From the Guidelines
Fournier gangrene requires immediate aggressive treatment with a combination of surgical debridement, broad-spectrum antibiotics, and supportive care. The treatment approach should prioritize surgical intervention as the cornerstone of treatment, which should be performed urgently, involving extensive debridement of all necrotic tissue until healthy, bleeding tissue is encountered, as recommended by the 2021 WSES-AAST guidelines 1.
Key Components of Treatment
- Surgical debridement: Early and aggressive surgical debridement improves survival and reduces the number of surgical revisions, as shown in the 2018 WSES/SIS-E consensus conference recommendations 1.
- Antibiotic therapy: Broad-spectrum antibiotics should be started immediately, with coverage for gram-positive, gram-negative, aerobic, and anaerobic bacteria, and an anti-MRSA agent, as recommended by the 2021 WSES-AAST guidelines 1.
- Supportive care: Supportive measures include fluid resuscitation, pain management, nutritional support, and glycemic control in diabetic patients.
Antibiotic Regimen
The choice of antibiotic regimen should be based on the most recent guidelines, such as the 2024 European Association of Urology guidelines, which suggest a combination of piperacillin-tazobactam, vancomycin, and imipenem-cilastatin or meropenem as a suitable regimen for Fournier’s gangrene 1.
Surgical Approach
The surgical approach should be multidisciplinary and tailored to the individual patient, with consideration for fecal diversion, urinary diversion, and reconstructive surgery as needed, as suggested by the 2021 WSES-AAST guidelines 1.
Adjunctive Treatments
Hyperbaric oxygen therapy may be considered as an adjunctive treatment in some cases, and negative pressure wound therapy (NPWT) can be used to manage soft tissue infections, as discussed in the 2021 WSES-AAST guidelines 1.
Overall, the aggressive approach is necessary because Fournier gangrene is a rapidly progressive, polymicrobial infection that causes extensive tissue destruction through synergistic enzymatic mechanisms, with mortality rates of 20-30% if not promptly treated, as highlighted in the 2018 WSES/SIS-E consensus conference recommendations 1.
From the Research
Clinical Signs of Fournier Gangrene
- Scrotal and labial pain
- Fever
- Abscesses
- Crepitus
- Erythema
- Cellulitis 2
- The disease often begins as a simple abscess or cellulitis with progression to necrotizing soft tissue infection (NSTI) 3
Treatment for Fournier Gangrene
- Emergent surgical debridement of all necrotic tissue 4, 5, 6, 2
- Broad-spectrum antibiotics 4, 5, 6, 2
- Resuscitation with intravenous fluids and vasoactive medications 4
- The use of adjunctive therapies such as hyperbaric oxygen and vacuum assisted closure are supported in some aspects of the literature and disputed in others 5
- The value of unprocessed honey as a topical antimicrobial agent has been highlighted in the literature for small lesions in uncomplicated patients 5
- Reconstruction of perineal defects using skin grafts, flaps, and urethral reconstruction using gracilis flaps can reduce the morbidity associated with FG and provide acceptable functional and aesthetic outcomes 6
Importance of Early Diagnosis and Treatment
- Early recognition and high clinical suspicion are important in making a timely diagnosis, as early manifestations are often subtle 3
- Delays in diagnosis and treatment confer high mortality 3
- Patient survival was found to be directly related to the time from diagnosis to treatment when they underwent surgical debridement 2