Fournier gangrene represents a urologic emer-gency with a potentially high mortality rate. It is arapidly progressing, polymicrobial necrotizingfasciitis of the perineal, perianal, and genital re-gions, with a mortality rate ranging from 15% totion result in an impaired local blood supply,leading to vascular thrombosis in the cutaneousand subcutaneous tissues. Perifascial dissectionwith subsequent spread of bacteria and progres-sion to gangrene of the overlying tissues ensues.The rate of fascial necrosis has been noted to beas high as 2–3 cm per hour, making early diagno-sis crucial (5,6).Early diagnosis is important because immedi-ate surgical de´bridement and aggressive antibiotictreatment are indicated. Although the diagnosisof Fournier gangrene is often made clinically, ra-diologic imaging—particularly computed tomog-raphy (CT)—can help conﬁrm the diagnosis inclinically ambiguous or questionable cases. Radi-ography or ultrasonography (US) can also dem-onstrate some of the ﬁndings of Fournier gan-grene, but CT has greater speciﬁcity for the diag-nosis and for demonstration of disease extent(1,7). It is important that radiologists be aware of the imaging features of Fournier gangrene to per-mit accurate diagnosis and immediate surgicaltreatment.In this article, we discuss and illustrateFournier gangrene in terms of history; predispos-ing factors; clinical manifestations; routes of spread; imaging characteristics at CT, radiogra-phy, and US; and treatment and outcome.
Fournier gangrene was ﬁrst described by JeanAlfred Fournier, a French venereologist, in 1883.At that time, it was described as abrupt in onsetwith rapid progression to gangrene, but without aclear etiology (8). The disease was noted to occurmost commonly in young males. Today, Fourniergangrene is most commonly found in middle-aged men (mean age, 50–60 years) (3–5,9,10)and, to a much lesser extent, in women and chil-dren. Males are 10 times more likely to developFournier gangrene than are females (2,9,11), per-haps due to easier drainage of the female peri-neum via the vaginal route, which may hinderdevelopment of the disease (2,12). In addition, itis thought that the diagnosis of Fournier gangrenein females is underreported (12).Nowadays, the cause of Fournier gangrene isusually identiﬁed, with only 10% of cases beingidiopathic (5). The disease is most often due to alocal infection adjacent to a point of entry, includ-ing abscesses (particularly in the perianal, perirec-tal, and ischiorectal regions), anal ﬁssures, andcolonic perforations. Fournier gangrene has alsobeen reported secondary to rectal carcinoma anddiverticulitis (13). The urologic sources of Fournier gangrene include urethral strictures,chronic urinary tract infection, neurogenic blad-der, recent instrumentation, and epididymitis (1).In women, additional causes of Fournier gan-grene have included septic abortion, Bartholingland or vulvar abscess, episiotomy, and hysterec-tomy (9). Insect bites, burns, trauma, and cir-cumcision have been reported as causes of pediat-ric Fournier gangrene, which is rarely seen (1).Although the actual incidence of Fournier gan-grene is unknown, the disease is relatively uncom-mon.
The most common predisposing factors forFournier gangrene are diabetes mellitus and alco-hol abuse (5,9). Coexisting diabetes mellitus hasbeen found in up to 40%–60% of patients withFournier gangrene (11,14). Other important pre-disposing factors include indwelling catheters,localized trauma, surgical procedure, malignancy,steroids, chemotherapy, radiation therapy, pro-longed hospitalization, and human immunodeﬁ-ciency virus.
The most common presenting symptoms of Fournier gangrene include scrotal swelling, pain,hyperemia, pruritus, crepitus, and fever (9,13). Afoul-smelling discharge may also be present. Theonset of symptoms tends to occur over a 2–7-dayperiod (7,10). Soft-tissue gas may be presentprior to the detection of clinical crepitus. Crepitusis identiﬁed at physical examination in 19%–64%of patients (15). Air in the soft tissues representsinsoluble gas produced by anaerobic bacteria andconsists primarily of nitrogen, hydrogen, nitrousoxide, and hydrogen sulﬁde (7,15). Systemicﬁndings in Fournier gangrene may include leuko-cytosis, dehydration, tachycardia, thrombocyto-
520 March-April 2008
50% (1–4).Inﬂammation and edema from infec-