Fournier’s Gangrene

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It is an acute fulminant polymicrobial necrotising fascitis or gangrene affecting the scrotum and sometimes extending to the perineum, penis and lower abdomen. It is also called idiopathic gangrene of the scrotum. 

The synergistic infections of anaerobic and aerobic bacteria coupled with obliterative arteritis results in the extensive gangrene. The risk factors include diabetes mellitus,  HIV/Immunosuppression, perineal abscess/ infection of scrotum and contents, trauma, extravasation of urine, periurethral abscess and urethral stricture/calculi. The complications of Fournier’s gangrene include septicaemia, extravasation of urine, exposure of testes and fistula formation.

Cause

  • Staphylococcus spp
  • Microaerophilic Streptococcus
  • E. coli 
  • Fusibacteria
  • Clostridium welchii
  • Bacteroides

Symptoms

  • Acute onset of painful anterior scrotal swelling in previously healthy tissue
  • Fever
  • Pain in affected scrotum
  • General malaise

Signs

  • Fever
  • Prostration
  • Rapidly progressing gangrene
  • Foetid odour 
  • Sharp demarcation between ‘dead’ tissue and healthy tissue
  • Crepitus on palpation of affected tissue
  • Testis is usually spared
  • Urinary extravasation 
  • Presence of risk or predisposing factors

Investigations

  • Wound culture and sensitivity
  • Serum culture and sensitivity
  • Urinalysis
  • FBC and ESR
  • Grouping and cross-matching 
  • Fasting blood glucose
  • HIV screening
  • Plain X-ray of pelvis will reveal gas in affected tissue

TreatmentTreatment Objectives

  • To resuscitate patient
  • To treat the infection 
  • To manage concomitant risk factors
  • To salvage the testes 
  • To prevent/treat complications

Non-pharmacological treatment

  • Surgical intervention
  • Radical debridement 
  • Reconstructive surgery:
  • Testis buried in upper thigh temporarily to prevent dessication 
  • Skin grafting and reconstruction of scrotum (scrotoplasty)
  • Myocutaneous flaps
  • Nutrition supplement
  • Wound care
  • Management of diabetes mellitus if present
  • Management of HIV/AIDS if present  

Pharmacological treatment

Evidence Rating:  [C]

IV fluids, haemotransfusion and hyperbaric oxygen

As required for patients clinical state

Antibiotics

  • Gentamicin, IV, 80 mg 8 hourly

And 

  • Ampicillin, IV, 500 mg 6 hourly 

And 

  • Metronidazole, IV, 500 mg 8 hourly

 

Or

  • Amoxicillin + Clavulanic Acid, IV, 1 g 12 hourly 

And

  • Metronidazole, IV, 500 mg 8 hourly

 

Or

  • Cefuroxime, IV, 750 mg 8 hourly 

And

  • Metronidazole, IV, 500 mg 8 hourly

Referral Criteria

  • Refer all cases with septic shock after resuscitation and all those who require reconstructive surgery to a urologist or surgical specialist