Basics
Description
- Inadequate hygiene leads to scrotal skin maceration and excoriation:
- Portal of entry for bacteria in tissue
- Once skin barrier is broken, polymicrobial flora spread along fascial planes of perineum.
- Colles fascia fuses with urogenital diaphragm, slowing propagation posteriorly and laterally.
- Anteriorly, Buck and Scarpa fascia are continuous, allowing rapid extension to anterior abdominal wall and laterally along fascia lata.
- Testes and urethra are usually spared.
- 3 anatomic origins account for most cases:
- Lower urinary tract (40%): Urethral strictures, indwelling catheters
- Penile or scrotal (30%): Condom catheters, hydradenitis, balanitis
- Anorectal (30%): Fistulas, perirectal infections, hemorrhoids
- Rarely, intra-abdominal sources such as perforating appendicitis, diverticulitis, or pancreatitis have produced Fournier gangrene by dependent contiguous spread.
Etiology
- Infection by polymicrobial flora (mixed aerobic and anaerobic organisms)
- Mixed bacteria exert synergistic tissue-destructive effect.
- End arterial thrombosis in subcutaneous tissues produces anaerobic environment.
- Bacterial toxins and tissue necrosis factors may contribute to clinical presentation.
- Risk factors:
- Trauma
- Diabetes
- Alcoholism
- Other immunocompromised states
- Morbid obesity
- Abdominal surgery
Diagnosis
Signs and Symptoms
- Rapidly progressive necrotizing infection of perineum involving subcutaneous and fascial tissues and often muscle layers:
- Usually seen in diabetics or immunocompromised patients
- Sources of infection may be flora from genitourinary, rectal, or penile/scrotal regions.
- Though unusual in children, >50 cases have been described.
- Most often are complications of burns, circumcision, balanitis, severe diaper rashes, or insect bites
- Organisms are more frequently Staphylococcus or Streptococcus.
- Pediatric patients have more local disease and are less toxic.
History
- Duration of symptoms:
- Fevers or chills
- Pain is out of proportion to exam in early phases, but eventually dead tissue becomes insensate.
- Nausea and vomiting
- Urinary infection symptoms
- Rapidity with which symptoms are progressing
- Identify if diabetic or immunocompromised
- Lethargy and inappropriate indifference to the illness are common.
Physical Exam
- Patients are often toxic in appearance with nausea, vomiting, fever, chills, and pain.
- Careful exam of the genitalia and perirectal region
- Assess for skin findings:
- Bronze or violaceous discoloration of skin
- Thin brown watery discharge
- Ulceration, bullous vesicles
- Crepitance, SC air
- Frank necrosis and eschar formation
Essential Workup
- Fournier gangrene is a clinical diagnosis.
- History and physical exam with special attention to perineum
- Evaluate for signs of sepsis.
- Early surgical consultation for emergent d ©bridement is essential.
- Other workup directed toward relevant comorbid factors such as diabetes or immunocompromised status
Diagnosis Tests & Interpretation
Lab
- Other than Gram stain of tissue and associated drainage, there are no specific lab tests that are diagnostic of Fournier gangrene.
- Urinalysis should be performed.
- Leukocytosis, anemia, electrolyte imbalances, acidosis, and renal failure are common.
- Disseminated intravascular coagulation (DIC) may be present; PT, PTT, fibrin-split products, and fibrinogen levels help identify.
- If patient is suspected of or known to have diabetes, glucose, electrolytes, and serum ketones to evaluate for diabetes and diabetic ketoacidosis (DKA)
- Culture of blood, urine, and tissue (when available)
Imaging
- Plain films of the pelvis may reveal subcutaneous emphysema and ileus.
- CT scanning helps if intra-abdominal or ischiorectal source is suspected.
- US may be useful in differentiating from other causes of acute scrotum.
Diagnostic Procedures/Surgery
Retrograde urethrography, anoscopy, proctosigmoidoscopy, and barium enemas may be helpful to localize anatomic sources of infection.
Differential Diagnosis
- Epididymitis/orchitis
- Insect and human bites
- Perirectal infections
- Scrotal abscess/inguinal abscess
- Scrotal cellulitis
- Testicular torsion
- Tinea cruris
Treatment
Pre-Hospital
Patients may be hypotensive from septic shock and require aggressive fluid resuscitation and vasopressor support.
Initial Stabilization/Therapy
- Manage airway and resuscitate as indicated.
- Central venous access, aggressive fluid resuscitation, and pressure support as indicated:
- Avoid femoral access, femoral venipuncture, and lower extremity venous access
- Early goal-directed therapy if septic
- Foley catheter placement or suprapubic access if indicated
Ed Treatment/Procedures
- Empiric broad-spectrum antibiotics
- Early emergent aggressive surgical d ©bridement
- Adjunctive hyperbaric oxygen therapy coordinated with surgical care
- Treat dehydration and correct electrolytes.
- Blood products as needed for DIC or anemia; oxygen debt can be minimized by keeping hematocrit >30%.
- Tetanus prophylaxis as indicated
- More conservative surgical approach
- Adequate staphylococcal coverage
Medication
- Antibiotic regimens:
- Multidrug regimen:
- Ampicillin: 2 g IV q6h (peds: 50 mg/kg) and
- Clindamycin: 900 mg IV q8h (peds: 10 mg/kg) and
- Gentamicin: 5 mg/kg daily load IV q8h
- Ciprofloxacin: 500 mg IV and
- Clindamycin: 900mg IV initial ED dose
- Single-drug regimens (peds: Safety not established)
- Ampicillin/sulbactam: 3 g IV initial ED dose
- Imipenem: 1 g IV initial ED dose
- Piperacillin/tazobactam: 3.375 g IV initial ED dose
- Ticarcillin/clavulanate: 3.1 g IV initial ED dose
- Cover for possible MRSA with Vancomycin 1 g IV initial ED dose
- Blood products as indicated
- Dopamine or dobutamine IV drips starting at 5 Ī¼g/kg/min titrating to effect if hypotensive after aggressive hydration
- Insulin adjusted to control glucose and acidosis
Follow-Up
Disposition
Admission Criteria
- All patients with Fournier gangrene require admission and surgical ICU care.
- Mortality estimates of 3-38% emphasize need for early aggressive care.
- Consider early transfer to facility capable of providing adjunctive hyperbaric oxygen therapy if stable for transport.
Discharge Criteria
No patients with Fournier gangrene should be discharged.
Pearls and Pitfalls
- Failure to perform a careful genital exam, particularly in a pediatric patient
- Failure to initiate antibiotics in a timely manner
Additional Reading
- Burch DM, Barreiro TJ, Vanek VW. Fourniers gangrene: Be alert for this medical emergency. JAAPA. 2007;20(11):44-47.
- Davis JE, Silverman M. Scrotal emergencies. Emerg Med Clin North Am. 2011;29(3):469-484.
- Jallali N, Withey S, Butler PE. Hyperbaric oxygen as adjuvant therapy in the management of necrotizing fasciitis. Am J Surg. 2005;189:462-466.
- Levenson RB, Singh AK, Novelline RA. Fournier gangrene: Role of imaging. Radiographics. 2008;28(2):519-528.
- Pais VM. Fournier Gangrene. Emedicine. Available at http://emedicine.medscape.com/article/2028899- overview. Accessed March 22, 2014.
See Also (Topic, Algorithm, Electronic Media Element)
- Cellulitis
- Urinary Tract Infection, Adult
Codes
ICD9
608.83 Vascular disorders of male genital organs
ICD10
N49.3 Fournier gangrene
SNOMED
- 398318005 Fourniers gangrene
- 236782005 Fournier's gangrene of scrotum
- 397900003 Fournier's gangrene of penis