Fournier gangrene Background Fournier gangrene was first identified in 1883, when the French venereologist Jean Alfred

Fournier described a series in which 5 previously healthy young men suffered from a rapidly progressive gangrene of the penis and scrotum without apparent cause. This condition, which came to be known as Fournier gangrene, is defined as a polymicrobial necrotizing fasciitis of the perineal, perianal, or genital areas (see the image below.) In contrast to Fournier's initial description, the disease is not limited to young people or to males, and a cause is now usually identified.

Trauma, Penile Fracture and Urethral Trauma. Historical background

and

Trauma,

In 1764, Baurienne originally described an idiopathic, rapidly progressive soft-tissue necrotizing process that led to gangrene of the male genitalia. However, the disease was named after Jean-Alfred Fournier, a Parisian venereologist, on the basis of a transcript from an 1883 clinical lecture in which Fournier presented a case of perineal gangrene in an otherwise healthy young man, adding this to a compiled series of 4 additional cases.[2] He differentiated these cases from perineal gangrene associated with diabetes, alcoholism, or known urogenital trauma, although these are currently recognized risk factors for the perineal gangrene now associated with his name. This manuscript outlining Fournier’s initial series of fulminant perineal gangrene provides a fascinating insight into both the societal background and the practice of medicine at the time. In anecdotes, Fournier described recognized causes of perineal gangrene, including placement of a mistress’ ring around the phallus, ligation of the prepuce (used in an attempt to control enuresis or as an attempted birth control technique practiced by an adulterous man to avoid impregnating his married lover, placement of foreign bodies such as beans within the urethra, and excessive intercourse in diabetic and alcoholic persons. He calls upon physicians to be steadfast in obtaining confession from patients of “obscene practices.”

Photomicrograph of Fournier gangrene (necrotizing fasciitis), oil immersion at 1000X magnification. Note the acute inflammatory cells in the necrotic tissue. Bacteria are located in the haziness of their cytoplasm. Courtesy of Billie Fife, MD, and Thomas A. Santora, MD. Impaired immunity (eg, from diabetes) is important for increasing susceptibility to Fournier gangrene. Trauma to the genitalia is a frequently recognized vector for the introduction of bacteria that initiate the infectious process.[1] For more information, see the Medscape Reference articles Testicular Trauma, Scrotal

a working knowledge of the anatomy of the male lower urinary tract and external genitalia is critical for the clinician treating a patient with Fournier gangrene. defines the superficial perineal space. . to variable degrees. the overlying skin. Skin and superficial fascia Because Fournier gangrene is predominately an infectious process of the superficial and deep fascial planes. Scarpa fascia forms another distinct layer deep to Camper fascia. Several important anatomic relationships should be considered. the flank. The skin cephalad to the inguinal ligament is backed by Camper fascia. ultimately limiting the cephalad extension of an infection that may have originated in the perineum. As the microorganisms responsible for the infection multiply. The perineal membrane is also known as the inferior fascia of the urogenital diaphragm and. and even the chest wall. Note how Colles fascia completely envelops the scrotum and penis. This infectious process involves the superficial and deep fascial planes of the genitalia. which is a layer of fat-containing tissue of varying thickness and the superficial vessels to the skin that run through it. Colles fascia is attached to the pubic arch and the base of the perineal membrane. together with Colles fascia. often sparing the deep muscular structures and. one can see how a process that starts in the perineum can spread to the abdominal wall. Colles fascia is in continuity cephalad to the level of the clavicles. Superiorly. Fascial envelopment of the perineum (male).Anatomy The complex anatomy of the male external genitalia influences the initiation and progression of Fournier gangrene. Understanding the tendency of necrotizing fasciitis to spread along fascial planes and the fascial anatomy. This phenomenon has implications for both initial debridement and subsequent reconstruction. and it is continuous with the superficial Dartos fascia of the scrotal wall. infection spreads along the anatomical fascial planes. while it is continuous with Dartos fascia of the penis and scrotum (see the image below). Scarpa and Camper fascia coalesce and attach to the clavicles. Scarpa fascia blends into Colles fascia (also known as the superficial perineal fascia). In the perineum. understanding the anatomic relationship of the skin and subcutaneous structures of the perineum and abdominal wall is important. A potential space between the Scarpa fascia and the deep fascia of the anterior wall (external abdominal oblique) allows for the extension of a perineal infection into the anterior abdominal wall. In the inguinal region. this fascial layer is known as Scarpa fascia. Therefore.

perineal structures. thus limiting progression in these directions. Penis and scrotum The contents of the scrotum. epididymides. The fascial layers described in this section do not become involved with an infection of the superficial perineal space and can limit the depth of tissue destruction in a necrotizing infection of the genitalia. bulbar urethra. Testicular involvement is rare. or vice versa. and the ensuing cutaneous and subcutaneous vascular necrosis leads to localized ischemia and further bacterial proliferation. The next deeper layer is the internal spermatic fascia. deep in the pelvis. several important anatomic relationships should be considered. and bulbourethral glands. . Ultimately. testes. or rectum can drain into the superficial perineal space and can extend into the scrotum or into the anterior abdominal wall up to the level of the clavicles. Branches of the external and internal pudendal arteries supply the scrotal wall. With the exception of the internal pudendal artery.This space contains the membranous urethra. this space is adjacent to the anterior anal wall and ischiorectal fossae. Vascular supply to the skin of the lower abdomen and genitalia Branches from the inferior epigastric and deep circumflex iliac arteries supply the lower aspect of the anterior abdominal wall. Rates of fascial destruction as high as 2-3 cm/h have been described. which is continuous with the external aponeurosis of the superficial inguinal ring (external abdominal oblique). each of these vessels travels within Camper fascia and can therefore become thrombosed in the progression of Fournier gangrene. while the superficial and deep fascia and the skin are destroyed. Often. Colles fascia is attached to the perineal body and urogenital diaphragm posteriorly and to the pubic rami laterally. an obliterative endarteritis develops. Again. namely the testicles. The corpora cavernosa. or to the anterior abdominal wall via Scarpa fascia. Infectious disease of the male urethra. and cord structures. Buck fascia fuses to the dense tunica albuginea of the corpora cavernosa. Pathophysiology Localized infection adjacent to a portal of entry is the inciting event in the development of Fournier gangrene. bulbourethral glands. the posterior aspect of the scrotal wall supplied by the internal pudendal artery remains viable and can be used in the reconstruction following resolution of the infection. the corpora cavernosa. Thrombosis jeopardizes the viability of the skin of the anterior scrotum and perineum. Infection of superficial perineal fascia (Colles fascia) may spread to the penis and scrotum via Buck and dartos fascia. which is continuous with the transversalis fascia. are invested by several fascial layers distinct from the Dartos fascia of the scrotal wall. In addition. The most superficial layer of the testis and cord is the external spermatic fascia. as the testicular arteries originate directly from the aorta and thus have a blood supply separate from the affected region. urethra. and the anterior urethra. and cord structures are usually spared in Fournier gangrene. A deep fascia termed Buck fascia covers the erectile bodies of the penis.

including Fournier gangrene. from a combination of microorganisms acting synergistically in a susceptible immunocompromised host. and (2) the virulence of the causative microorganisms. the compromised immunity provides a favorable environment to initiate the infection. thus. Microorganism virulence results from the production of toxins or enzymes that create an environment conducive to rapid microbial .The following are pathognomonic findings of Fournier gangrene upon pathologic evaluation of involved tissue:  Necrosis of the superficial and deep fascial planes Fibrinoid coagulation of the nutrient arterioles Polymorphonuclear cell infiltration Microorganisms identified within the involved tissues  multiplication. The following are microorganisms:        common causative Infection represents an imbalance between (1) host immunity.[3] For example. which is frequently compromised by one or more comorbid systemic processes. The etiologic factors allow the portal for entry of the microorganism into the perineum.[3] Although Meleney in 1924 attributed the necrotizing infections to streptococcal species only. See the image below. Streptococcal species Staphylococcal species Enterobacteriaceae Anaerobic organisms Fungi Most authorities believe that polymicrobial involvement is necessary to create the synergy of enzyme production that promotes rapid multiplication and spread of Fournier gangrene. These latter microorganisms. recovering only streptococcal species is unusual. and the virulence of the microorganism promotes the rapid spread of the disease. in turn. collagenase). The resultant tissue hypoxia allows growth of facultative anaerobes and microaerophilic organisms. lecithinase. 7. one microorganism might produce the enzymes necessary to cause coagulation of the nutrient vessels. 8.[4] subsequent clinical series have emphasized the multiorganism nature of most cases of necrotizing infection. Thrombosis of these nutrient vessels reduces local blood supply.[10] Rather. 9] Presently. may produce enzymes (eg. thus fueling the rapid extension of the infection. Fascial necrosis and digestion are hallmarks of this disease process. streptococcal organisms are cultured along with as many as 5 other organisms.[5. 6. this is important to Necrotizing infection results from infection with an extremely virulent microorganism or. which lead to digestion of fascial barriers. tissue oxygen tension falls. most commonly.

anal fissures. Accidental. septic abortions. or appendicitis. therefore. and trauma. Dermatologic causes include hidradenitis suppurativa. if the fascial plane can be separated easily from the surrounding tissue by blunt dissection. into the thighs. hysterectomy. Urogenital tract causes include infection in the bulbourethral glands. Etiology Although originally described as idiopathic gangrene of the genitalia. 14] inflammatory bowel disease. the urogenital tract. or surgical [16] trauma and the presence of foreign bodies may also lead to the disease. Fournier gangrene has an identifiable cause in 75-95% of cases. vulvar or Bartholin gland abscesses. occasionally. orchitis. In men. it is quite likely to be involved with the ischemic-infectious process. urethral injury. iatrogenic injury secondary to urethral stricture manipulation. These may be a consequence of colorectal injury or a complication of colorectal malignancy. and colonic perforations. either from blunt trauma to the area or by spread of rectally carried microbes. The following have been reported in the literature as precipitating factors:         Blunt thoracic trauma Superficial soft-tissue injuries Genital piercings Penile self-injection with cocaine[17] Urethral instrumentation Prosthetic penile implants Intramuscular injections Steroid enemas (used for treatment of radiation proctitis) Rectal foreign body[18] the  In women. or the skin of the genitalia. In children.[12] Anorectal causes of Fournier gangrene include perianal. along the torso. in patients with long-term indwelling urethral catheters). and. perirectal.[13. intentional. Inability to practice adequate perineal hygiene. Far-advanced or fulminant Fournier gangrene can spread from the fascial envelopment of the genitalia throughout the perineum. Specifically.[15] colonic diverticulitis.[11] The necrotizing process commonly originates from an infection in the anorectum. any such dissected tissue should be excised. such as in paraplegic patients.appreciate because it provides the surgeon with a clinical marker of the extent of tissue involvement. epididymitis. and episiotomy are documented sources. or lower urinary tract infection (eg. ulceration due to scrotal pressure. and ischiorectal abscesses. results in increased risk. the following have led to the disease:       Circumcision Strangulated inguinal hernia Omphalitis Insect bites Trauma Urethral instrumentation . anal intercourse may increase risk of perineal infection.

acute nonlymphoid leukemia. but the exact incidence of the disease is unknown. microflora include the Proteus Staphylococcus Enterococcus Streptococcus (aerobic and anaerobic) Pseudomonas Klebsiella Clostridium Predisposition to disease Any condition that depresses cellular immunity may predispose a patient to the development of Fournier gangrene. In a review of Fournier gangrene in 1992.[24] A retrospective case review revealed 1726 cases documented in the literature from 1950-1999. with an average of 97 cases per year reported from 19891998. Escherichia coli is the predominant aerobe. yielding a prevalence of 1 case in 7500 persons. from long-term corticosteroid therapy) Epidemiology Fournier gangrene is relatively uncommon. rather. the apparent increase in the number of cases in the literature most likely results from increased reporting. Examples include the following:  Diabetes mellitus (present in as many as 60% of cases)[19] Morbid obesity Alcoholism Cirrhosis Extremes of age Vascular disease of the pelvis      . acute myeloblastic leukemia)[20.[25] Other researchers have reported approximately 600 cases of Fournier gangrene in the world literature since 1996. Paty and coworkers calculated that approximately 500 cases of the infection have been reported in the literature since Fournier’s 1883 report. 21] Systemic lupus erythematosus[22] Crohn disease HIV infection[23] Malnutrition Iatrogenic immunosuppression (eg. Other common following:             Malignancy (eg. acute promyelocytic leukemia. and Bacteroides is the predominant anaerobe.  Perirectal abscesses Systemic infections  Pathogens Wound cultures from patients with Fournier gangrene reveal that it is a polymicrobial infection with an average of 4 isolates per case.[26] The frequency of Fournier gangrene has not likely changed appreciably.

The scrotum has a remarkable ability to heal and regenerate once the infection and necrosis have subsided. To date. A literature review found only 56 pediatric cases. Lower incidence in females may be caused by better drainage of the perineal region through vaginal secretions.[29. Laor and colleagues introduced the Fournier Gangrene Severity Index [31] (FGSI). Consultation with a psychiatrist may    Each parameter is assigned a score between 0 and 4. perineal.[28] Most reported cases occur in patients aged 30-60 years. especially for infections caused by communityassociated methicillinresistant Staphylococcus aureus (MRSA). Men who have sex with men may be at higher risk. 30] Therefore.[27] Sexual and age-related differences in incidence The typical patient with Fournier gangrene is an elderly man in his sixth or seventh decade of life with comorbid diseases. approximately 50% of men with penile involvement have pain with erection. The FGSI is based on deviation from reference ranges of the following clinical parameters:       Temperature Heart rate Respiratory rate White blood cell count Hematocrit Serum sodium Serum potassium Serum creatinine Serum bicarbonate Prognosis Large scrotal. however. the prognosis for patients following reconstruction for Fournier gangrene is usually good. penile. help some patients deal with the emotional stress of an altered body image. often related to genital scarring. The male-tofemale ratio is approximately 10:1. If extensive soft tissue is lost. However. the majority of studies of Fournier gangrene have been retrospective reviews. The FGSI represents the sum of all the parameters’ values. with 66% of those in infants younger than 3 months. and abdominal wall skin defects may require reconstructive procedures. In 1995. Fournier gangrene is not indigenous to any region of the world. the utility of drawing reliable prognostic information from these studies is very limited. Laor and colleagues determined that an FGSI greater than 9 correlated with increased . with the higher values indicating greater deviation from normal. lymphatic drainage may be impaired.No seasonal variation occurs. Use of external support may be beneficial to minimize this postoperative problem. dependent edema and cellulitis may result. although the largest clinical series originate from the African continent. thus.

Yilmazlar and colleagues updated the FGSI (UFGSI).[38. pain may be out of proportion to physical findings. the age-adjusted Charlson Comorbidity Index (ACCI) and the surgical APGAR score (sAPGAR). shock or sepsis at presentation. 100 deaths occurred. However.[40] Death usually results from systemic illness. History The hallmark of Fournier gangrene is intense pain and tenderness in the genitalia. Dusky appearance of the overlying skin. in the 600 cases of Fournier gangrene discovered during a Medline search dating back to 1996. 39] Factors associated with high mortality include an anorectal source. As .[36. The clinical course usually progresses through the following phases: 1. In some studies. Fatal tetanus associated with Fournier gangrene has been reported in the literature.5%.[37] They both assessed this retrospectively then prospectively with a 30day follow-up. Factors associated with an improved prognosis include age younger than 60 years. such as sepsis (usually gram negative). Increasing genital pain and tenderness with progressive erythema of the overlying skin 4. localized clinical disease. and sterile blood cultures.[35] These 2 groups conclude that the mortality risk in general may be directly proportional to the age of the patient and the extent of disease burden and systemic toxicity upon admission.mortality. pruritus may also be present 3. ranging as high as 75%. acute renal failure. They noted that ACCI and sAPGAR performed as well as the FGSI and UFGSI and were easier to calculate at the bedside. coagulopathy. diabetes and HIV infection are not associated with higher mortality. subcutaneous crepitation 5. for a mortality rate of 16. which may be present for 27 days 2. Again. or multiple organ failure. Fournier gangrene that originates from anorectal diseases carries a worse prognosis than cases caused by other factors. 33. absence of systemic toxicity (eg. adding two additional parameters --age and extent of disease --to further refine the prognostic utility of the FGSI. Intense genital pain and tenderness that is usually associated with edema of the overlying skin.[32.[31] The FGSI has been validated in several retrospective studies. 34] In 2010. Prodromal symptoms of fever and lethargy. low FGSI). increasing age and medical comorbidities were associated with increased risk of death. 35] Most recently. diabetic ketoacidosis. Roghmann et al queried whether these increasingly complex scoring systems actually outperformed 2 existing and less burdensome morbidity scoring systems. the mortality rate ranged from 4-54%. with most studies reporting mortality rates of 20-30%. advanced age. purulent drainage from wounds Early in the course of the disease. renal failure. Obvious gangrene of a portion of the genitalia.[37] Surprisingly. extensive disease (involving abdominal wall or thighs). The reported mortality rates for Fournier gangrene vary widely. In the series that included more than 20 patients. and hepatic dysfunction.

Skin appearance often Differential Diagnoses    Balanitis in Emergency Medicine Cellulitis Emergent Management Epididymitis of Acute  Emergent Management of Necrotizing Fasciitis Gas Gangrene in Emergency Medicine Hernias Hydrocele in Emergency Medicine Orchitis     . Crepitus may be present. bronzed. See image below. Courtesy of Thomas A. Santora. Fluctuance. An examination with the patient under anesthesia was necessary to discover the necrotizing infection that appeared to originate in the right bulbourethral gland. to assess for signs of the disease and to seek a potential portal of entry. blistered. and/or frankly gangrenous. pain may actually subside as nerve tissue becomes necrotic. he presented with exquisite perineal pain. This condition led to urinary incontinence. Systemic effects of this process vary from local tenderness with no toxicity to florid septic shock. edematous. hypotension) may be present. DDx        Testicular hematoma Testicular abscess Scrotal abscess Vasculitis Warfarin gangrenosum Polyarteritis nodosum Wegener granulomatosis Photograph of a morbidly obese male with long-standing phimosis. fever. Physical Examination The physician should direct particular attention to palpation of the genitalia and perineum and to the digital rectal examination.gangrene develops. cyanotic. tachycardia. Skin overlying the affected region may be normal. MD. Systemic symptoms (eg. A feculent odor may be present secondary to infection with anaerobic bacteria. indurated. Ultimately. the more profound the systemic effects. or occult wounds in any of these sites should alert the examiner to possible Fournier disease. soft-tissue crepitation. but its absence does not exclude the presence ofClostridium species or other gas-producing organisms. perineal diaper rash–like dermatitis. and urinary tract infection. localizing tenderness. the greater the degree of necrosis. underestimates the degree of underlying disease. erythematous. In general.

The following studies are indicated:     progresses. Blood Tests Obtain a CBC to assess the immunologic stress induced by the infectious process. fibrinogen level) is helpful to look for sepsis-induced coagulopathy. 42] Gas within the soft tissues is detected more commonly with imaging modalities than with the physical examination. especially when the clinical examination findings are inconclusive. although sensitivities and specificities of different radiologic modalities are not established. (Note that in the setting of a clinical suspicion of Fournier gangrene. and treatment is based on these clinical findings.[41. Incisional biopsy may ultimately confirm the diagnosis. and to evaluate for glucose intolerance. Soft-tissue gas collections (manifest as areas of Complete blood cell count (CBC) Arterial blood gas (ABG) sampling Blood and urine cultures Disseminated intravascular coagulation (DIC) panel Cultures of any open wound or abscess  Pelvic imaging studies can be extremely valuable. and evaluate the potential for sepsis-induced thrombocytopenia. Acidosis with hyperglycemia or hypoglycemia may be present. Consider type and screen if surgical exploration is undertaken.) Plain radiography should be the initial imaging study. Blood samples should be drawn for culture to assess for septicemia. Chemistry Panel and Blood Gases Perform a chemistry panel to evaluate possible electrolyte disturbances. platelet count. Testicular Medicine Torsion in Emergency Approach Considerations Diagnosis of Fournier gangrene is based primarily on clinical findings. prothrombin time. Plain Radiography Radiography should be considered to evaluate for the presence and extent of Fournier disease. which may be due to preexisting diabetes or sepsis-induced metabolic disturbance. It may reveal moderate-tolarge amounts of soft-tissue gas. In both cases. Arterial blood gas (ABG) sampling provides a more accurate assessment of acid/base disturbance. while computed tomography (CT) should be considered the imaging study of choice. A coagulation profile (ie. which tends to occur as the disease . In addition. foreign bodies. demonstration of soft-tissue gas or detection of subcutaneous crepitation is an absolute indication for surgical exploration. to look for laboratory evidence of dehydration (elevated blood urea nitrogen [BUN]/creatinine ratio). activated partial thromboplastin time. or scrotal tissue edema. check the adequacy of the red blood cell mass. any test deemed necessary to assess exacerbation of a comorbid condition (eg. electrocardiogram and cardiac enzyme evaluation in patients with coronary artery disease) is warranted. the presence of subcutaneous air are very suggestive of the diagnosis in the presence of an appropriate clinical history. Plain radiography should be the initial imaging study.

fat stranding.[43. Histologic Findings Pathologic evaluation of the involved tissue may reveal the following pathognomonic findings of Fournier gangrene:  Necrosis of the superficial and deep fascial planes Fibrinoid thrombosis of the nutrient arterioles Polymorphonuclear cell infiltration   . CT scan often identifies the underlying cause of the infection (eg. limit the practical usefulness of MRI. Ultrasonography may reveal other causes of acute scrotal pain. The former would benefit from excisional debridement. This sample may be sent for frozen-section analysis to assess for fascial necrosis. Early fascial involvement may appear as edematous fascia on gross inspection but may appear as frank necrosis on microscopic analysis. especially in patients with critical illness. MRI yields greater soft tissue detail than does CT scanning. The findings may assist in surgical planning. including intratesticular injury. The biopsy sample should be taken from the point of maximal tenderness.hyperlucency) may be evident on radiography before they become clinically apparent. as it defines the extent of the disease more specifically than plain films or ultrasound. 44] Findings include soft-tissue and fascial thickening. with limited ability for patient monitoring during testing. Biopsy An incisional biopsy at the time of surgical debridement allows pathological distinction of Fournier gangrene (ie. absence of air on plain films does not exclude the diagnosis. and inguinal hernia. patients with Fournier gangrene probably will not be able to tolerate this procedure. Magnetic Resonance Imaging Use of MRI in Fournier gangrene is not well described in the literature. testicular torsion. Computed Tomography CT scanning is readily available in most hospitals and should be considered the imaging study of choice.[45] Gas in the scrotal wall is the "sonographic hallmark" of Fournier gangrene. Use of MRI should not delay operative intervention if the diagnosis is highly suspected. and soft-tissue gas collections. while the latter rarely requires surgical excision. epididymo-orchitis. scrotal cellulitis. and it should include skin and superficial and deep fascia. Scrotal wall edema may be seen. These logistical challenges. MRI requires greater time. CT scanning can reveal smaller amounts of soft-tissue gas than plain radiography and can demonstrate fluid collections that track along the deep fascial planes. Ultrasonography Ultrasonography can be used to detect fluid or gas within the soft tissues. however. Testes and epididymides are usually normal. However. perirectal abscess). The drawback of ultrasonography is the need for direct pressure on the involved tissue. which are not shared by CT scanning. necrotizing infection) from severe cellulitis. Air may be appreciated in perineal and/or perirectal areas.

Tetanus prophylaxis is indicated if soft-tissue injury is present. Early. as is the presence of causative microorganisms within the tissues. Clindamycin is particularly useful in the treatment of necrotizing soft-tissue infections because of its gram-positive and anaerobic spectrum of activity. A reasonable empiric regimen might consist of ciprofloxacin and clindamycin. the emergency department (ED) treatment of patients with Fournier gangrene includes aggressive resuscitation in anticipation of surgery.[46] In patients who present with systemic toxicity manifesting as hypoperfusion or organ failure. In cases associated with sepsis syndrome. Microorganisms identified within the involved tissues Fibrinoid thrombosis of the nutrient vessels that supply the superficial and deep fascia is the finding that most commonly indicates Fournier disease. give supplemental oxygen. Crystalloid replacement is indicated for patients who are dehydrated or displaying signs of shock. Antibiotic and Antifungal Therapy Treatment of Fournier gangrene involves the institution of broad-spectrum antibiotic therapy. aggressive resuscitation to restore normal organ perfusion and function must take precedence over diagnostic maneuvers. Vancomycin can be used to provide coverage for methicillinresistant Staphylococcus aureus (MRSA). The antibiotic spectrum should cover staphylococci. Thus.[47] Other possible choices include ampicillin/sulbactam. and anaerobes. ticarcillin/clavulanate. Provide airway management if indicated. alcoholism) must ultimately be addressed. Failure to adequately manage the comorbid conditions may threaten the success of even the most appropriate interventions to resolve the infectious disease. diabetes. broad-spectrum antibiotics are indicated. Widespread necrosis of the fascia with acute inflammatory cell infiltration and necrotic debris is frequently evident. Approach Considerations Treatment of Fournier gangrene involves several modalities. or piperacillin/tazobactam in combination with an aminoglycoside and metronidazole or clindamycin. therapy with intravenous immunoglobulin (IVIG). any underlying comorbid conditions (eg. the Enterobacteriaceae family of organisms. especially if these diagnostic studies could compromise the resuscitative interventions. clindamycin has been shown to yield response rates superior to those of penicillin or erythromycin. Such conditions are common in these patients. streptococci. even in the context of delayed treatment. This extensive inflammatory process is frequently present deep to intact skin. and potentially predispose to Fournier gangrene. Surgery is necessary for definitive diagnosis and excision of necrotic tissue. Earlier surgical intervention has been associated with reduced mortality. The skin itself is often minimally involved with the inflammatory process until late in the disease. which is thought to neutralize . In animal models of streptococcal infection. and establish intravenous (IV) access and continuous cardiac monitoring. In addition.

Occasionally. the overlying skin has impaired blood supply and should be excised if significantly undermined. See image below.38) than those whose intervention was delayed to 3 days or later. Courtesy of Thomas A. The testicles were not involved. Send samples of excised tissue for aerobic and anaerobic cultures and a histologic assessment. The authors strongly recommend radical excisional debridement (see below image) with electrocautery in order to reduce the considerable operative blood loss if the area of involvement is extensive. has been shown to be a good adjuvant to appropriate antibiotic coverage and complete surgical debridement. Those who underwent earlier intervention had a lower fatality rate (odds ratio. All fascial planes that separate easily with blunt dissection should be considered involved and therefore excised. 0. Surgical Diagnosis and Debridement In the event of a presumptive diagnosis based on a clinical examination or diagnostic study. Sugihara et al confirmed the opinion that early surgical intervention reduces mortality. obtain an incisional biopsy sample of the deep fascia for frozen-section evaluation to exclude early necrotizing disease. In a large retrospective review of 379 patients. early-stage Fournier disease manifests as severe cellulitis. If an incision is made. gangrene. all necrotic tissue must be excised. In this instance.[46] The skin should be opened widely to expose the full extent of the underlying fascial and subcutaneous tissue necrosis. the fascia may appear edematous rather than exhibiting the gray-black appearance of well-established Fournier Given the characteristic thrombosis of the nutrient vessels. streptotoxins A and B) believed to mitigate the exaggerated cytokine response. . the definitive diagnosis of Fournier gangrene is provided by examination with the patient under anesthesia followed by incision into the area of greatest clinical concern. Excising necrotic tissue Once a diagnosis of Fournier gangrene is established. the diagnosis of Fournier gangrene is established. In a man with alcoholism and known cirrhosis who presented with exquisite pain limited to the scrotum. The dissection should be carried out to include bleeding tissues (ie. potassium hydroxide [KOH] stain) show fungi. If frankly gangrenous tissue is found or purulence is drained. Santora.superantigens (eg. MD. tissue that is well vascularized). add an empiric antifungal agent such as amphotericin B or caspofungin. opening of the scrotum along the median raphe liberated foul-smelling brown purulence and exposed necrotic tissue throughout the mid scrotum.[48] If initial tissue stains (ie.

Investigational Treatments The role of topical agents in wound care requires further investigation. ischiorectal space) Hyperbaric Oxygen Therapy Patient with Fournier gangrene following radical debridement. or myonecrosis or deep tissue involvement. taking into consideration the stability of the patient.[54] Decisions regarding HBO must be made on an individual basis. A dorsal slit was made in the prepuce to expose the glans penis. Options for following:  Hyperbaric oxygen therapy (HBO) has been used as an adjuvant to surgical and antimicrobial therapy. This patient made a full recovery. Reconstruction of this defect was performed in a staged approach. The role of HBO in the treatment of Fournier disease needs to be clarified with a prospective controlled trial. HBO has shown some promising results. Urethral catheterization was performed. sterilize. Indications include failure of conventional treatment. the salutatory effect of honey is likely related to its physical property of hyperosmolarity. there was actually a trend toward increased mortality in patients undergoing HBO. Reconstruction Once the infection is eradicated. applied directly to the surface of the wounds. in one series. However. this signifies the time to proceed to reconstruction. Unprocessed honey. place the exposed testicle in a subcutaneous pocket to prevent desiccation.[54]although this trend may have been related to selection bias. which are used to fill a cavity (eg. A gracilis rotational muscle flap taken from the right thigh was used to fill the cavity in the posterior right perineum as the first step. Use of HBO must not delay surgical debridement.[51. honey holds reconstruction include the Primary closure of the skin. Incision into the point of maximal tenderness on the right side of the perineum revealed gangrenous necrosis that involved the anterior and posterior aspects of the perineum. HBO is postulated to reduce systemic toxicity. The remainder of the defect was covered with split-thickness skin grafts.[55] Therefore. If it is uninvolved. The skin and involved fascia were excised from these areas. if possible . 53] However. documented clostridial involvement. The testicles are often spared in the necrotizing process. performorchiectomy. and inhibit growth of anaerobic bacteria. has been reported by some authors to enzymatically debride. and dehydrate wounds and to improve local tissue oxygenation and re-epithelialization. 52.   Local skin flap coverage Split-thickness skin grafts Muscular flaps. If a testicle is involved in the necrotic process or its viability is questioned. healthy granulation tissue develops. and the posterior medial aspect of the right thigh. the entirety of the right hemiscrotum. prevent extension of necrotizing infection.

[56] The application of growth hormones and other trophic agents holds the potential to promote faster wound healing. and anaerobes. a general surgeon. and anaerobic bacteria is essential. covers skin. follow creatinine clearance (CrCl). Class Summary Initiate early broad-spectrum antibiotics as soon as possible. including a urologist. Dose adjustment may be necessary in patients with renal impairment. combine with an agent active against enteric flora and/or anaerobes. Transfer to a tertiary facility may be required if these resources are not available at the initial facility. To avoid toxicity. assay of vancomycin trough levels after the third dose drawn 0. One published case report advocates irrigation of the perineum with superoxidized water as well as application of gauze soaked in zinc peroxide and hydrogen peroxide. It is useful for the treatment of septicemia and skin structure infections.5 h prior to next dosing currently is recommended. Vancomycin is indicated for patients who cannot receive or have failed to respond to penicillins and cephalosporins or for those who have infections with resistant staphylococci. Ticarcillin and (Timentin) clavulanate potassium This antipseudomonal penicillin plus betalactamase inhibitor provides coverage against most gram-positive and gram-negative organisms and most anaerobes. Transfer Fournier gangrene is a true surgical emergency. It contains . Vancomycin (Vancocin) Vancomycin is a potent antibiotic directed against gram-positive organisms and active against enterococcal species. Ampicillin-sulbactam sodium (Unasyn) This is a drug combination that uses a betalactamase inhibitor with ampicillin. gram-negative. At minimum. immediate urologic or general surgical consultation is mandatory. Penicillins and beta-lactamase inhibitors or triple antibiotics are potential choices. enteric flora. aerobic. and an intensive care specialist.little advantage over other hygroscopic agents. Providing coverage for gram-positive. and management often requires a multidisciplinary team. not ideal for nosocomial pathogens. Arrange for transfer once the patient has been stabilized and resuscitative efforts have begun. Initial debridement may be performed if required in anticipation of transfer. For abdominal penetrating injuries.

where it preferentially binds to the 50S ribosomal subunit. Piperacillin and tazobactam (Zosyn) This combination of an antipseudomonal penicillin and a beta-lactamase inhibitor inhibits biosynthesis of bacterial cell wall mucopeptide and is effective during the stage of active multiplication. gentamicin is commonly used in combination with both an agent against gram-positive organisms and one that covers anaerobes. except enterococci. Immunizations Class Summary Fatal tetanus associated with Fournier gangrene has been documented in the literature. when bacterial susceptibility tests and clinical judgment indicate use. This agent inhibits bacterial protein synthesis by inhibiting peptide chain initiation at the bacterial ribosome. Patients with noncurrent tetanus status require immunization in the emergency department. except when used for Clostridium difficile enterocolitis. unstable intermediate compounds are formed that bind DNA and inhibit synthesis. it is also effective against aerobic and anaerobic streptococci.4. Dosing regimens are numerous and are adjusted on the basis of CrCl and changes in the volume of distribution. Ticarcillin inhibits biosynthesis of bacterial cell wall mucopeptide and is effective during the active growth stage. This toxoid commonly is combined with diphtheria toxoid. Metronidazole is active against various anaerobic bacteria and protozoa. then. . Gentamicin An aminoglycoside antibiotic used for gramnegative bacterial coverage. Clindamycin (Cleocin) Clindamycin is a lincosamide useful in treatment against serious skin and soft-tissue infections caused by most staphylococci strains. and in mixed infections caused by susceptible strains of staphylococci and gram-negative organisms. and both serve to induce production of serum antibodies to toxins produced by the bacteria. It is usually given in combination with other antimicrobial agents. causing bacterial growth inhibition. Consider using gentamicin when penicillins or other less toxic drugs are contraindicated. It appears to be absorbed into cells of microorganisms that contain nitroreductase. in which case monotherapy is appropriate. causing cell death. Gentamicin may be administered IV or IM.7-5 mEq of sodium per gram. Diphtheria and tetanus toxoid (Decavac) Tetanus toxoid is manufactured by first culturing Clostridium tetani and then detoxifying the toxin with formaldehyde. Metronidazole (Flagyl) Metronidazole is an imidazole ring-based antibiotic that is active against anaerobes.