Fournier's Gangrene
The condition you're asking about is called Fournier's gangrene—a necrotizing fasciitis of the scrotum, penis, and perineum that represents a true surgical emergency with mortality rates approaching 20-50%. 1
Definition and Clinical Characteristics
Fournier's gangrene is an aggressive, polymicrobial soft-tissue infection involving the external genitalia, perineum, and perianal region. 1 The disease was first described by Baurinne in 1764 and named after French dermatologist Jean Alfred Fournier who characterized it in 1883. 1
The infection typically presents with painful swelling of the scrotum or perineum accompanied by sepsis, though up to 40% of cases have a more insidious onset with undiagnosed pain that delays treatment. 1
Key Risk Factors
The most critical predisposing factors include:
- Diabetes mellitus (the single most important risk factor) 1, 2
- Immunocompromised status from malnutrition or other causes 1
- High body mass index/obesity 1, 2
- Recent urethral or perineal surgery 1
- Advanced age (mean presentation age 51 years) 2
Microbiology
This is a polymicrobial infection involving both aerobic organisms (Streptococcus species, Staphylococcus species, Escherichia coli) and anaerobic bacteria (Bacteroides, Clostridium, Peptostreptococcus). 2, 3 The mixed flora creates a synergistic infection that causes rapid tissue destruction through obliterative endarteritis, vascular thrombosis, and subsequent tissue ischemia. 2
Clinical Presentation Features
Look specifically for:
- Scrotal or perineal erythema, edema, and tenderness 1
- Subcutaneous crepitations (gas in tissues) 1
- Patches of gangrene or necrosis 1
- Foul-smelling purulent discharge 1
- Systemic signs of sepsis (fever, tachycardia, hypotension) 4
A critical pitfall: The degree of internal necrosis vastly exceeds what external examination suggests, so a high index of suspicion is essential, particularly in obese patients where examination is limited. 1
Anatomic Spread Pattern
The infection extends along fascial planes—Colles' fascia is continuous with Scarpa's fascia of the anterior abdominal wall and Buck and Dartos' fascia of the penis and scrotum. 1 This allows cranial extension to the abdominal wall and caudal spread to the thighs. 1, 2 Testicular involvement is rare due to the separate blood supply from the spermatic vessels. 1