Fournier Gangrene Treatment & Management

Treatment of Fournier gangrene involves several modalities, including restoration of normal organ perfusion. In patients who present with systemic toxicity manifesting as hypoperfusion or organ failure, aggressive resuscitation to return normal organ perfusion and function must take precedence over diagnostic maneuvers, especially if these diagnostic studies could compromise the resuscitative interventions.

Treatment of Fournier gangrene also involves the institution of broad-spectrum antibiotic therapy. The antibiotic spectrum should cover staphylococci, streptococci, the Enterobacteriaceae family of organisms, and anaerobes. A reasonable empiric regimen might consist of ciprofloxacin and clindamycin. Clindamycin is particularly useful in the treatment of necrotizing soft-tissue infections because of its gram-positive and anaerobic spectrum of activity. In animal models of streptococcal infection, clindamycin has been shown to yield response rates superior to those of penicillin or erythromycin, even in the context of delayed treatment.^[31]

If initial tissue stains (ie, KOH stain) show fungi, add an empiric antifungal agent such as amphotericin B or caspofungin. In cases associated with sepsis syndrome, therapy with intravenous immunoglobulin (IVIG), which is thought to neutralize superantigens such as the streptotoxins (A, B) believed to mitigate the exaggerated cytokine response, has been shown to be a good adjuvant to appropriate antibiotic coverage and complete surgical debridement.^[32]

Hyperbaric oxygen, if available, has shown some promising results.^{[33, 34, 35]} This therapy needs to be balanced with the stability of the patient. Surgical debridement must not be delayed for consideration of hyperbaric oxygen.

In addition to the above treatment interventions used to address the infectious process, the underlying comorbid conditions that frequently coexist and that potentially predispose to Fournier gangrene must ultimately be addressed. For example, blood sugar needs to be controlled in patients with diabetes, and alcohol withdrawal needs to be addressed in patients with alcoholism. Failure to adequately manage the comorbid conditions may threaten the success of even the most appropriate interventions to resolve the infectious disease.

• Establishing the diagnosis

  • In the event of a presumptive diagnosis based on a clinical examination or diagnostic study, the definitive diagnosis of Fournier gangrene is established by examination with the patient under anesthesia (see the image below) followed by incision into the area of greatest clinical concern. Examination of an anesthetized man with alcoholism and known cirrhosis who presented with exquisite pain limited to the scrotum. Note the erythema of the scrotum and the look of skepticism on the face of one of the surgeons. Courtesy of Thomas A. Santora, MD.
  • If frankly gangrenous tissue is found or purulence is drained (see the image below), the diagnosis of Fournier gangrene is established. The same patient depicted in the previous image. The scrotum has been opened along the median raphe, which liberated foul-smelling brown purulence and exposed necrotic tissue throughout the mid scrotum. The testicles were not involved. Courtesy of Thomas A. Santora, MD.
  • Occasionally, early-stage Fournier disease manifests as severe cellulitis. If an incision is made, the fascia may appear edematous rather than the gray-black appearance of well-established Fournier gangrene. In this instance, obtain an incisional biopsy sample of the deep fascia for frozen-section evaluation to eliminate the potential for early necrotizing disease.
• Excising necrotic tissue

  • Once a diagnosis of Fournier gangrene is established, all necrotic tissue must be excised. The skin should be opened widely to expose the full extent of the underlying fascial and subcutaneous tissue necrosis. All fascial planes that separate easily with blunt dissection should be considered involved and therefore excised. The dissection should be carried out to include bleeding tissues (ie, tissue that is well vascularized).^[36]
  • Send tissue for aerobic and anaerobic cultures and a histologic assessment.
  • Given the characteristic thrombosis of the nutrient vessels, the overlying skin has impaired blood supply and should be excised if significantly undermined. The authors strongly recommend radical excisional debridement (see the image below) with electrocautery in order to reduce the considerable operative blood loss if the area of involvement is extensive. Photograph of a morbidly obese male with long-standing phimosis, following the first radical debridement procedure. A dorsal slit was made in the prepuce to expose the glans penis. Urethral catheterization was performed. Incision into the point of maximal tenderness on the right side of the perineum revealed gangrenous necrosis that involved the anterior and posterior aspects of the perineum, the entirety of the right hemiscrotum, and the posterior medial aspect of the right thigh. The skin and involved fascia were excised from these areas. Reconstruction of this defect was performed in a staged approach. A gracilis rotational muscle flap taken from the right thigh was used to fill the cavity in the posterior right perineum as the first step. The remainder of the defect was covered with split-thickness skin grafts. This patient made a full recovery.
  • Given the potential fulminant nature of this necrotizing process, consider repeated operative debridement procedures to ensure complete eradication of the infection.
  • Once the results of the tissue cultures are known, alter the antibiotic regimen to cover the causative organisms. Continue antibiotics for 10-14 days or until reconstruction is accomplished.
  • If the perineal involvement is extensive, fecal diversion should be considered at subsequent operative explorations to eliminate the potential for fecal contamination of the wounds. Fecal diversion is usually unnecessary when the necrosis is limited to the genitalia but is mandatory when the perianal area is extensively involved.
  • Urinary diversion is accomplished with a urethral catheter in most cases. Suprapubic cystostomy is used when urethral drainage of the bladder is not possible because of pathology (eg, stricture disease, prostatic hypertrophy).
  • The testicles are often spared in the necrotizing process. If uninvolved, place the exposed testicle in a subcutaneous pocket to prevent desiccation. If a testicle is involved in the necrotic process or its viability is questioned, perform orchiectomy.
  • Once the infection is eradicated, healthy granulation tissue develops; this signifies the time to proceed to reconstruction.
  • Vacuum-assisted closure (VAC) has shown great promise in the hastening wound healing in these patients with Fournier gangrene.^[37] Application after initial debridement may shorten the hospital stay and may speed up the grafting and flap placement process.
• Options for reconstruction^[38]

  • Primary closure of the skin, if possible
  • Local skin flap coverage
  • Split-thickness skin grafts (see the image below)Patient with alcoholism and known cirrhosis who presented with exquisite pain limited to the scrotum. Following resolution of the infection, the wound was covered with a split-thickness skin graft. The option of delayed primary closure of this wound was not chosen in this patient because of concern for tension on the closure. Courtesy of Thomas A. Santora, MD.
  • Muscular flaps, which are used to fill a cavity (eg, ischiorectal space)

The main complication associated with Fournier disease is unresolved sepsis, often caused by one of the following:

• Unrecognized cause of the infection (eg, perforated peptic ulcer disease, appendicitis, diverticulitis) or extension of the necrotizing process outside the obvious wound (A CT scan is helpful for evaluating these two possibilities.)
• Complication of severe acute illness (eg, line sepsis, bacterial endocarditis, pneumonia)
• The plethora of comorbid conditions (eg, acute myocardial infarction, respiratory failure, pressure ulcerations, delirium) or the bedrest conditions imposed on patients who are acutely ill (eg, pulmonary embolus, deep venous thrombosis, atelectasis, pneumonia)

To date, all studies of Fournier gangrene have been in the form of clinical series reviewed retrospectively.^{[39, 40]} Therefore, drawing reliable prognostic information from these studies is scientifically unsound. Given that proviso, Laor and colleagues introduced the Fournier Gangrene Severity Index (FGSI) based on deviation from reference ranges of 9 clinical parameters (temperature, heart rate, respiratory rate, white blood cell count, and levels of sodium, potassium, creatinine, hematocrit, sodium bicarbonate). Each parameter was valued between 0 and 4, with the higher value assigned to the greatest deviation from normal. The FGSI represents the sum of all the parameters values. They determined that advanced age (not a factor in the FGSI) and a FGSI greater than 9 correlated with increased mortality.^[41] Corcoran et al validated the FGSI in a retrospective review of 68 patients.^[42]

In summary, the mortality risk may be directly proportional to the age of the patient and the extent of systemic toxicity upon admission (FGSI), as well as to the extent of the local tissue involvement.^[43]

In some studies, Fournier disease that originates from diseases of the anorectum carries a worse prognosis than cases caused by other factors. In the 600 cases of Fournier gangrene discovered during a Medline search dating back to 1996, 100 deaths occurred (16.5%). In the series that included more than 20 patients, the mortality rate ranged from 4-54%, with most studies reporting mortality rates of 20-30%.^{[44, 45]}

The prognosis of Fournier disease following reconstruction is usually good. Approximately 50% of men with penile involvement have pain upon arousal. This pain is often related to limited mobility of the genitalia due to scarring. Consultation with a psychiatrist may be beneficial in some patients in order to 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.

The role of hyperbaric oxygen therapy in the treatment of Fournier disease needs to be clarified with a prospective controlled trial.^[46]

The role of topical agents in wound care also requires further investigation. Although reports from Africa extol the beneficial chemical effects of unprocessed honey, the salutatory effect of honey is likely related to its physical property of hyperosmolarity.^[47] Therefore, honey holds little advantage over other hygroscopic agents.^[48] The application of growth hormones and other trophic agents holds the potential to promote faster wound healing. The use of vacuum dressing technologies to hasten the wound closure has only recently been used to treat these wounds.