From the Guidelines
Fournier gangrene is a rare but life-threatening bacterial infection that causes tissue death (gangrene) in the genital, perineal, and perianal regions, requiring immediate hospitalization for aggressive surgical debridement and broad-spectrum intravenous antibiotics.
Definition and Causes
Fournier gangrene is a type of necrotizing fasciitis that primarily affects men, particularly those with diabetes, immune system disorders, alcoholism, or poor hygiene 1. The infection typically begins with trauma or an infection in the genital area that rapidly spreads along fascial planes, causing severe pain, swelling, redness, and foul-smelling discharge.
Symptoms and Diagnosis
The condition is characterized by perineal and/or scrotal pain, swelling, and erythema, with systemic features such as fever and tachycardia often present 1. Diagnosis is mainly clinical, with a focused medical history and complete physical examination, including a digital rectal examination, being essential for diagnosis 1.
Treatment and Management
Treatment requires immediate hospitalization for aggressive surgical debridement to remove all dead tissue, broad-spectrum intravenous antibiotics, and intensive supportive care including fluid resuscitation and pain management 1. Early and extensive initial surgical debridement in Fournier’s gangrene patients improves survival 1. Multiple surgeries are often needed, and mortality rates range from 20-40% despite treatment.
Key Considerations
The decision regarding the need for fecal or urinary diversion and the best way to achieve them should be made by a multidisciplinary team and should be tailored to the characteristics of the individual patient 1. Negative pressure wound therapy (NPWT) plays an important role in managing soft tissue infections, but its use should be limited to short periods of time to avoid intra-rectal damage due to the device itself 1.
Prognosis and Outcome
The Fournier’s Gangrene Severity Index (FGSI) is a standard score for predicting outcome in patients with FG, with a score above 9 being sensitive and specific as a mortality predictor 1. Early recognition and immediate surgical intervention are crucial for survival, with prompt appropriate antibiotic therapy, hemodynamic support, and early debridement being essential for treatment 1.
From the Research
Definition and Overview of Fournier Gangrene
- Fournier gangrene (FG) is a rare, life-threatening infection that can result in significant morbidity and mortality 2.
- It is a mixed infection of aerobic and anaerobic bacterial flora, often affecting the genitourinary tract, gastrointestinal tract, or perineum 2.
- FG is characterized by a polymicrobial infection of the perineal, genital, or perianal region, leading to thrombosis of the small subcutaneous vessels and necrosis of the overlying skin 3.
Risk Factors and Demographics
- FG has a higher incidence in males, with risk factors including diabetes, HIV, alcoholism, and other immune-compromised states 4, 5.
- Advanced age and comorbidities affecting microvascular circulation and immune system function are also common among patients with FG 2.
- The disease can affect patients without risk factors, but certain conditions such as diabetes mellitus, hypertension, and alcoholism are predisposing factors to a more severe or fatal course 3.
Clinical Presentation and Diagnosis
- FG often begins as a simple abscess or cellulitis with progression to necrotizing soft tissue infection (NSTI) 5.
- The initial presentation may be subtle, with patients presenting subacutely with findings similar to cellulitis 2.
- Laboratory studies and imaging, including point-of-care ultrasound, conventional radiography, and computed tomography, are important diagnostic adjuncts, although negative results cannot exclude diagnosis 2.
Treatment and Management
- Emergent surgical debridement of all necrotic tissue, broad-spectrum antibiotics, and resuscitation with intravenous fluids and vasoactive medications are essential components of treatment 2, 4.
- Early recognition and high clinical suspicion are crucial in making a timely diagnosis, as delays in diagnosis and treatment confer high mortality 5.
- Coordination of both inpatient medical and surgical teams to implement appropriate therapy is vital to successful outcomes 5.