From the Guidelines
Fournier gangrene presents with rapidly progressive necrotizing fasciitis of the perineal, genital, or perianal regions, characterized by severe pain, erythema, edema, and tenderness, with systemic manifestations including fever, tachycardia, hypotension, and altered mental status indicating sepsis. The clinical findings of Fournier gangrene include cutaneous manifestations such as erythema, subcutaneous crepitations, patches of gangrene, and a foul smell, as well as systemic signs of sepsis 1. The diagnosis is based on clinical signs and physical examination, including a digital rectal examination, and may be supported by imaging studies such as CT or MRI to confirm the extent of soft-tissue involvement 1.
Key Clinical Features
- Severe pain that may seem disproportionate to initial physical findings
- Erythema, edema, and tenderness of the affected areas
- Skin changes progressing from erythema to dusky blue discoloration, followed by frank gangrene and necrosis with crepitus
- Systemic manifestations including fever, tachycardia, hypotension, and altered mental status indicating sepsis
- Laboratory findings showing leukocytosis, elevated inflammatory markers, hyperglycemia, electrolyte abnormalities, and renal dysfunction
Risk Factors
- Diabetes mellitus
- Alcoholism
- Immunocompromised status
- Local trauma
- Recent urethral or perineal surgery
- High body mass index
Management
The management of Fournier gangrene involves prompt surgical intervention, broad-spectrum antibiotics, and hemodynamic support 1. Early and aggressive surgical debridement is crucial to improve survival and reduce the number of surgical revisions. The use of scoring systems such as the Fournier’s Gangrene Severity Index (FGSI) can help predict patient mortality and guide management 1.
Scoring Systems
- Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC) score
- Fournier’s Gangrene Severity Index (FGSI)
- Simplified FGSI (SFGSI)
- Uludag FGSI (UFGSI)
It is essential to note that the management of Fournier gangrene should be individualized, and the use of adjunctive treatments should be considered on a case-by-case basis 1.
From the Research
Clinical Findings of Fournier Gangrene
The clinical findings of Fournier gangrene include:
- A rare, life-threatening infection that can result in significant morbidity and mortality 2
- A strong association with male patients with advanced age and comorbidities affecting microvascular circulation and immune system function, most commonly those with diabetes or alcohol use disorder 2, 3
- The initial infectious nidus is usually located in the genitourinary tract, gastrointestinal tract, or perineum 2
- A mixed infection of aerobic and anaerobic bacterial flora 2, 4
- The development and progression of gangrene is often fulminant and can rapidly cause multiple organ failure and death 2
- Patients may present subacutely with findings similar to cellulitis 2
Diagnostic Findings
Diagnostic findings include:
- Laboratory studies and imaging, such as point-of-care ultrasound, conventional radiography, and computed tomography, which are important diagnostic adjuncts 2
- A clinical diagnosis, with relevant laboratory and radiography investigations serving as useful adjuncts to expedite surgical management, hemodynamic resuscitation, and antibiotic administration 2
- The Fournier's gangrene severity index (FGSI) score can be used to evaluate patients 5
Risk Factors
Risk factors for Fournier gangrene include:
- Diabetes 2, 3, 6, 4
- Alcoholism 2, 3, 6
- Immunocompromise, including human immunodeficiency virus (HIV) 3, 6
- Advanced age 2, 3
- Male gender 2, 3
- Malnutrition and low socioeconomic status 4
Treatment
Treatment of Fournier gangrene includes: