Fourniers gangrene

Dr. Vinod Jain

26.08.2014

Fourniers gangrene

Definition
Etiology & risk factors
Pathogenesis & pathology
Incidence
Clinical features
Differential diagnosis
Investigations
Treatment
- Medical
- Surgical
Complications

Definition
Named after French venereologist
Jean Alfred Fournier (1883).
Fournier gangrene is defined as a
polymicrobial necrotizing fasciitis
of the perineal, perianal, or genital
areas.

Etiology & risk factors

Initially described as idiopathic
Now in more than 75% cases
inciting cause in known
Necrotizing process commonly
originates from infection in
anorectum, urogenital tract or skin
of genitalia

Etiology
1. Ano-rectal causes
infection in the perineal glands
Manifestation of colorectal injury,
malignancy or diverticulitis
2. Uro-genital causes
infection in the bulbourethral glands
urethral injury
Iatrogenic injury
Lower urinary tract infections

Etiology (contd.)
3. Dermatologic causes

Hidradenitis suppurativa
Ulceration from scrotal pressure
Trauma to scrotum or perineum

4. Other less common causes

Consequence of bone marrow malignancy

Systemic lupus erythematosus
Crohns diseases

Risk factors

Diabetes mellitus
Alcoholism
Malignancies
Cirrhosis Liver
Chronic steroid use
HIV infection
Malnutrition
Morbid Obesity

Causative Bacteria

Polymicrobial infection
Minimum of four isolates per case
Most common aerobe E. coli
Most common anaerobes Bacteroids
Others Streptococcus, Staphylococcus,
MRSA Methicillin Resistant Staphylococcus
aureus, Klebsiella Pseudomonas, Proteus &
Clostridium.

Pathogenesis
Bacteria act synergistically causing
obliterative endarteritis & production of
various enzymes causing destruction
There is imbalance between host
immunity & virulence of organism

Mechanism of spread
Entry of bacteria (act through synergism)

Fibrinoid coagulation of nutrient vessels

Decreased locally blood supply to skin
Decreased tissue oxygen tension
Growth of anaerobes & microaerophilic
organisms
Production of enzyme (Collagenase,
Lecithinase, Hyaluronidase )
Digestion of fascial barrier
Rapid spread of infection

Pathology

Pathognomonic findings on pathological

evaluation of tissue are :Necrosis of superficial & deep fascial planes
Fibrinoid coagulation of the nutrient
arterioles
Polymorphonuclear cell infiltration
Presence of micro organisms with in the
involved tissues
Air in the perineal tissue

Incidence
Age
Sex

30 60 years
10 times more common in
males
Social habits More common in male
homosexuals (more prone
for Rectal injury)

Clinical features

Begins with insidious onset of pruritus and

discomfort of external genitalia
Prodromal symptoms of fever and lethargy, which
may be present for 2-7 days before gangrene
The hallmark of Fournier gangrene is out of
proportion pain and tenderness in the genitalia.
Increasing genital pain and tenderness with
progressive erythema of the overlying skin
Dusky appearance of the overlying skin;
subcutaneous crepitation; feculent odor
Obvious gangrene of a portion of the genitalia;
purulent discharge from wounds
As gangrene develops, pain subsides (Nerve necrosis)

Differential diagnosis

Balanitis
Cellulitis
Epididymitis
Gas gangrene
Compicated hernias
Complicated hydrocele
Necrotizing fasciitis
Orchitis
Testicular torsion

Other Problems to be Considered

Testicular fracture
Testicular hematoma
Testicular abscess
Scrotal abscess
Vasculitis
Warfarin gangrenosum
Polyarteritis nodosum
Wegeners granulomatosis

Investigations

(CBC) Complete blood count

Electrolytes
BUN / Serum creatinine
Blood Sugar
ABG
Blood and urine culture with sensitivity
Coagulation profile for DIC

Investigations (contd.)
Imaging

Conventional radiography
Ultrasonography
C.T. Scanning
MRI

Conventional radiography
Consider where clinical findings
are inconclusive
Presence of gas in soft tissue

Ultrasonography
Can be used to detect fluid or
gas in soft tissue
Sonographic hallmark
Presence of gas in scrotal tissue
Excludes other conditions
Testicular blood flow - N
Limitations Direct pressure on
involved tissue causes
inconvenience

C.T. Scanning
Can detect smaller amount of
soft tissue gas
Defines extent more specifically
Identifies underlying causes eg.
Small perineal abscess
MRI
Yields greater soft tissue details
Create logistic challenges,
especially in critically ill patients

Treatment
Medical
Surgical

Medical Treatment
1.
2.
3.

Restoration of normal organ perfusion

Reduction of systemic toxicity
Broad spectrum antibiotics to cover anaerobes as well
(cipro+clinda+metro)
4. Vancomycin for MRSA
5. Tetanus prophylaxis
6. Irrigation with super oxidised water
7. Hyperbaric oxygen therapy
8. IV immunoglobulins to neutralize super antigen as
streptotoxin A & B (as adjuvant)
9. Antifungal if required
10. Non conventional
- Unprocessed honey enzyme action
- dressing with gauge soaked with zinc per oxide

Surgical treatment
Repeated aggressive debridement
Preservation of testes (subcutaneous
pocket from desiccation)
Reconstruction after infection is over
Fecal diversion
Urinary diversion
Vacuum assisted closure (VAC)

Complications

ARF
ARDS
Septicemia and gram negative shock
MSOF
Tetanus
Death

Questions ?

Let us revise

Definition
Etiology & risk factors
Pathogenesis & pathology
Incidence
Clinical features
Differential diagnosis
Investigations
Treatment
- Medical
- Surgical
Complications