Fournier Gangrene

What is Fournier Gagrene?

It is a type of necrotizing infection that affects the perineum. It was first identified by the French venereologist Jean Alfred Fournier. It is a rare but life-threatening disease. A mixed infection, it is caused by both aerobic and anaerobic bacterial flora. The development and progression of this disease spreads rapidly and ultimately leads to multiple organ failure and death. Infective necrotizing fasciitis commonly affects men but can also affect women and children.

There are two main types of Gangrene – Dry and Wet. Fournier Gangrene (FG) is a type of Wet Gangrene.

Fournier Gangrene Causes

In most cases of FG, the sources of infection are either perineal or genital skin infections. The microorganisms that cause this condition are:

Picture of Fournier Gangrene

Picture 1 – Fournier Gangrene

  • Anaerobic organisms
  • Streptococcal species
  • Enterobacteriaceae
  • Staphylococcal species
  • Fungi

Anaerobic bacteria, like Clostridium and Fusobacterium, and aerobic bacteria such as Coli, Enterococci and Klebsiella are known to cause this infection. The infection usually arises from an underlying infection such as that of the urinary tract.

Blood also plays an important part here. If blood cannot flow freely throughout the body the cells cannot survive and infections develop.

Fournier Gangrene Risk Factors

Several other conditions can affect the blood flow and increase the risk of FG. These include:

  • Diabetes
  • Trauma or injury
  • Atherosclerosis
  • Narrowing of blood vessels (Raynaud’s phenomenon)
  • Peripheral arterial disease

Fournier Gangrene Symptoms

The symptoms of FG are:

  • Intense pain and tenderness in the genital region.
  • Inflammation in the genital region, caused by swelling of tissues under the affected skin, which adds to the discomfort.
  • Necrosis of cells in the genitalia, with destruction of local cells around the penis. The cells in the genital region and in the perineal region get destroyed quickly.
  • Redness of the genitalia, which is one of the early symptoms of the condition.
  • Rigidness in the genital and in the perineal region, due to stretching of skin in the penis area.
  • Duskiness of skin in the genital region.
  • Possible occurrence of high fever, which usually lasts for about 2 days a week.

Fournier Gangrene Diagnosis

The diagnosis of this infection usually involves blood tests. Regular laboratory tests are done to find out if there are chances of sepsis. In some cases, ultrasound tests are carried out to examine the extent of thickness of the scrotal wall. Ultrasound imaging helps in detecting trapped air in tissues. Presence of air in tissues is a sign of FG. These tests also reveal testicular infection and epididymitis. CT scans may be required if doctors suspect a colorectal origin.

Fournier Gangrene Differential Diagnosis

A doctor may also conduct a differential diagnosis to differentiate this infection from other diseases that produce similar symptoms. Thus, a physician may look for the following conditions as well at the time of diagnosis:

Image of Fournier Gangrene

Picture 2 – Fournier Gangrene

  • Vasculitis
  • Wegener granulomatosis
  • Testicular fracture
  • Testicular abscess
  • Warfarin gangrenoum
  • Testicular hematoma
  • Polyarteritis nodasum
  • Scrotal abscess
  • Hernias
  • Cellulitis
  • Gas Gangrene
  • Testicular torsion
  • Hydrocele

Fournier Gangrene Treatment

The treatment of FG involves the following:

Hyperbaric Oxygen Therapy

This therapy is effective in destroying and minimizing anaerobic bacterial growth in the affected region.

Antibiotics

Immediate usage of antibiotic medicines can stop the progression of this infection. Antibiotic drugs like Gentamicin, Metronidazole and Cephalosporin can treat the infection. Clindamycin is very helpful in treating necrotizing soft tissue infections. If tissue stains reveal the presence of fungi, antifungal agents like Amphotericin B or Caspofungin can be taken. Other possible options include piperacillin/tazobactam, ampicillin/sulbactam and ticarcillin/clavulanate in combination with metronidazole and aminoglycoside.

Fournier Gangrene Debridement

A surgery is an immediate requirement for the removal of infected tissues. This is because the infected tissues can spread to other areas of the body. A radical surgery involving complete removal of the necrotic tissue in the affected area is sufficient to treat the infection. Orchiectomy or removal of one of the testes is very rare. However, it may only be required sometimes. A surgical operation usually alters the shape of the genital region. A reconstruction is required to give it a correct shape.

Emergency treatment

For patients with severe conditions, emergency treatment options include:

  • Airway management
  • Supplying oxygen
  • Intravenous access
  • Constant cardiac monitoring

Crystalloid replacement is done in patients who are dehydrated and show signs of shock.

References