Fournier Gangrene

Fournier Gangrene

National Organization for Rare Disorders, Inc.

Important

It is possible that the main title of the report Fournier Gangrene is not the name you expected. Please check the synonyms listing to find the alternate name(s) and disorder subdivision(s) covered by this report.

Synonyms

  • Fournier disease
  • Fournier gangrenes
  • necrotizing fasciitis of the perineum and genitalia
  • synergistic necrotizing fasciitis of the perineum and genitalia

Disorder Subdivisions

  • None

General Discussion

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

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.

Causes

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).

Affected Populations

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.

Standard Therapies

Diagnosis

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.



Treatment

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.

Investigational Therapies

Information on current clinical trials is posted on the Internet at www.clinicaltrials.gov. All studies receiving U.S. government funding, and some supported by private industry, are posted on this government web site.



For information about clinical trials being conducted at the NIH Clinical Center in Bethesda, MD, contact the NIH Patient Recruitment Office:



Tollfree: (800) 411-1222

TTY: (866) 411-1010

Email: prpl@cc.nih.gov



For information about clinical trials sponsored by private sources, contact:

www.centerwatch.com

References

TEXTBOOKS

Corman ML. Colon and rectal surgery. 4th ed. Philadephia; PA: Lippincott-Raven, 1998.



REVIEW ARTICLES

Mopurgo E, Galandiuk S. Fournier's gangrene. Surg Clin North Am. 2002;1213-24.



Korhonen K. Hyperbaric oxygen therapy in acute necrotizing infections with a special reference to the effects on tissue gas tensions. Ann Chir Gynaecol Suppl. 2000;214:7-36.



Yagham RJ, Al-Jaberi TM, Bani-Hani I. Fournier's gangrene: changing face of the disease. Dis Colon Rectum. 2000;43:1300-08.



Eke N. Fournier's gangrene: a review of 1726 cases. Br J Surg. 2000;87:718-28.



JOURNAL ARTICLES

Korkut M, Icoz G, Dayangac M, et al. Outcome analysis in patients with Fournier's gangrene: report of 45 cases. Dis Colon Rectum. 2003;46:649-52.



Norton KS, Johnson LW, Perry T, et al. Management of Fournier's gangrene: an eleven year retrospective analysis of early recognition, diagnosis, and treatment. Am Surg. 2002;68:709-13.



Xeropotamos NS, Nousias VE, Kappas AM. Fournier's gangrene: diagnostic approach and therapeutic challenge. Eur J Surg. 2002;168:91-95.



Faucher LD, Morris SE, Edelman LS, Phil M, Saffle JR. Burn center management of necrotizing soft-tissue surgical infections in unburned patients. Am J Surg. 2001; 182:563-569.



Fillo J, Cervenakov I, Labas P, et al. Fournier's gangrene: can aggressive treatment save life. Int Urol Nephrol. 2001;33:533-36.



Nisbet AA, Thompson IM. Impact of diabetes mellitus on the presentation and outcomes of Fournier's gangrene. Urology. 2000; 60(5):775-779



Corman JM, Moody JA, Aronson WJ. Fournier's gangrene in a modern surgical setting: improved survival with aggressive management. BJU Int. 1999;84:85-88.



Burciaga-Alvarado A, Bracho-Riquelme RL, Betancourt-Valdivia JC. La Gangrena de Fournier: Serie de casos del Hospital General "C" de Durango, SSA. Cirugía (Durango, Mexico). 1995;4(1):11-17.



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.

Resources

NIH/National Institute of Arthritis and Musculoskeletal and Skin Diseases

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For a Complete Report

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