Fournier gangrene: Difference between revisions
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==Background==
==Background==
[[File:Gray1144.png|thumb|Scrotal anatomy]]
*Necrotizing fasciitis of the perineum, genitalia, and/or perianal area
[[File:Figure 28 01 02.jpg|thumb|Scrotal anatomy]]
*A '''life-threatening surgical emergency''' with mortality 20-40%<ref name="eke">Eke N. Fournier's gangrene: a review of 1726 cases. ''Br J Surg''. 2000;87(6):718-728. PMID 10848848.</ref>
*Life-threatening polymicrobial necrotizing fasciitis of perineum, genitalia, or perianal area.
*Polymicrobial infection: aerobic + anaerobic organisms (E. coli, Bacteroides, Streptococcus, Clostridium, S. aureus)
**Mostly bacteria lower GI system - [[B. fragilis]] and [[E. coli]]
*Rapidly progressive — tissue destruction can advance centimeters per hour
**Obliterative endarteritis of subcutaneous arterioles leads to gangrene of overlying skin<ref name="Shyam">Shyam DC, Rapsang AG. Fournier's gangrene. Surgeon. 2013 Aug;11(4):222-32. doi: 10.1016/j.surge.2013.02.001.</ref>
*Source: perianal (most common), urogenital, or cutaneous infection
*Mortality - often cited as 20-40%, but up to 80% in some studies<ref name="Concepts" />


===Risk Factors===
==Risk Factors==
*[[Diabetes mellitus]] (most common)
*Diabetes mellitus (present in 40-60% of cases)
*[[Hypertension]]
*Immunosuppression (HIV, malignancy, chemotherapy, transplant)
*[[Alcoholism]]
*Obesity
*Advanced age
*Chronic alcohol use
*Para/Quadriplegic
*Peripheral vascular disease
*Males>Females (10:1)<ref name="Shyam" />, (likely under-diagnosed in women<ref name="Concepts">Wróblewska M et al. Fournier's gangrene: current concepts. Pol J Microbiol. 2014;63(3):267-73.</ref>)
*Perianal abscess, urethral stricture, urinary tract instrumentation
*Recent surgery or trauma to the perineum


==Clinical Features==
==Clinical Features==
[[File:Thumbnail_IMG_9537.jpg|thumb|Early Fournier's Gangrene with classic spotted area of ecchymosis (right lower scrotum) and draining lesion (mid scrotum). Draining lesions are not always present initially and even small areas of ecchymosis should be considered highly concerning for Fournier's Gangrene.]]
*Severe perineal/genital pain (often out of proportion to examination findings early on)
[[File:Fournier-Gangrene.png|thumb|Progression of Fournier's Gangrene to larger draining lesion.]]
*Erythema, edema, and tenderness of perineum/scrotum/vulva
[[File:PMC3560168 JCAS-5-273-g004.png|thumb|Fournier's Gangrene]]
*Rapid progression: skin changes from erythema → dusky → bullae → necrosis → gangrene
*Initial event is usually local trauma or extension of a UTI or perianal infection<ref name="Shyam" />
*Crepitus on palpation (subcutaneous gas — pathognomonic but not always present)
**Gangrene develops over 2-7 days
*Fever, tachycardia, systemic toxicity / [[Sepsis (main)|septic shock]]
*Marked pain, localized swelling, crepitus, ecchymosis to genital or perineal area.
*Scrotal swelling with disproportionate pain
*Fever
*May appear deceptively benign early in the course
*Malodorous purulent drainage
*In late or severe cases, patient may present in septic shock
 
==Differential Diagnosis==
{{Template:Testicular DDX}}


==Evaluation==
==Evaluation==
===Work-up===
*'''Clinical diagnosis''' — do not delay surgical consultation for imaging
*CBC - very elevated leukocytosis
*Labs: CBC (leukocytosis often >15,000), BMP, lactate, blood cultures, CRP
*CMP - hyponatremia
*CT with contrast: subcutaneous gas, fascial thickening, fat stranding, abscess formation
*ESR
**CT has high sensitivity (~90%) but should not delay surgery<ref name="levenson">Levenson RB, et al. Fournier gangrene: role of imaging. ''Radiographics''. 2008;28(2):519-528. PMID 18349455.</ref>
*CRP
*LRINEC score may help risk-stratify (see [[LRINEC score calculator]])
*Lactate
*X-ray: may show subcutaneous emphysema
*Type and Screen
*Wound Culture
*Blood Cultures
*CT Abdomen/pelvis (only if diagnosis unclear or if requested by surgery/urology)
 
===Evaluation===
*Clinical diagnosis, based on history and physical exam
*LRINEC score here: [[Necrotizing fasciitis]]


==Management==
==Management==
*Immediate surgery and urology consult for surgical debridement (gangrene can spread at rate of 2-3 cm/hr<ref name="Shyam" />)
*Emergent surgical debridement — the single most important intervention
*[[Antibiotics]] - Must cover [[gram positive]], [[gram negative]], and [[anaerobes]]
**Often requires multiple return trips to OR for serial debridement
**[[Vancomycin]] + ([[imipenem]] 1gm IV q24hr '''OR''' [[meropenem]] 500mg-1gm IV q8hr '''OR''' [[piperacillin-tazobactam]] 3.375gm to 4.5gm IV q6h) +/- ([[clindamycin]] 600mg-900mg IV q8h '''OR''' [[metronidazole]] 1gm IV then 500mg IV q8h)
**Early surgery correlates with decreased mortality
**[[Piperacillin-Tazobactam]] 3.375-4.5g q6hr and [[linezolid]] 600mg q12hr is an alternative regimen<ref>Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America [published correction appears in Clin Infect Dis. 2015 May 1;60(9):1448. Dosage error in article text]. Clin Infect Dis. 2014;59(2):e10-e52. doi:10.1093/cid/ciu444</ref>
*Broad-spectrum IV antibiotics
*Aggressive supportive care, including fluid resuscitation (and [[Vasopressors|pressors]], if indicated)
**Vancomycin (or Linezolid) +
**Piperacillin-tazobactam (or Meropenem) +
**Clindamycin (for toxin suppression and synergistic coverage)
*Aggressive IV fluid resuscitation and vasopressors for [[Septic shock|septic shock]]
*Tetanus prophylaxis
*Wound care: vacuum-assisted closure (VAC) after debridement
*Consider hyperbaric oxygen therapy (HBO) as adjunct (limited evidence)


==Disposition==
==Disposition==
*Admit to ICU
*ICU admission with emergent surgical consultation
*Urology and/or general surgery
*High mortality — early recognition and aggressive surgery are key


==See Also==
==See Also==
*[[Necrotizing Fasciitis]]
*[[Necrotizing fasciitis]]
*[[Testicular Diagnoses]]
*[[Perianal abscess]]
*[[Necrotizing Soft Tissue Infections]]
*[[Testicular torsion]]
*[[EBQ:LRINEC Score]]
*[[Septic shock]]


==References==
==References==
<references/>
<references/>


[[Category:ID]]
[[Category:Infectious Disease]]
[[Category:Urology]]
[[Category:Urology]]
[[Category:Surgery]]

Latest revision as of 09:36, 22 March 2026

Background

  • Necrotizing fasciitis of the perineum, genitalia, and/or perianal area
  • A life-threatening surgical emergency with mortality 20-40%[1]
  • Polymicrobial infection: aerobic + anaerobic organisms (E. coli, Bacteroides, Streptococcus, Clostridium, S. aureus)
  • Rapidly progressive — tissue destruction can advance centimeters per hour
  • Source: perianal (most common), urogenital, or cutaneous infection

Risk Factors

  • Diabetes mellitus (present in 40-60% of cases)
  • Immunosuppression (HIV, malignancy, chemotherapy, transplant)
  • Obesity
  • Chronic alcohol use
  • Peripheral vascular disease
  • Perianal abscess, urethral stricture, urinary tract instrumentation
  • Recent surgery or trauma to the perineum

Clinical Features

  • Severe perineal/genital pain (often out of proportion to examination findings early on)
  • Erythema, edema, and tenderness of perineum/scrotum/vulva
  • Rapid progression: skin changes from erythema → dusky → bullae → necrosis → gangrene
  • Crepitus on palpation (subcutaneous gas — pathognomonic but not always present)
  • Fever, tachycardia, systemic toxicity / septic shock
  • Scrotal swelling with disproportionate pain
  • May appear deceptively benign early in the course

Evaluation

  • Clinical diagnosis — do not delay surgical consultation for imaging
  • Labs: CBC (leukocytosis often >15,000), BMP, lactate, blood cultures, CRP
  • CT with contrast: subcutaneous gas, fascial thickening, fat stranding, abscess formation
    • CT has high sensitivity (~90%) but should not delay surgery[2]
  • LRINEC score may help risk-stratify (see LRINEC score calculator)
  • X-ray: may show subcutaneous emphysema

Management

  • Emergent surgical debridement — the single most important intervention
    • Often requires multiple return trips to OR for serial debridement
    • Early surgery correlates with decreased mortality
  • Broad-spectrum IV antibiotics
    • Vancomycin (or Linezolid) +
    • Piperacillin-tazobactam (or Meropenem) +
    • Clindamycin (for toxin suppression and synergistic coverage)
  • Aggressive IV fluid resuscitation and vasopressors for septic shock
  • Tetanus prophylaxis
  • Wound care: vacuum-assisted closure (VAC) after debridement
  • Consider hyperbaric oxygen therapy (HBO) as adjunct (limited evidence)

Disposition

  • ICU admission with emergent surgical consultation
  • Urology and/or general surgery
  • High mortality — early recognition and aggressive surgery are key

See Also

References

  1. ↑ Eke N. Fournier's gangrene: a review of 1726 cases. Br J Surg. 2000;87(6):718-728. PMID 10848848.
  2. ↑ Levenson RB, et al. Fournier gangrene: role of imaging. Radiographics. 2008;28(2):519-528. PMID 18349455.
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