What is the treatment for Fournier gangrene?

Treatment of Fournier Gangrene

Fournier gangrene requires immediate surgical debridement as soon as the diagnosis is suspected—do not delay surgery for imaging, laboratory results, or any other reason in clinically obvious or hemodynamically unstable patients. 1, 2

Immediate Surgical Management

Timing is critical for survival. The World Journal of Emergency Surgery provides a strong recommendation that surgical intervention must occur as soon as possible, as delayed treatment directly increases mortality. 1

Initial Debridement

• Remove all visible necrotic tissue completely at the first operation—this is the single most important intervention for survival. 1, 2
• Obtain microbiological samples (cultures of infected fluid and tissue) during the index operation to guide subsequent antibiotic de-escalation. 2
• The infection spreads along fascial planes and is far more extensive than the visible skin changes suggest—debride aggressively beyond what appears affected on the surface. 3

Repeat Debridements

• Plan serial surgical revisions every 12-24 hours until no necrotic tissue remains, as this approach reduces mortality and decreases the total number of debridements ultimately required. 1, 2
• Continue repeat debridements based on patient condition until the patient is completely free of necrotic tissue. 1

Organ-Sparing Approach

• Avoid orchiectomy or extensive genital surgery unless absolutely necessary—the testes, glans penis, bladder, and rectum are usually spared due to their separate blood supplies. 1, 2, 3
• Obtain urology consultation before considering orchiectomy or other genital procedures. 1, 2

Fecal and Urinary Diversion

• Delay the decision regarding colostomy for 48 hours after initial surgery to allow acute inflammation and edema to subside, enabling proper evaluation of sphincter integrity. 1, 2
• Consider colostomy only for: anal sphincter involvement, fecal incontinence, or continued fecal contamination of the wound. 1, 2
• Note that temporary stoma formation significantly increases healthcare costs without affecting mortality rates or hospital length of stay. 1
• Consider suprapubic cystostomy for extensive urethral involvement or continued urinary contamination. 1

Antibiotic Therapy

• Start empiric broad-spectrum antibiotics immediately upon suspicion of Fournier gangrene, before surgical intervention. 2
• Coverage must include gram-positive organisms (including MRSA), gram-negative organisms, and anaerobes, as this is a polymicrobial synergistic infection. 2, 4, 3
• De-escalate antibiotics based on culture results, clinical improvement, and rapid diagnostic tests when available. 2

Hemodynamic Resuscitation

• Aggressive fluid resuscitation and cardiopulmonary support are essential components of management alongside surgery and antibiotics. 1, 3
• Vasoactive medications may be required for hemodynamic stabilization. 4
• Nutritional support is of major importance in the perioperative period. 3

Diagnostic Imaging (When Appropriate)

Critical caveat: Do not delay surgery for imaging in clinically obvious cases or hemodynamically unstable patients—imaging is not mandatory when clinical or hemodynamic impairment is present. 1, 2

When Imaging is Appropriate

• If the patient is stable and diagnosis is uncertain, contrast-enhanced CT is the preferred modality with 90% sensitivity and 93.3% specificity for evaluating disease extent and identifying underlying causes. 1, 2, 4, 5
• Bedside point-of-care ultrasound is useful when CT is unavailable or transport is unsafe, demonstrating scrotal skin thickening, soft tissue inflammation, collections/abscesses, and subcutaneous gas. 1, 2, 4
• Plain radiographs can demonstrate gas in soft tissue planes but have limited utility. 1
• MRI has excellent soft tissue resolution but is impractical in emergency settings due to extended examination time and limited access. 1

Multidisciplinary Team Involvement

• Involve general/emergency surgeons, urologists, intensivists, and plastic surgeons early in the treatment course. 1, 2
• A multidisciplinary approach is essential for managing both acute complications and planning reconstruction of surgical defects. 1, 2

Adjunctive Therapies

• Vacuum-assisted closure (VAC) can be used after debridement in select patients, though it may increase hospital length of stay and number of debridements. 6, 7
• Hyperbaric oxygen therapy remains theoretically beneficial but unproven in terms of mortality benefit—consider for patients unresponsive to conventional treatment. 3, 7

Prognostic Assessment

• Calculate the Fournier's Gangrene Severity Index (FGSI) using physiological parameters (temperature, heart rate, respiration rate, sodium, potassium, creatinine, leukocytes, hematocrit, bicarbonate) to predict outcomes. 2, 7
• Despite optimal management, mortality rates remain 20-50% in contemporary series, emphasizing the critical importance of early recognition and aggressive treatment. 2, 4, 3, 7