eMedicine Specialties > Urology > Infections and Related Inflammatory Conditions

Fournier Gangrene: Workup

Author: Thomas Santora, MD, Professor and Vice-Chair for Clinical Affairs, Department of Surgery, Temple University Hospital and School of Medicine
Coauthor(s): Daniel B Rukstalis, MD, Director of Urological Services, Geisinger Medical Center, Geisinger Medical Group
Contributor Information and Disclosures

Updated: Mar 19, 2009

Workup

Laboratory Studies

  • Complete history and physical examination
    • Direct particular attention to palpation of the genitalia and perineum and to the digital rectal examination.
    • Fluctuance, soft-tissue crepitation, localizing tenderness, or occult wounds in any of these sites should alert the examiner to possible Fournier disease.
  • Chemistry panel: Perform these tests to evaluate possible electrolyte disturbances, to look for laboratory evidence of dehydration (elevated BUN/creatinine ratio), and to evaluate for glucose intolerance (due to preexisting diabetes or sepsis-induced metabolic disturbance).
  • Blood tests
    • Obtain a complete blood cell count to assess the immunologic stress induced by the infectious process, check the adequacy of the red blood cell mass, and evaluate the potential for sepsis-induced thrombocytopenia.
    • Blood samples should be drawn for culture to assess for septicemia.
    • A coagulation profile (prothrombin time, activated partial thromboplastin time, platelet count, fibrinogen level) is helpful to look for sepsis-induced coagulopathy.
    • Consider type and screen if surgical exploration is undertaken.
  • Other: Any test deemed necessary to assess exacerbation of a comorbid condition (eg, ECG and cardiac enzyme evaluation in patients with coronary artery disease) is warranted.

Imaging Studies

  • Radiography
    • Radiography should be considered to evaluate for the presence and extent of Fournier disease, especially when the clinical examination findings are inconclusive26,27 Gas within the soft tissues is detected more commonly with imaging modalities than with the physical examination. (Note that demonstration of soft-tissue gas or detection of subcutaneous crepitation is an absolute indication for surgical exploration.)
    • Plain film radiography should be the initial imaging study. It may reveal moderate-to-large amounts of soft-tissue gas or foreign bodies.
  • Ultrasonography28
    • Ultrasonography can be used to detect fluid or gas within the soft tissues. In addition, ultrasonography can be used to assess the blood flow to the testes if testicular torsion is a possibility.
    • The drawback of ultrasonography is the need for direct pressure on the involved tissue; patients with Fournier gangrene probably will not be able to tolerate this procedure.
  • CT scanning
    • CT scanning can reveal smaller amounts of soft-tissue gas than plain radiography and can demonstrate fluid collections that track along the deep fascial planes.29,30
    • CT scanning is readily available in most hospitals and should be considered the diagnostic tool of choice.
  • MRI: This study yields greater soft tissue detail than does CT scanning; however, MRI requires greater time and limits monitoring during testing. These logistical challenges, which are not shared by CT scanning, limit the practical usefulness of MRI, especially in patients with critical illness.

Diagnostic Procedures

The diagnostic test of choice for Fournier gangrene is an incisional biopsy, which allows pathological distinction of necrotizing infection from severe cellulitis. The former would benefit from excisional debridement, while the latter rarely requires surgical excision.

The biopsy sample should be taken from the point of maximal tenderness, and it should include skin and superficial and deep fascia. This sample should then be sent for frozen-section analysis to assess for fascial necrosis. Early fascial involvement may appear as edematous fascia to the gross vision of the operating surgeon but may appear as frank necrosis on microscopic analysis.

Histologic Findings

Upon pathologic evaluation of the involved tissue, the pathognomonic findings of Fournier gangrene include (1) necrosis of the superficial and deep fascial planes, (2) fibrinoid coagulation of the nutrient arterioles, (3) polymorphonuclear cell infiltration, and (4) microorganisms identified within the involved tissues.

The characteristic finding that most commonly indicates Fournier disease is fibrinoid thrombosis of the nutrient vessels that supply the superficial and deep fascia. A frequent occurrence is widespread necrosis of the fascia with acute inflammatory cell infiltration, necrotic debris, and frequent demonstration of causative microorganisms within the tissues. This extensive inflammatory process is frequently present deep to intact skin, which is often minimally involved with the inflammatory process until late in the disease.

More on Fournier Gangrene

Overview: Fournier Gangrene
Workup: Fournier Gangrene
Treatment: Fournier Gangrene
Follow-up: Fournier Gangrene
Multimedia: Fournier Gangrene
References
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Further Reading

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Keywords

Fournier gangrene, Fournier's gangrene, genital gangrene, penile gangrene, idiopathic gangrene of the penis and scrotum, spontaneous fulminant gangrene of the scrotum, necrotizing fasciitis of the scrotum, necrotizing fasciitis of the male genitalia, infectious gangrene of the scrotum and penis, scrotal gangrene, synergistic gangrene of the male genitalia, gangrenous erysipelas of the scrotum, streptococcal gangrene of the scrotum, necrotizing fasciitis, genital necrotizing fasciitis, scrotal necrotizing fasciitis, penile necrotizing fasciitis, testicular necrotizing fasciitis, Fournier’s disease, Fournier disease

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Contributor Information and Disclosures

Author

Thomas Santora, MD, Professor and Vice-Chair for Clinical Affairs, Department of Surgery, Temple University Hospital and School of Medicine
Thomas Santora, MD is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Surgeons, American Trauma Society, Association for Academic Surgery, and Eastern Association for the Surgery of Trauma
Disclosure: Nothing to disclose.

Coauthor(s)

Daniel B Rukstalis, MD, Director of Urological Services, Geisinger Medical Center, Geisinger Medical Group
Daniel B Rukstalis, MD is a member of the following medical societies: American Association for the Advancement of Science and American Urological Association
Disclosure: Nothing to disclose.

Medical Editor

Alex Jacocks, MD, Program Director, Professor, Department of Surgery, University of Oklahoma School of Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

David L Morris, MD, PhD, Professor, Department of Surgery, St George Hospital, University of New South Wales, Australia
Disclosure: Nothing to disclose.

CME Editor

J Stuart Wolf Jr, MD, FACS, David A Bloom Professor of Urology, Director of Division of Minimally Invasive Urology, Department of Urology, University of Michigan
J Stuart Wolf Jr, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Catholic Medical Association, Endourological Society, Society for Urology and Engineering, Society of Laparoendoscopic Surgeons, Society of University Urologists, and Society of Urologic Oncology
Disclosure: Terumo Corporation Consulting fee Consulting; Omeros Corporation Consulting fee Consulting

Chief Editor

Bradley Fields Schwartz, DO, FACS, Professor of Urology, Director, Center for Laparoscopy and Endourology, Department of Surgery, Southern Illinois University School of Medicine
Bradley Fields Schwartz, DO, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Association of Military Osteopathic Physicians and Surgeons, Endourological Society, Society of Laparoendoscopic Surgeons, and Society of University Urologists
Disclosure: Nothing to disclose.

 
 
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