Fournier's scrotal gangrene

Fourniere's Gangrene is a soft tissue infection of the perineum and strictly, the genitalia. Described by Jean-Alfred Fourniere in 1883, It is a localised form of soft tissue necrotising fasciitis.

Fournier's gangrene is a fulminant necrotizing fasciitis of the external genitalia, scrotum, or perineal area (1,2)

• men are affected exceedingly more than women, and the majority of patients suffer from multiple health comorbidities including obesity, diabetes, and immunodeficiency
  • men are more often affected than women, with a ratio of 10:1, and the disease can affect people of all ages (mean age, 50 years) (3)
  • incidence of the disease is estimated at 1.6 men per 100 000. Mortality rate remains high at 20% to 40% despite improvements in medical care (3)
    
    
• clinical findings include fever, pain and swelling, erythema or dark discoloration, discharge from the wound, induration, and crepitus of the affected area
  
  
• key component in accurate diagnosis is imaging with CT being the study of choice by some (2) - important findings include fascial thickness and subcutaneous air (2)
  • a delay of even a few hours from suspicion of Fournier gangrene to surgical debridement significantly increases the risk of death (4)
  • differential diagnosis of Fournier gangrene includes scrotal and perineal disorders, as well as intra-abdominal disorders such as cellulitis, abscess, strangulated hernia, pyoderma gangrenosum, allergic vasculitis, vascular occlusion syndromes, and warfarin necrosis
    
    
• pathogenesis is usually bacterial and the most common organisms identified include Escherichia coli, Klebsiella pneumoniae, Staphylococcus aureus, Bacteroides fragilis, Streptococcus species, and Clostridium species
  
  
• if Fournier's gangrene is suspected then urgent secondary care management is indicated - urgently start treatment (including antibiotics and surgical debridement as required)
  • treatment is broad-spectrum antibiotics and adequate surgical debridement - commonly used antibiotic regimens for Fournier's gangrene include a second- or third-generation cephalosporin, fluoroquinolones or gentamicin, and clindamycin; metronidazole may also be included in the regime as coverage for anaerobic bacteria
  • once infection is cleared, later reconstruction of soft tissues may be required

Reference:

• Chernyadyev S. et al. Fournier's Gangrene: Literature Review and Clinical Cases. Urologia Internationalis. 2018;101(1):91-97.
• Chennamsetty A. et al. Contemporary diagnosis and management of Fournier's gangrene. Therapeutic Advances in Urology. 2015;7(4):203-215.
• Semenic D, Kolar P.Fournier's Gangrene Does Not Spare Young Adults.Wounds. 2018 Jul;30(7):E73-E76
• Singh A et al. Fournier's gangrene. A clinical review. Arch Ital Urol Androl 2016; 88(3):157-164.