Fournier gangrene

1. Fournier gangrene

4. Introduction • Gangrene affecting the male genitalia

5. Aetiology • Anorectal causes: • Colorectal injury • Infection of the perianal glands • Urethral injury • Infection of the bulbourethral glands • Idiopathic

6. Comorbid conditions • Diabetes mellitus (cited most often) • Morbid obesity • Cirrhosis • Vascular disease of the pelvis • Malignancies • High-risk behaviors (e.g. alcoholism, intravenous drug abuse) • Immune suppression due to systemic disease or steroid administration

7. Common organisms involved • Streptococcal species • Staphylococcal species • Genera of the Enterobacteriaceae family • Anaerobic organisms • Fungi

8. Clinical features • The hallmark of Fournier gangrene is intense pain and tenderness in the genitalia. • The clinical course usually progresses through the following phases: • Prodromal symptoms of fever and lethargy, which may be present for 2-7 days • Intense genital pain and tenderness that is usually associated with edema of the overlying skin • Increasing genital pain and tenderness with progressive erythema of the overlying skin • Dusky appearance of the overlying skin; subcutaneous crepitation • Obvious gangrene of a portion of the genitalia; purulent drainage from wounds

9. Examination of an anesthetized man with alcoholism and known cirrhosis who presented with exquisite pain limited to the scrotum. Note the erythema of the scrotum and the look of skepticism on the face of one of the surgeons.

10. Work up • A detailed history • Blood: TC, DC, ESR, culture, BUN, coagulation profile • X- ray of the genitalia • USG • CT scan

11. Work up • A detailed history • Blood: TC, DC, ESR, culture, BUN, coagulation profile • X- ray of the genitalia • USG • CT scan • Local wound discharge for culture & sensitivity test

12. Treatment • Broad spectrum antibiotics • Surgical excision of the involved tissue

13. The same patient depicted above. The scrotum has been opened along the median raphe, which liberated foul-smelling brown purulence and exposed necrotic tissue throughout the mid scrotum. The testicles were not involved.

14. The same patient depicted above, following the first radical debridement procedure. A dorsal slit was made in the prepuce to expose the glans penis. Urethral catheterization was performed. Incision into the point of maximal tenderness on the right side of the perineum revealed gangrenous necrosis that involved the anterior and posterior aspects of the perineum, the entirety of the right hemiscrotum, and the posterior medial aspect of the right thigh. The skin and involved fascia were excised from these areas. Reconstruction of this defect was performed in a staged approach. A gracilis rotational muscle flap taken from the right thigh was used to fill the cavity in the posterior right perineum as the first step. The remainder of the defect was covered with split-thickness skin grafts. This patient made a full recovery.

15. The same patient depicted above. Following resolution of the infection, the wound was covered with a split-thickness skin graft