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fournier’s gangrene

What is Fournier’s gangrene

Fournier’s gangrene is a life-threatening fulminant form of infective, polymicrobial, necrotizing fasciitis affecting the perineal, genital and perianal regions 1. Fournier gangrene has a particularly high death rate ranging from 15% to 50% 1. Fournier’s gangrene commonly affects men in their 60s or 70s and often suffer from other concomitant illnesses 2, but women and children may also develop this type of tissue necrosis. Fournier’s gangrene cases in children have been reported from resource-poor countries where poor hygiene is prevalent and in immunocompromised children 3. The male-to-female ratio is 10: 1 4.

Fournier’s gangrene was named after Jean-Alfred Fournier (1832–1914), a Parisian venereologist who reported in 1883 a compiled series of 5 otherwise healthy young men who suffered from a rapidly progressive gangrene of the penis and scrotum without any apparent cause 5. More than 1700 cases of necrotizing fasciitis have been reported in the literature from 1950 to 1999 4.

Fournier’s gangrene may occur due to insufficient or lack of blood supply in the affected area and a concomitant infection.

According to the majority of authors, the most important predisposing factors are 6, 7, 8:

  • diabetes mellitus,
  • alcoholism,
  • atherosclerosis,
  • peripheral arterial disease,
  • trauma or injury,
  • Raynaud’s phenomenon,
  • malnutrition,
  • medical immunosuppression (e.g., chemotherapy, steroids, and malignancy),
  • HIV infection,
  • leukemia,
  • liver diseases, and debilitating illness.

Multiple predisposing factors predict a poor prognosis and correlate significantly with mortality 9. Several authors state that the most important parameters that predict outcome of Fournier’s gangrene are hemostatic abnormalities at presentation with this disease and renal failure 10. Diabetes mellitus is reported to be present in 20–70% of patients with Fournier’s gangrene and chronic alcoholism in 25–50% of Fournier’s gangrene patients, with some authors reporting increased mortality in patients with diabetes 11.

Early diagnosis remains imperative, as the rate of fascial necrosis has been noted as high as 2–3 cm per hour 12. Treatment of Fournier’s gangrene entails treating sepsis, stabilizing medical parameters and urgent surgical debridement. Despite timely and aggressive management, the condition is life threatening as most studies report mortality rates of between 20% and 40% 13, but it can be as high as 70–80%, particularly if sepsis is present at the time of hospital admission 14. Interestingly, the mortality has been shown to be higher in technologically advanced countries such as the United States, Canada and Europe than in underdeveloped countries 4.

Figure 1. Fournier’s gangrene of the scrotum

[Source 1]

Figure 2. Fournier gangrene in a 58-year-old female diabetic patient

[Source 15]

Is Fournier gangrene contagious?

People rarely spread necrotizing fasciitis to other people. If you’re in close contact with someone who has necrotizing fasciitis, you may be given a course of antibiotics to reduce your risk of infection.

In general, someone with necrotizing fasciitis does not spread the infection to others. Most cases of necrotizing fasciitis occur randomly.

Fournier gangrene symptoms

The clinical features of Fournier’s gangrene include sudden intense pain and tenderness with swelling in the scrotum, pus or wound discharge, crepitation, fluctuance, prostration, pallor and fever greater than 38°C (Figure 1) 16. Usually the infection starts as an inflammation adjacent to the portal of entry, commonly in the perineum or perineal region, with the appearance of a black spot, called Brodie’s sign 17. From this moment, the necrotic inflammation spreads briskly, moving along the fascial planes and stretching into the surrounding areas (perineum, scrotum, hypogastrium, and sometimes affecting the region from the thigh up to the diaphragm causing rapid deterioration of the patient’s general condition 18.

The affected area is often swollen, dusky and covered by macerated skin and presents with a characteristic feculent odor, which is attributed to the role of anaerobes in the infection 19. Patients also may have pronounced systemic signs, usually out of proportion to the local extent of the disease. In those with severe clinical presentation, progression of the gangrenous process to malodorous drainage and sloughing in affected sites results in deterioration of the patient’s overall condition. Ferreira and colleagues reviewed 43 cases and found the most common presentations were scrotal swelling, fever and pain 20. In another review of 70 patients, Ersay and colleagues found the most common presentation was perianal/scrotal pain (79%) followed by tachycardia (61%), purulent discharge from the perineum (60%), crepitus (54%) and fever (41%) 21. Crepitus of the inflamed tissues is a common feature due to the presence of gas-forming organisms 22. As the subcutaneous inflammation worsens, necrosis and suppuration of subcutaneous tissues progresses to extensive necrosis 23. Patients can rapidly deteriorate as sepsis and multiorgan failure, the most common cause of death in these cases, develop 24.

What causes Fournier’s gangrene

Fournier’s gangrene was initially defined as an idiopathic entity, but recent research has shown that less than a quarter of Fournier’s gangrene cases are now considered idiopathic 25. Colorectal sources (30–50% of cases), urogenital sources (20–40% of cases), cutaneous infections (20% of cases) and local trauma are frequently identified as the cause of Fournier’s gangrene 4. Colorectal sources include local infection, abscesses (particularly in the perianal, perirectal and ischiorectal regions), anal fissures, colonic perforations, diverticulitis, hemorrhoidectomy and rectal carcinoma 26. Urologic sources of Fournier’s gangrene include urethral strictures, chronic urinary tract infection, neurogenic bladder, epididymitis and recent instrumentation 27. In women, additional sites of origin include Bartholin gland or vulvar abscess, episiotomy, hysterectomy and septic abortion 28. Insect bites, burns, trauma and circumcision have also been reported as causes of pediatric Fournier’s gangrene 27.

Causes of Fournier’s gangrene 29:

  • Anorectal
    • Trauma
    • Ischiorectal, perirectal, or perianal abscesses, appendicitis,
    • Diverticulitis, colonic perforations
    • Perianal fistulotomy, perianal biopsy, rectal biopsy,
    • Hemorrhoidectomy, anal fissures excision
    • Steroid enemas for radiation proctitis
    • Rectal cancer
  • Genitourinary
    • Trauma
    • Urethral strictures with urinary extravasation
    • Urethral catheterization or instrumentation,
    • Penile implantsinsertion, prostatic biopsy, vasectomy,
    • Hydrocele aspiration,genital piercing, intracavernosal cocaine
    • Injection periurethral infection; chronic urinary tract infections
    • Epididymitis or orchitis
    • Penile artificial implant, foreign body
    • Hemipelvectomy
    • Cancer invasion to external genitalia
    • Septic abortion
    • Bartholin’s duct abscess
    • Episiotomy
  • Dermatologic sources
    • Scrotal furuncle
    • Genital toilet (scrotum)
    • Blunt perineal trauma; intramuscular injections, genital piercings
    • Perineal or pelvic surgery/inguinal herniography.
  • Idiopathic

Pathogenesis and organisms involved

The predisposing factors of Fournier’s gangrene provide a favorable environment for the infection by decreasing the host immunity and allowing a portal of entry for the microorganism into the perineum. The incident leading to the inoculation may be so trivial that the patient or physician may fail to notice. Characteristically, Fournier’s gangrene exists due to synergism between multiple bacteria that theoretically are not highly aggressive when presented alone. The polymicrobial nature of Fournier’s gangrene with contributions by both aerobic and anaerobic bacteria is necessary to create the production of various exotoxins and enzymes like collagenase, heparinase, hyaluronidase, streptokinase and streptodornase, which promote rapid multiplication and spread of infection. The aerobic bacteria cause platelet aggregation and induce complement fixation, thereby causing acceleration of coagulation. The anaerobic bacteria promote the formation of clots by producing collagenase and heparinase. Other organisms like Bacteroides inhibit the phagocytosis of aerobic bacteria, aiding in further spread of the infection 30.

The organisms that tend to be found in Fournier’s gangrene are species that normally exist below the pelvic diaphragm in the perineum and genitalia 4. The most commonly isolated aerobic microorganisms are Escherichia coli, Klebsiella pneumoniae and Staphylococcus aureus, while the most commonly isolated anaerobic microorganism is Bacteroides fragilis 22. Other organisms include Streptococcus, Enterococcus, Clostridium, Pseudomonas and Proteus species. In some series, an average of more than three organisms were cultured from each patient 11. Group A streptococcal is the most common cause of monomicrobial necrotizing fasciitis 31. Although rare, necrotizing fasciitis due to Candida species as well as Lactobacillus gasseri has also been reported 32. Ultimately, the microorganism’s virulence promotes the rapid spread of the disease from a localized infection near the portal of entry into an obliterative endoarteritis with cutaneous and subcutaneous vascular necrosis, leading to local ischemia and further bacterial proliferation 33.

The infection in Fournier’s gangrene tends to spread along the fascial planes with initial involvement of the superficial (Colles fascia) and deep fascial planes of the genitalia. Subsequently, there is spread to the overlying skin with sparing of the muscles. Infection of Colles fascia may then spread to the penis and scrotum via Buck’s and Dartos fascia, or to the anterior abdominal wall via Scarpa’s fascia, or vice versa. The inferior epigastric and deep circumflex iliac arteries supply the lower aspect of the anterior abdominal wall, whereas the external and internal pudendal arteries supply the scrotal wall. With the exception of the internal pudendal artery, each of these vessels travels within Camper’s fascia and can therefore become thrombosed in the progression of Fournier’s gangrene 34. The Colles fascia is attached laterally to the pubic rami and fascia lata and posteriorly to the urogenital diaphragm, thus limiting progression in these directions. In contrast, anorectal sources of infection usually start in the perianal area, a clinical variation that can serve as a guide to localizing the foci of infection 35. Testicular involvement is limited in Fournier’s gangrene by the fact that the blood supply is derived from the aorta, independent from the affected region 36. However, involvement of the testis suggests retroperitoneal origin or spread of infection 37. Even though thrombosis of the corpus spongiosum and cavernosum has been reported, corpora involvement is rare while the penile skin sloughs off 38.

Fournier’s gangrene diagnosis

The diagnosis of Fournier’s gangrene is primarily based on clinical findings of fluctuance, crepitus, localized tenderness and wounds of the genitalia and perineum. Although diagnosis is straightforward when the lesions are found, failure to examine the genitals, especially in the older or obtunded patient, can result in misdiagnosis. The common laboratory findings are nonspecific and may show anemia, leukocytosis, thrombocytopenia, electrolyte abnormalities, hyperglycemia, elevated serum creatinine level, azotemia and hypoalbuminemia 39. The diagnosis of Fournier’s gangrene is primarily clinical, and in most cases imaging is neither necessary nor desirable. Under no circumstances should surgery be delayed significantly for imaging of any kind. However, imaging modalities may be useful in cases when the presentation is atypical or when there is concern regarding the true extent of the disease.

Conventional radiography can be used to detect the presence of soft tissue air in the area overlying the scrotum and perineum before clinical crepitus is detected. In addition to demonstrating significant swelling of the scrotal soft tissue, radiographs may also detect subcutaneous emphysema extending from the scrotum and perineum to the inguinal regions, anterior abdominal wall and thighs. However, the absence of subcutaneous air, which is demonstrated in 10% of patients, does not exclude the diagnosis of Fournier’s gangrene 40. A significant weakness of radiography in the diagnosis and evaluation of Fournier’s gangrene is the lack of detection of deep fascial gas 41.

Ultrasound (US) findings in Fournier’s gangrene include a thickened, edematous scrotal wall containing hyperechoic foci that demonstrate reverberation artifacts, causing ‘dirty’ shadowing which represents gas within the scrotal wall 42. In addition, US can demonstrate paratesticular fluid, which is seen prior to clinical crepitus. This imaging modality is also useful in differentiating Fournier’s gangrene from inguinoscrotal hernias. Overall, US is considered superior to conventional radiography as soft tissue air is more obvious and scrotal contents along with Doppler blood flow can be examined.

Computed tomography (CT) plays an important role in the diagnosis of Fournier’s gangrene as well as the evaluation of the extent of the disease to guide appropriate surgical treatment. CT findings include asymmetric fascial thickening, fluid collections, abscess formation, fat stranding around involved structures and subcutaneous emphysema 42]. The underlying cause of Fournier’s gangrene, such as a perianal abscess, a fistulous tract, or an intraabdominal or retroperitoneal infectious process, may also be demonstrated by CT 43. It can help to evaluate both the superficial and the deep fascia, and to differentiate Fournier’s gangrene from less aggressive entities such as soft-tissue edema or cellulitis, which may appear similar to Fournier’s gangrene on physical examination. As a whole, CT has greater specificity for evaluating disease extent than does radiography, US or even physical examination 43.

Magnetic resonance imaging (MRI) offers an important diagnostic adjunct in the management of Fournier’s gangrene as it is more useful than conventional radiography and US for specifying range of infection. Some argue that MRI is even more helpful than CT in planning any operative intervention 44.

Fournier’s gangrene treatment

The management of Fournier’s gangrene is underscored by three main principles: rapid and aggressive surgical debridement of necrotized tissue, hemodynamic support with urgent resuscitation with fluids, and broad-spectrum parental antibiotics 45. As the rate of fascial necrosis has been noted as high as 2–3 cm per hour, Fournier’s gangrene is considered a surgical emergency with prompt, pragmatic and individualized therapy being the cornerstone for effective treatment 45.

Radical surgical debridement

In addition to broad-spectrum parental antibiotics, early and aggressive surgical debridement has been shown to improve survival in patients presenting with Fournier’s gangrene as patients often undergo more than one debridement during their hospitalization 13. In a retrospective study of 219 patients presenting with a diagnosis of Fournier’s gangrene, Proud and colleagues 46 found that there was no statistically significant difference in mortality between patients who underwent debridement before transfer or within 24 hour of presentation to those who had not. The authors attributed this seemingly counterintuitive observation to the range in severity of necrotizing soft tissue infections and to the notion that patients are less likely to succumb to localized infections. Regardless, the authors still advocate rapid and timely surgical debridement 46.

Since the treatment of Fournier’s gangrene often requires highly acute and intensive multidisciplinary care, Sorensen and colleagues 13 examined the difference in case severity and management between teaching and nonteaching hospitals. Overall, the authors analyzed 1641 cases of Fournier’s gangrene at a total of 593 hospitals. It was found that more Fournier’s gangrene cases were treated per year at teaching hospitals where more surgical procedures, debridements and supportive care were reported. Interestingly, patients treated at teaching hospitals had longer length of stay, greater hospital charges and a higher case fatality rate secondary to more acutely ill patients. After adjusting for patient and hospital factors, it was found that patients treated at hospitals where more individuals with Fournier’s gangrene were treated had 42–84% lower mortality than hospitals where only one patient per year was treated. This finding is likely attributable to more aggressive diagnosis and management of Fournier’s gangrene at experienced hospitals. Overall, the data in the study revealed that hospitals where more patients with Fournier’s gangrene are treated had lower mortality rates, supporting the need to regionalize care for patients with this disease 13.

In a retrospective study of 19 patients diagnosed with Fournier’s gangrene, Chawla and colleagues 37 studied the utilization of the Fournier’s gangreneSI to determine length of stay and survival. In this study, nonsurvivors had a higher Fournier’s gangreneSI compared with survivors but length of stay was not predicted by the Fournier’s gangreneSI. Moreover, it was found that mean number of surgical debridements in survivors was lower compared with that of nonsurvivors. Furthermore, length of stay was not affected by urinary or fecal diversion. Interestingly, it was observed that patient outcomes were similar regardless of management by general surgery or urology services 37.

Broad-spectrum antibiotic coverage

Broad-spectrum parental antibiotic therapy is administered empirically upon diagnosis of Fournier’s gangrene and then subsequently tailored based on culture results. It is imperative that the antibiotic regimen chosen is effective against staphylococcal, streptococcal and gram-negative bacteria, coliforms, Pseudomonas, Bacteroides and Clostridium 33. Triple antibiotic therapy consisting of a broad-spectrum penicillin or third-generation cephalosporins, an aminoglycoside (e.g. gentamicin) and metronidazole or clindamycin is typically instituted empirically 33. Moreover, many have suggested adding penicillin for treatment of streptococci and, in particular, when Clostridia is suspected. Alternatively, clindamycin and chloramphenicol can be substituted empirically to facilitate coverage of gram-positive cocci and anaerobes until culture results return 47. In patients infected with methicillin-resistant S. aureus, vancomycin should be utilized. Amphotericin B or caspofungin should be added to the empiric regimen should fungi be detected in tissue cultures 48.

Topical therapy

After initial radical debridement, open wounds are generally managed with sterile dressings or negative-pressure wound therapy. In a retrospective review of 14 patients, Altunoluk and colleagues 49 compared the efficacy of wound management with daily povidone iodine dressing versus Dakin’s solution (sodium hypochlorite). Dakin’s solution has wide antimicrobial efficacy against aerobic and anaerobic organisms. The authors found that the length of hospitalization was significantly shorter in patients managed with Dakin’s solution compared with iodine dressing (8.9 days versus 13 days) perhaps secondary to the antimicrobial effects of the former 49. The use of topical honey has also been described in the management of Fournier’s gangrene because of its ability to inhibit microbial growth likely related to the osmotic effect of its high sugar content 50. Efem described the use of honey in conjunction with oral amoxicillin/clavulanic acid and metronidazole in 20 patients presenting with Fournier’s gangrene. Despite longer hospitalization compared with those undergoing wound debridement with systemic antibiotics, treatment with topical honey obviated the need for anesthesia and expenses associated with surgical operations. Moreover, response to treatment was found to be expedited in those treated with topical honey 51. Tahmaz and colleagues found the efficacy of unprocessed honey to be similar in a retrospective review of 33 patients treated with topical honey versus radical surgical debridement 50.

Vacuum-assisted closure therapy

Negative-pressure wound therapy or vacuum-assisted closure (VAC) therapy has been studied in the postoperative management of Fournier’s gangrene. Vacuum-assisted closure therapy works by exposing a wound to subatmospheric pressure for an extended period to promote debridement and healing (Figure 3) 33. Negative-pressure wound therapy can be used in wound management utilizing the lower limit of pressure, which is recommended to be between 50 and 125 mmHg. The negative pressure in negative-pressure wound therapy leads to an increased blood supply and thus encourages migration of inflammatory cells into the wound region. Also, this promotes and accelerates the formation of granulation tissue by removing bacterial contamination, end products, exudates and debris compared with traditional dressing 52. Czymek and colleagues prospectively collected data on 35 patients diagnosed with Fournier’s gangrene to assess the effectiveness of vacuum-assisted closure therapy versus daily antiseptic (polyhexadine) dressings. Patients treated with VAC therapy had significantly longer hospitalization and lower mortality. However, significantly more patients required fecal diversion in the group receiving VAC therapy because of the need to reapply the vacuum dressing after each bowel movement. Fecal diversions may have be partially responsible for a higher mean number of surgical procedures in patients treated with vacuum-assisted closure therapy compared with those whose wounds were treated with conventional dressings that were more easily changed on the wards. Overall, the authors state that vacuum-assisted closure is not superior to conventional dressings in terms of length of hospital stay or clinical outcome. However, they are still clinically effective and successfully used in the management of large wounds 53.

Figure 3. Vacuum-assisted closure therapy in Fournier’s gangrene

vacuum-assisted closure therapy in fournier's gangrene

Hyperbaric oxygen therapy

A modality that has shown some promise as an adjunct to treatment of Fournier’s gangrene is hyperbaric oxygen therapy, which entails exposing the patient to increased ambient pressure while breathing 100% oxygen 33. The physiological effects are believed to be enhanced leukocyte ability to kill aerobic bacteria, stimulation of collagen formation and increased levels of superoxide dismutase resulting in better tissue survival. Several case reports have demonstrated enhanced patient survival with the use of hyperbaric oxygen in the setting of necrotizing fasciitis when combined with surgical debridement 54.

Fecal and urinary diversion

Colostomy has been used for fecal diversion in cases of severe perineal involvement. Indications for colostomy include anal sphincter involvement, fecal incontinence and continued fecal contamination of the wound’s margins. Although colostomy can be beneficial with regard to wound healing by avoiding fecal contamination, it should be performed only in selected cases because it increases morbidity. The estimated percentage of patients requiring colostomy after debridement of Fournier’s gangrene is approximately 15%, and an increased mortality has been noted in patients requiring diversion 33. In their study of 44 patients presenting with Fournier’s gangrene, Ozturk and colleagues 55 found that in 18 patients that required temporary stoma formation, significant increases in healthcare costs were observed without an effect on outcomes. Overall, stoma creation and closure increased costs by approximately $6650. Therefore, it is recommended that stoma formation be reserved for patients with fecal incontinence caused by extensive damage to the anal sphincter 55. Nevertheless, the potential need for colostomy underscores the importance of a multidisciplinary approach to the management of the patient presenting with Fournier’s gangrene 56. In a series of 28 consecutive patients with Fournier’s gangrene, Corman and colleagues found that general surgical service was involved in 52% of the initial operations to perform perianal and sometimes perirectal debridement 57. Alternatively, the Flexi-Seal Fecal Management System has been introduced for fecal diversion, which can be utilized as an alternative method to colostomy as it successfully prevents fecal contamination of the wound 52. In regards to urinary diversion, some authors suggest cystostomy, although most suggest that urinary catheterization provides satisfactory diversion 58. In a review of 26 cases of Fournier’s gangrene treated at a university medical center, Hollabaugh and colleagues 59 utilized suprapubic diversion in 16 cases with 15 of those patients receiving diversion at the time of initial debridement. Indications for suprapubic urinary diversion included patients with extensive penile and perineal debridement, or periurethral abscesses 59. In 74 patients presenting with Fournier’s gangrene at an Egyptian medical center, adequate urinary diversion was accomplished with the use of a urethral Foley catheter in all but one patient who had experienced a urethral injury. In this series, suprapubic cystostomy was recommended in patients experiencing urethral disruption or stricture 60.

Reconstructive surgery

After extensive debridement, many patients sustain significant defects of the skin and soft tissue, creating a need for reconstructive surgery for wound coverage as well as satisfactory functional and cosmetic results. Various workers have used different techniques to provide skin cover including transplantation of testes, free skin grafts, axial groin flaps, and myocutaneous flaps. Split thickness skin graft seems to be the treatment of choice in treating perineal and scrotal skin defects. Parkash and Gajendran 61 reported their series of treatment of 43 cases in the past 11 years. In three cases the gangrene had spread beyond the scrotum and penis and cover had to be supplemented with split-skin grafts. In all the other cases, cover was provided with scrotal skin remnants at the edge of the lesion and on the penis with the inner layer of the prepuce, which had remained intact.

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