- Author: Vernon M Pais, Jr, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS more...
Fournier gangrene was first identified in 1883, when the French venereologist Jean Alfred Fournier described a series in which 5 previously healthy young men suffered from a rapidly progressive gangrene of the penis and scrotum without apparent cause. This condition, which came to be known as Fournier gangrene, is defined as a polymicrobial necrotizing fasciitis of the perineal, perianal, or genital areas (see the image below.) In contrast to Fournier's initial description, the disease is not limited to young people or to males, and a cause is now usually identified.
Impaired immunity (eg, from diabetes) is important for increasing susceptibility to Fournier gangrene. Trauma to the genitalia is a frequently recognized vector for the introduction of bacteria that initiate the infectious process. For more information, see the Medscape Reference articles Testicular Trauma, Scrotal Trauma, Penile Fracture and Trauma, and Urethral Trauma.
In 1764, Baurienne originally described an idiopathic, rapidly progressive soft-tissue necrotizing process that led to gangrene of the male genitalia. However, the disease was named after Jean-Alfred Fournier, a Parisian venereologist, on the basis of a transcript from an 1883 clinical lecture in which Fournier presented a case of perineal gangrene in an otherwise healthy young man, adding this to a compiled series of 4 additional cases. He differentiated these cases from perineal gangrene associated with diabetes, alcoholism, or known urogenital trauma, although these are currently recognized risk factors for the perineal gangrene now associated with his name.
This manuscript outlining Fournier’s initial series of fulminant perineal gangrene provides a fascinating insight into both the societal background and the practice of medicine at the time. In anecdotes, Fournier described recognized causes of perineal gangrene, including placement of a mistress’ ring around the phallus, ligation of the prepuce (used in an attempt to control enuresis or as an attempted birth control technique practiced by an adulterous man to avoid impregnating his married lover, placement of foreign bodies such as beans within the urethra, and excessive intercourse in diabetic and alcoholic persons. He calls upon physicians to be steadfast in obtaining confession from patients of “obscene practices.”
The complex anatomy of the male external genitalia influences the initiation and progression of Fournier gangrene. This infectious process involves the superficial and deep fascial planes of the genitalia. As the microorganisms responsible for the infection multiply, infection spreads along the anatomical fascial planes, often sparing the deep muscular structures and, to variable degrees, the overlying skin.
This phenomenon has implications for both initial debridement and subsequent reconstruction. Therefore, a working knowledge of the anatomy of the male lower urinary tract and external genitalia is critical for the clinician treating a patient with Fournier gangrene.
Skin and superficial fascia
Because Fournier gangrene is predominately an infectious process of the superficial and deep fascial planes, understanding the anatomic relationship of the skin and subcutaneous structures of the perineum and abdominal wall is important.
The skin cephalad to the inguinal ligament is backed by Camper fascia, which is a layer of fat-containing tissue of varying thickness and the superficial vessels to the skin that run through it. Scarpa fascia forms another distinct layer deep to Camper fascia. In the perineum, Scarpa fascia blends into Colles fascia (also known as the superficial perineal fascia), while it is continuous with Dartos fascia of the penis and scrotum (see the image below).
Several important anatomic relationships should be considered. A potential space between the Scarpa fascia and the deep fascia of the anterior wall (external abdominal oblique) allows for the extension of a perineal infection into the anterior abdominal wall. Superiorly, Scarpa and Camper fascia coalesce and attach to the clavicles, ultimately limiting the cephalad extension of an infection that may have originated in the perineum.
Colles fascia is attached to the pubic arch and the base of the perineal membrane, and it is continuous with the superficial Dartos fascia of the scrotal wall. The perineal membrane is also known as the inferior fascia of the urogenital diaphragm and, together with Colles fascia, defines the superficial perineal space.
This space contains the membranous urethra, bulbar urethra, and bulbourethral glands. In addition, this space is adjacent to the anterior anal wall and ischiorectal fossae. Infectious disease of the male urethra, bulbourethral glands, perineal structures, or rectum can drain into the superficial perineal space and can extend into the scrotum or into the anterior abdominal wall up to the level of the clavicles.
Vascular supply to the skin of the lower abdomen and genitalia
Branches from the inferior epigastric and deep circumflex iliac arteries supply the lower aspect of the anterior abdominal wall. Branches of the external and internal pudendal arteries supply the scrotal wall. With the exception of the internal pudendal artery, each of these vessels travels within Camper fascia and can therefore become thrombosed in the progression of Fournier gangrene.
Thrombosis jeopardizes the viability of the skin of the anterior scrotum and perineum. Often, the posterior aspect of the scrotal wall supplied by the internal pudendal artery remains viable and can be used in the reconstruction following resolution of the infection.
Penis and scrotum
The contents of the scrotum, namely the testicles, epididymides, and cord structures, are invested by several fascial layers distinct from the Dartos fascia of the scrotal wall. Again, several important anatomic relationships should be considered.
The most superficial layer of the testis and cord is the external spermatic fascia, which is continuous with the external aponeurosis of the superficial inguinal ring (external abdominal oblique). The next deeper layer is the internal spermatic fascia, which is continuous with the transversalis fascia. A deep fascia termed Buck fascia covers the erectile bodies of the penis, the corpora cavernosa, and the anterior urethra. Buck fascia fuses to the dense tunica albuginea of the corpora cavernosa, deep in the pelvis.
The fascial layers described in this section do not become involved with an infection of the superficial perineal space and can limit the depth of tissue destruction in a necrotizing infection of the genitalia. The corpora cavernosa, urethra, testes, and cord structures are usually spared in Fournier gangrene, while the superficial and deep fascia and the skin are destroyed.
Localized infection adjacent to a portal of entry is the inciting event in the development of Fournier gangrene. Ultimately, an obliterative endarteritis develops, and the ensuing cutaneous and subcutaneous vascular necrosis leads to localized ischemia and further bacterial proliferation. Rates of fascial destruction as high as 2-3 cm/h have been described.
Infection of superficial perineal fascia (Colles fascia) may spread to the penis and scrotum via Buck and dartos fascia, or to the anterior abdominal wall via Scarpa fascia, or vice versa. Colles fascia is attached to the perineal body and urogenital diaphragm posteriorly and to the pubic rami laterally, thus limiting progression in these directions. Testicular involvement is rare, as the testicular arteries originate directly from the aorta and thus have a blood supply separate from the affected region.
The following are pathognomonic findings of Fournier gangrene upon pathologic evaluation of involved tissue:
Necrosis of the superficial and deep fascial planes
Fibrinoid coagulation of the nutrient arterioles
Polymorphonuclear cell infiltration
Microorganisms identified within the involved tissues
Infection represents an imbalance between (1) host immunity, which is frequently compromised by one or more comorbid systemic processes, and (2) the virulence of the causative microorganisms. The etiologic factors allow the portal for entry of the microorganism into the perineum, the compromised immunity provides a favorable environment to initiate the infection, and the virulence of the microorganism promotes the rapid spread of the disease. See the image below.
Microorganism virulence results from the production of toxins or enzymes that create an environment conducive to rapid microbial multiplication. Although Meleney in 1924 attributed the necrotizing infections to streptococcal species only, subsequent clinical series have emphasized the multiorganism nature of most cases of necrotizing infection, including Fournier gangrene.[5, 6, 7, 8, 9]
Presently, recovering only streptococcal species is unusual. Rather, streptococcal organisms are cultured along with as many as 5 other organisms.
The following are common causative microorganisms:
Most authorities believe that polymicrobial involvement is necessary to create the synergy of enzyme production that promotes rapid multiplication and spread of Fournier gangrene. For example, one microorganism might produce the enzymes necessary to cause coagulation of the nutrient vessels. Thrombosis of these nutrient vessels reduces local blood supply; thus, tissue oxygen tension falls.
The resultant tissue hypoxia allows growth of facultative anaerobes and microaerophilic organisms. These latter microorganisms, in turn, may produce enzymes (eg, lecithinase, collagenase), which lead to digestion of fascial barriers, thus fueling the rapid extension of the infection.
Fascial necrosis and digestion are hallmarks of this disease process; this is important to appreciate because it provides the surgeon with a clinical marker of the extent of tissue involvement. Specifically, if the fascial plane can be separated easily from the surrounding tissue by blunt dissection, it is quite likely to be involved with the ischemic-infectious process; therefore, any such dissected tissue should be excised.
Far-advanced or fulminant Fournier gangrene can spread from the fascial envelopment of the genitalia throughout the perineum, along the torso, and, occasionally, into the thighs.
Although originally described as idiopathic gangrene of the genitalia, Fournier gangrene has an identifiable cause in 75-95% of cases. The necrotizing process commonly originates from an infection in the anorectum, the urogenital tract, or the skin of the genitalia.
Anorectal causes of Fournier gangrene include perianal, perirectal, and ischiorectal abscesses; anal fissures; and colonic perforations. These may be a consequence of colorectal injury or a complication of colorectal malignancy,[13, 14] inflammatory bowel disease, colonic diverticulitis, or appendicitis.
Urogenital tract causes include infection in the bulbourethral glands, urethral injury, iatrogenic injury secondary to urethral stricture manipulation, epididymitis, orchitis, or lower urinary tract infection (eg, in patients with long-term indwelling urethral catheters).
Dermatologic causes include hidradenitis suppurativa, ulceration due to scrotal pressure, and trauma. Inability to practice adequate perineal hygiene, such as in paraplegic patients, results in increased risk.
Accidental, intentional, or surgical trauma and the presence of foreign bodies may also lead to the disease. The following have been reported in the literature as precipitating factors:
Blunt thoracic trauma
Superficial soft-tissue injuries
Penile self-injection with cocaine 
Prosthetic penile implants
Steroid enemas (used for the treatment of radiation proctitis)
Rectal foreign body 
In women, septic abortions, vulvar or Bartholin gland abscesses, hysterectomy, and episiotomy are documented sources. In men, anal intercourse may increase risk of perineal infection, either from blunt trauma to the area or by spread of rectally carried microbes.
In children, the following have led to the disease:
Strangulated inguinal hernia
Wound cultures from patients with Fournier gangrene reveal that it is a polymicrobial infection with an average of 4 isolates per case. Escherichia coli is the predominant aerobe, and Bacteroides is the predominant anaerobe.
Other common microflora include the following:
Streptococcus (aerobic and anaerobic)
Predisposition to disease
Any condition that depresses cellular immunity may predispose a patient to the development of Fournier gangrene. Examples include the following:
Diabetes mellitus (present in as many as 60% of cases) 
Extremes of age
Vascular disease of the pelvis
Malignancy (eg, acute promyelocytic leukemia, acute nonlymphoid leukemia, acute myeloblastic leukemia) [20, 21]
Systemic lupus erythematosus 
HIV infection [23, 24]
Iatrogenic immunosuppression (eg, from long-term corticosteroid therapy)
Fournier gangrene is relatively uncommon, but the exact incidence of the disease is unknown. In a review of Fournier gangrene in 1992, Paty and coworkers calculated that approximately 500 cases of the infection have been reported in the literature since Fournier’s 1883 report, yielding a prevalence of 1 case in 7500 persons. A retrospective case review revealed 1726 cases documented in the literature from 1950-1999, with an average of 97 cases per year reported from 1989-1998.
Other researchers have reported approximately 600 cases of Fournier gangrene in the world literature since 1996. The frequency of Fournier gangrene has not likely changed appreciably; rather, the apparent increase in the number of cases in the literature most likely results from increased reporting.
No seasonal variation occurs. Fournier gangrene is not indigenous to any region of the world, although the largest clinical series originate from the African continent.
Sexual and age-related differences in incidence
The typical patient with Fournier gangrene is an elderly man in his sixth or seventh decade of life with comorbid diseases. The male-to-female ratio is approximately 10:1. Lower incidence in females may be caused by better drainage of the perineal region through vaginal secretions. Men who have sex with men may be at higher risk, especially for infections caused by community-associated methicillin-resistant Staphylococcus aureus (MRSA).
Most reported cases occur in patients aged 30-60 years. A literature review found only 56 pediatric cases, with 66% of those in infants younger than 3 months.
Large scrotal, perineal, penile, and abdominal wall skin defects may require reconstructive procedures; however, the prognosis for patients following reconstruction for Fournier gangrene is usually good. The scrotum has a remarkable ability to heal and regenerate once the infection and necrosis have subsided. However, approximately 50% of men with penile involvement have pain with erection, often related to genital scarring. Consultation with a psychiatrist may help some patients deal with the emotional stress of an altered body image.
If extensive soft tissue is lost, lymphatic drainage may be impaired; thus, dependent edema and cellulitis may result. Use of external support may be beneficial to minimize this postoperative problem.
To date, the majority of studies of Fournier gangrene have been retrospective reviews.[29, 30] Therefore, the utility of drawing reliable prognostic information from these studies is very limited.
In 1995, Laor and colleagues introduced the Fournier Gangrene Severity Index (FGSI). The FGSI is based on deviation from reference ranges of the following clinical parameters:
White blood cell count (WBC)
Each parameter is assigned a score between 0 and 4, with the higher values indicating greater deviation from normal. The FGSI represents the sum of all the parameters’ values.
In 2010, Yilmazlar and colleagues updated the FGSI (UFGSI), adding two additional parameters—age and extent of disease—to further refine the prognostic utility of the FGSI.
These two groups conclude that the mortality risk in general may be directly proportional to the age of the patient and the extent of disease burden and systemic toxicity upon admission. Factors associated with an improved prognosis include age younger than 60 years, localized clinical disease, absence of systemic toxicity (eg, low FGSI), and sterile blood cultures.[36, 35]
Most recently, Roghmann et al queried whether these increasingly complex scoring systems actually outperformed two existing and less burdensome morbidity scoring systems, the age-adjusted Charlson Comorbidity Index (ACCI) and the surgical APGAR score (sAPGAR). They both assessed this retrospectively then prospectively with a 30-day follow-up. They noted that ACCI and sAPGAR performed as well as the FGSI and UFGSI and were easier to calculate at the bedside. Again, increasing age and medical comorbidities were associated with increased risk of death.
Bozkurt et al reached a similar conclusion in their comparison of the FGSI; the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC), which is based on the WBC, hemoglobin, serum sodium, glucose, serum creatinine, and C-reactive protein levels; and the neutrophil/lymphocyte ratio (NLR)—a marker for inflammation that has been studied as a prognostic indicator in a variety of conditions, primarily cancer and heart disease. In their retrospective cohort studies, higher scores in all three scoring systems (FGSI ≥4, LRINEC ≥6, NLR ≥10) identified patients with a worse prognosis, including need for mechanical ventilation requirement and mortality. However, the NLR had the advantages of speed, simplicity, and low cost.
Surprisingly, diabetes and HIV infection are not associated with higher mortality. In some studies, Fournier gangrene that originates from anorectal diseases carries a worse prognosis than cases caused by other factors.
The reported mortality rates for Fournier gangrene have varied widely, ranging as high as 75%. However, using National Surgical Quality Improvement Program data from 2005 to 2009, Kim et al determined that the overall 30-day mortality rate for Fournier gangrene and necrotizing fasciitis of the genitalia was 10.1% (64 of 636 patients)—a rate about half that of historically published estimates, but similar to that in recent studies.
Factors associated with high mortality include an anorectal source, advanced age, extensive disease (involving abdominal wall or thighs), shock or sepsis at presentation, renal failure, and hepatic dysfunction.
Death usually results from systemic illness, such as sepsis (usually gram negative), coagulopathy, acute renal failure, diabetic ketoacidosis, or multiple organ failure. Fatal tetanus associated with Fournier gangrene has been reported in the literature.
Ekelius L, Björkman H, Kalin M, Fohlman J. Fournier's gangrene after genital piercing. Scand J Infect Dis. 2004. 36(8):610-2. [Medline].
Corman JM. Classic articles in colonic and rectal surgery. Dis Colon Rectum. 1988. 31:984-8.
Mergenhagen SE, Thonard JC, Scherp HW. Studies on synergistic infections. I. Experimental infections with anaerobic streptococci. J Infect Dis. 1958 Jul-Aug. 103(1):33-44. [Medline].
Meleney FL. Hemolytic Streptococcus gangrene. Arch Surg. 1924. 9:317-21.
Moses AE. Necrotizing fasciitis: flesh-eating microbes. Isr J Med Sci. 1996 Sep. 32(9):781-4. [Medline].
Benizri E, Fabiani P, Migliori G, et al. Gangrene of the perineum. Urology. 1996 Jun. 47(6):935-9. [Medline].
Benchekroun A, Lachkar A, Bjijou Y, et al. [Gangrene of the external genital organs. Apropos of 55 cases]. J Urol (Paris). 1997. 103(1-2):27-31. [Medline].
Ben-Aharon U, Borenstein A, Eisenkraft S, et al. Extensive necrotizing soft tissue infection of the perineum. Isr J Med Sci. 1996 Sep. 32(9):745-9. [Medline].
Basoglu M, Gül O, Yildirgan I, Balik AA, Ozbey I, Oren D. Fournier's gangrene: review of fifteen cases. Am Surg. 1997 Nov. 63(11):1019-21. [Medline].
Goyette M. Group A streptococcal necrotizing fasciitis Fournier's gangrene--Quebec. Can Commun Dis Rep. 1997 Jul 1. 23(13):101-3. [Medline].
Smith GL, Bunker CB, Dinneen MD. Fournier's gangrene. Br J Urol. 1998 Mar. 81(3):347-55. [Medline].
Clayton MD, Fowler JE Jr, Sharifi R, Pearl RK. Causes, presentation and survival of fifty-seven patients with necrotizing fasciitis of the male genitalia. Surg Gynecol Obstet. 1990 Jan. 170(1):49-55. [Medline].
Gould SW, Banwell P, Glazer G. Perforated colonic carcinoma presenting as epididymo-orchitis and Fournier's gangrene. Eur J Surg Oncol. 1997 Aug. 23(4):367-8. [Medline].
Brings HA, Matthews R, Brinkman J, Rotolo J. Crohn's disease presenting with Fournier's gangrene and enterovesical fistula. Am Surg. 1997 May. 63(5):401-5. [Medline].
Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft-tissue infections. Clin Infect Dis. 2005 Nov 15. 41(10):1373-406. [Medline].
Mouraviev VB, Pautler SE, Hayman WP. Fournier's gangrene following penile self-injection with cocaine. Scand J Urol Nephrol. 2002. 36(4):317-8. [Medline].
Abate G, Shirin M, Kandanati V. Fournier gangrene from a thirty-two-centimeter rectosigmoid foreign body. J Emerg Med. 2013 Feb. 44(2):e247-9. [Medline].
Rajbhandari SM, Wilson RM. Unusual infections in diabetes. Diabetes Res Clin Pract. 1998 Feb. 39(2):123-8. [Medline].
Faber HJ, Girbes AR, Daenen S. Fournier's gangrene as first presentation of promyelocytic leukemia. Leuk Res. 1998 May. 22(5):473-6. [Medline].
Martinelli G, Alessandrino EP, Bernasconi P, et al. Fournier's gangrene: a clinical presentation of necrotizing fasciitis after bone marrow transplantation. Bone Marrow Transplant. 1998 Nov. 22(10):1023-6. [Medline].
Kohagura K, Sesoko S, Tozawa M, et al. [A female case of Fournier's gangrene in a patient with lupus nephritis]. Nippon Jinzo Gakkai Shi. 1998 Jul. 40(5):354-8. [Medline].
Roca B, Cuñat E, Simón E. HIV infection presenting with Fournier's gangrene. Neth J Med. 1998 Oct. 53(4):168-71. [Medline].
Paty R, Smith AD. Gangrene and Fournier's gangrene. Urol Clin North Am. 1992 Feb. 19(1):149-62. [Medline].
Eke N. Fournier's gangrene: a review of 1726 cases. Br J Surg. 2000 Jun. 87(6):718-28. [Medline].
Ayumba BR, Magoha GA. Epidemiological aspects of Fournier's gangrene at Kenyatta National Hospital, Nairobi. East Afr Med J. 1998 Oct. 75(10):586-9. [Medline].
Diep BA, Chambers HF, Graber CJ, et al. Emergence of multidrug-resistant, community-associated, methicillin-resistant Staphylococcus aureus clone USA300 in men who have sex with men. Ann Intern Med. 2008 Feb 19. 148(4):249-57. [Medline].
Corman JM, Moody JA, Aronson WJ. Fournier's gangrene in a modern surgical setting: improved survival with aggressive management. BJU Int. 1999 Jul. 84(1):85-8. [Medline].
Chen CS, Liu KL, Chen HW, Chou CC, Chuang CK, Chu SH. Prognostic factors and strategy of treatment in Fournier's gangrene: a 12-year retrospective study. Changgeng Yi Xue Za Zhi. 1999 Mar. 22(1):31-6. [Medline].
Laor E, Palmer LS, Tolia BM, Reid RE, Winter HI. Outcome prediction in patients with Fournier's gangrene. J Urol. 1995 Jul. 154(1):89-92. [Medline].
Corcoran AT, Smaldone MC, Gibbons EP, Walsh TJ, Davies BJ. Validation of the Fournier's gangrene severity index in a large contemporary series. J Urol. 2008 Sep. 180(3):944-8. [Medline].
Yeniyol CO, Suelozgen T, Arslan M, Ayder AR. Fournier's gangrene: experience with 25 patients and use of Fournier's gangrene severity index score. Urology. 2004 Aug. 64(2):218-22. [Medline].
Ulug M, Gedik E, Girgin S, Celen MK, Ayaz C. The evaluation of microbiology and Fournier's gangrene severity index in 27 patients. Int J Infect Dis. 2009 Nov. 13(6):e424-30. [Medline].
Yilmazlar T, Ozturk E, Ozguc H, Ercan I, Vuruskan H, Oktay B. Fournier's gangrene: an analysis of 80 patients and a novel scoring system. Tech Coloproctol. 2010 Sep. 14(3):217-23. [Medline].
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 Aug. 68(8):709-13. [Medline].
Roghmann F, von Bodman C, Löppenberg B, Hinkel A, Palisaar J, Noldus J. Is there a need for the Fournier's gangrene severity index? Comparison of scoring systems for outcome prediction in patients with Fournier's gangrene. BJU Int. 2012 Nov. 110(9):1359-65. [Medline].
Bozkurt O, Sen V, Demir O, Esen A. Evaluation of the utility of different scoring systems (FGSI, LRINEC and NLR) in the management of Fournier's gangrene. Int Urol Nephrol. 2015 Feb. 47 (2):243-8. [Medline].
Kim SY, Dupree JM, Le BV, Kim DY, Zhao LC, Kundu SD. A contemporary analysis of Fournier gangrene using the National Surgical Quality Improvement Program. Urology. 2015 May. 85 (5):1052-6. [Medline].
Czymek R, Hildebrand P, Kleemann M, et al. New insights into the epidemiology and etiology of Fournier's gangrene: a review of 33 patients. Infection. 2009 Aug. 37(4):306-12. [Medline].
Fan CM, Whitman GJ, Chew FS. Radiologic-Pathologic Conferences of the Massachusetts General Hospital. Necrotizing fasciitis of the scrotum (Fournier's gangrene). AJR Am J Roentgenol. 1996 May. 166(5):1164. [Medline].
Rajan DK, Scharer KA. Radiology of Fournier's gangrene. AJR Am J Roentgenol. 1998 Jan. 170(1):163-8. [Medline].
Sherman J, Solliday M, Paraiso E, Becker J, Mydlo JH. Early CT findings of Fournier's gangrene in a healthy male. Clin Imaging. 1998 Nov-Dec. 22(6):425-7. [Medline].
Wysoki MG, Santora TA, Shah RM, Friedman AC. Necrotizing fasciitis: CT characteristics. Radiology. 1997 Jun. 203(3):859-63. [Medline].
Kane CJ, Nash P, McAninch JW. Ultrasonographic appearance of necrotizing gangrene: aid in early diagnosis. Urology. 1996 Jul. 48(1):142-4. [Medline].
Sugihara T, Yasunaga H, Horiguchi H, Fujimura T, Ohe K, Matsuda S, et al. Impact of surgical intervention timing on the case fatality rate for Fournier's gangrene: an analysis of 379 cases. BJU Int. 2012 Dec. 110(11 Pt C):E1096-100. [Medline].
Stevens DL, Gibbons AE, Bergstrom R, Winn V. The Eagle effect revisited: efficacy of clindamycin, erythromycin, and penicillin in the treatment of streptococcal myositis. J Infect Dis. 1988 Jul. 158(1):23-8. [Medline].
Cawley MJ, Briggs M, Haith LR Jr, et al. Intravenous immunoglobulin as adjunctive treatment for streptococcal toxic shock syndrome associated with necrotizing fasciitis: case report and review. Pharmacotherapy. 1999 Sep. 19(9):1094-8. [Medline].
Konofaos P, Hickerson WL. A Technique for Improving Cosmesis After Primary Scrotum Reconstruction With Skin Grafts. Ann Plast Surg. 2015 Aug. 75 (2):205-7. [Medline].
Korhonen K, Hirn M, Niinikoski J. Hyperbaric oxygen in the treatment of Fournier's gangrene. Eur J Surg. 1998 Apr. 164(4):251-5. [Medline].
Pizzorno R, Bonini F, Donelli A, Stubinski R, Medica M, Carmignani G. Hyperbaric oxygen therapy in the treatment of Fournier's disease in 11 male patients. J Urol. 1997 Sep. 158(3 Pt 1):837-40. [Medline].
Hollabaugh RS Jr, Dmochowski RR, Hickerson WL, Cox CE. Fournier's gangrene: therapeutic impact of hyperbaric oxygen. Plast Reconstr Surg. 1998 Jan. 101(1):94-100. [Medline].
Mindrup SR, Kealey GP, Fallon B. Hyperbaric oxygen for the treatment of fournier's gangrene. J Urol. 2005 Jun. 173(6):1975-7. [Medline].
Nomikos IN. Necrotizing perineal infections (Fournier's disease): old remedies for an old disease. Int J Colorectal Dis. 1998. 13(1):48-51. [Medline].
Asci R, Sarikaya S, Büyükalpelli R, Yilmaz AF, Yildiz S. Fournier's gangrene: risk assessment and enzymatic debridement with lyophilized collagenase application. Eur Urol. 1998. 34(5):411-8. [Medline].
Papachristodoulou AJ, Zografos GN, Papastratis G, et al. Fournier's gangrene: still highly lethal. Langenbecks Arch Chir. 1997. 382(1):15-8. [Medline].
Hejase MJ, Simonin JE, Bihrle R, Coogan CL. Genital Fournier's gangrene: experience with 38 patients. Urology. 1996 May. 47(5):734-9. [Medline].
Akcan A, Sözüer E, Akyildiz H, Yilmaz N, Küçük C, Ok E. Necessity of preventive colostomy for Fournier's gangrene of the anorectal region. Ulus Travma Acil Cerrahi Derg. 2009 Jul. 15(4):342-6. [Medline].
Kovacs LH, Kloeppel M, Papadopulos NA, Reeker W, Biemer E. Necrotizing fasciitis. Ann Plast Surg. 2001 Dec. 47(6):680-2. [Medline].