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Copyright 2004, 2011
NORD is very grateful to Rodolfo L. Bracho-Riquelme, MD, General and Colorectal Surgeon, Hospital General de Durango, Mexico, for assistance in the preparation of this report.
Fournier gangrene is a serious, rapidly progressive infective gangrene involving the scrotum, penis, and/or perineum caused by a broad array of microorganisms, acting in mutual support of one another (synergistically) and usually resulting from local trauma, operative procedures, or urinary tract disease.
Since 1950, more than 1,800 cases for study have been reported in English language medical literature. This disease occurs worldwide and, although it is recognized more frequently among male adults, has been identified also among women and children. Treatment usually consists of the surgical removal (debridement) of extensive areas of dead tissue (necrosis, necrotic) and the administration of broad-spectrum intravenous antibiotics. Surgical reconstruction may follow where necessary.
Symptoms include fever, general discomfort (malaise), moderate to severe pain and swelling in the genital and anal areas (perineal) followed by rankness and smell of the affected tissues (fetid suppuration) leading to full blown (fulminating) gangrene. Rubbing the affected area yields the distinct sounds (crepitus) of gas in the wound and of tissues moving against one another (palpable crepitus). In severe cases, the death of tissue can extend to parts of the thighs, through the abdominal wall and up to the chest wall.
This disease is commonly found in conjunction with other disorders (comorbidity), especially those that weaken the immune system. Some disorders that increase the predisposition to Fournier gangrene are diabetes mellitus, profound obesity, cirrhosis, interference with the blood supply to the pelvis, and various malignancies.
Portals of entry for the bacteria, fungi, and/or viruses responsible for a particular case of Fournier gangrene are generally either colorectal, urogenital or cutaneous in origin. Anorectal abscesses, urinary tract infections, improperly sterilized surgical instrumentation and other contributing factors have all been implicated. Some cases continue to be of unknown cause (idiopathic). Why this process occasionally develops in individuals with common ailments is still not understood.
There are many ways for the virulent microorganism to gain access to the host, where the compromised immunological system is unable to prevent the infection from taking hold. The virulence of the resulting disorder is thought to be enhanced by the toxins and enzymes produced by the combination of microorganisms (synergy).
The mean age of presentation is about 50 years, but the range of patient ages in reported cases is from eight days to 90 years. Fournier gangrene is diagnosed more frequently among males. It may be that the lopsidedness in male to female diagnosis is the result of the lack of recognition of this entity among women by physicians. It is believed that the male to female ratio may be anywhere from 5:1 to 10:1.
Symptoms of the following disorders can be similar to those of Fournier gangrene. Comparisons may be useful for a differential diagnosis.
Epididymitis is inflammation of the long, tightly coiled tube behind each testicle (epididymis) that carries sperm from the testicle to the spermatic duct. Affected individuals usually have painful swelling of the one epididymitis and the associated testicle. In some cases, the second testicle may also be tender. In addition, affected individuals have fever, painful swelling and redness (erythema) of the scrotum, and/or inflammation of the tube from which urine is carried from the bladder (urethritis). The two main forms of epididymitis are the sexually-transmitted form and the nonspecific bacterial form. (For more information on this disorder, choose "Epididymitis" as your search term in the Rare Disease Database.)
Gas gangrene is a severe form of tissue death usually caused by bacteria that do not need oxygen (anaerobes) to survive, such as Clostridium perfringens. It can also result from infections caused by Group A Streptococcus bacteria and Staphlococcus aureus and Vibrio vulnificus. Clostridium bacteria in an environment of low oxygen concentration produce toxins that cause tissue death and associated symptoms. Gas gangrene is rare, with only 1,000 to 3,000 cases occurring in the United States annually.
Hydrocele is a fluid-filled sack along the spermatic cord within the scrotum. Hydroceles are common in the newborn infant. They may be unilateral or bilateral and result when there is failure of the tract through which the testis descends from the abdomen into the scrotum to close. Peritoneal fluid drains through the open tract from the abdomen into the scrotum where it becomes trapped causing enlargement of the scrotum. Hydroceles may also be caused by inflammation or trauma of the testicle or epididymis or by fluid or blood obstruction within the spermatic cord. The incidence of this type of hydrocele is higher in older men.
Orchitis is an inflammation of one or both of the testicles, often caused by infection. Orchitis may be caused by numerous bacterial and viral organisms. It is usually a consequence of epididymitis (see above). The most common viral cause of orchitis is mumps. Approximately 30% of patients who have mumps will develop orchitis during the course of the illness. It is most common in post-pubertal boys (rare before 10 years of age). It usually manifests 4 to 6 days after the onset of mumps. In one-third of boys who get orchitis caused by mumps, testicular atrophy (shrinking of the testicles) will result.
Debilitating illnesses, such as diabetes, alcoholism, HIV infection, and malnutrition seem to increase the susceptibility of a person to Fournier gangrene but are not related disorders.
The diagnosis is basically made on clinical findings. Ultrasound evaluation may achieve early differentiation between Fournier gangrene and an acute inflammatory process, such as epididymitis or orchitis. Computed tomography may help to determine the portal of entry and extension of the process, but is not indispensable and should not delay surgical treatment.
X-ray studies are useful to confirm the location and extent of gas distribution in the wounds. Ultrasonography is useful to detect gases and/or fluids, but patients with severe pain may not be able to tolerate the pressures on the skin required to obtain an acceptable image. Computerized tomographic (CT) images are preferred because they resolve smaller amounts of soft tissue gases and fluids.
It is critical to recognize the disorder and to initiate aggressive resuscitation and administration of broad-spectrum intravenous antibiotics as quickly as possible. Such antibiotics must be followed by urgent surgical debridement of all affected dead (necrotic) skin and subcutaneous tissue involved, with repeated removal of wound margins as necessary. If colorectal or urogenital origin is established, source control is imperative, in accordance with each case. Patients with severe blood infection (sepsis) are at increased risk for developing blood clots (thrombembolic phenomena) and may require medication to reduce the risk for thrombosis Reconstructive surgery is undertaken, once infection is under control.
Colostomy remains controversial as a means of decreasing fecal contamination. Foley catheters generally get rid of urine adequately.
When available, a burn center may be a good location for the treatment of patients with necrotizing soft-tissue surgical infections, including Fournier gangrene.
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FROM THE INTERNET
Thomsen T, Legome E. Fournier Grangrene. eMedicine. Updated December 6, 2010.
www.emedicine.com/emerg/topic929.htm. Accessed. March 9, 2011.
Fournier's Gangrene. Urological Emergencies. Urologychannel. Last modified September 29, 2010. www.urologychannel.com/emergencies/fgangrene.shtml. Accessed March 9, 2011.
Santora T, Rukstalis DB. Fournier Gangrene. eMedicine. Updated March 19, 2009. www.emedicine.com/med/topic2814.htm. Accessed March 9, 2011.
Report last updated: 2011/03/09 00:00:00 GMT+0