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Fournier Gangrene, Emergency Medicine

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Fournier Gangrene, Emergency Medicine

Basics

Description

Retrograde urethrography, anoscopy, proctosigmoidoscopy, and barium enemas may be helpful to localize anatomic sources of infection.

Patients may be hypotensive from septic shock and require aggressive fluid resuscitation and vasopressor support.

608.83 Vascular disorders of male genital organs

  • 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 cathetersPenile or scrotal (30%): Condom catheters, hydradenitis, balanitisAnorectal (30%): Fistulas, perirectal infections, hemorrhoids
  • Rarely, intra-abdominal sources such as perforating appendicitis, diverticulitis, or pancreatitis have produced Fournier gangrene by dependent contiguous spread.
  • Portal of entry for bacteria in tissue
  • Lower urinary tract (40%): Urethral strictures, indwelling catheters
  • Penile or scrotal (30%): Condom catheters, hydradenitis, balanitis
  • Anorectal (30%): Fistulas, perirectal infections, hemorrhoids

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:TraumaDiabetesAlcoholismOther immunocompromised statesMorbid obesityAbdominal surgery
  • 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.
  • Usually seen in diabetics or immunocompromised patients
  • 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.
  • Duration of symptoms:Fevers or chillsPain is out of proportion to exam in early phases, but eventually dead tissue becomes insensate.Nausea and vomitingUrinary infection symptoms
  • Rapidity with which symptoms are progressing
  • Identify if diabetic or immunocompromised
  • Lethargy and inappropriate indifference to the illness are common.
  • 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
  • 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 skinThin brown watery dischargeUlceration, bullous vesiclesCrepitance, SC airFrank necrosis and eschar formation
  • 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

  • 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)
  • 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.

Differential Diagnosis

  • Epididymitis/orchitis
  • Insect and human bites
  • Perirectal infections
  • Scrotal abscess/inguinal abscess
  • Scrotal cellulitis
  • Testicular torsion
  • Tinea cruris

Treatment

Pre-Hospital

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
  • Avoid femoral access, femoral venipuncture, and lower extremity venous access

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) andClindamycin: 900 mg IV q8h (peds: 10 mg/kg) andGentamicin: 5 mg/kg daily load IV q8hCiprofloxacin: 500 mg IV andClindamycin: 900mg IV initial ED doseSingle-drug regimens (peds: Safety not established)Ampicillin/sulbactam: 3 g IV initial ED doseImipenem: 1 g IV initial ED dosePiperacillin/tazobactam: 3.375 g IV initial ED doseTicarcillin/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
  • Multidrug regimen:Ampicillin: 2 g IV q6h (peds: 50 mg/kg) andClindamycin: 900 mg IV q8h (peds: 10 mg/kg) andGentamicin: 5 mg/kg daily load IV q8hCiprofloxacin: 500 mg IV andClindamycin: 900mg IV initial ED dose
  • Single-drug regimens (peds: Safety not established)Ampicillin/sulbactam: 3 g IV initial ED doseImipenem: 1 g IV initial ED dosePiperacillin/tazobactam: 3.375 g IV initial ED doseTicarcillin/clavulanate: 3.1 g IV initial ED dose
  • 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
  • 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

Follow-Up

Disposition

  • 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.

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

ICD10

SNOMED

  • 398318005 Fourniers gangrene
  • 236782005 Fournier's gangrene of scrotum
  • 397900003 Fournier's gangrene of penis