.Ozturk E, Ozguc H, Yilmazlar T. The use of vacuum assisted closure therapy in the management of Fournier's gangrene. Am J Surg. 2009;197(5):660-665.
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6.Subrahmanyam M, Ugane SP. Honey dressing beneficial in treatment of Fournier's gangrene. Indian J Surg. 2004;66(2):75-77.
See Also
- Necrotizing Fasciitis
- Sepsis
Codes
ICD09
- 608.83 Vascular disorders of male genital organs
- 728.86 Necrotizing fasciitis
ICD10
- N49.3 Fournier gangrene
- M72.6 Necrotizing fasciitis
SNOMED
- 398318005 Fournier's gangrene
- 397900003 Fournier's gangrene of penis
- 236782005 Fournier's gangrene of scrotum
- 52486002 Necrotizing fasciitis (disorder)
Clinical Pearls
- Rapid diagnosis and surgical intervention is imperative; if the diagnosis is unclear, diagnostic testing and observation may be helpful.
- Emergent urologic consultation should occur as soon as the diagnosis is clinically suspected; do not wait for confirmatory tests.
- Treatment consists of surgical debridement, broad-spectrum antibiotics, and resuscitation.