Fournier Gangrene Workup

  • Author: Thomas Santora, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS   more...
 
Updated: Jan 20, 2012
 

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.
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Imaging Studies

  • Radiography
    • Radiography should be considered to evaluate for the presence and extent of Fournier disease, especially when the clinical examination findings are inconclusive[26, 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.
  • Ultrasonography[28]
    • 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.
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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.

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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.

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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, Temple University 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.

Specialty Editor Board

Alex Jacocks, MD  Program Director, Professor, Department of Surgery, University of Oklahoma School of Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

David L Morris, MD, PhD, FRACS  Professor, Department of Surgery, St George Hospital, University of New South Wales, Australia

David L Morris, MD, PhD, FRACS is a member of the following medical societies: British Society of Gastroenterology

Disclosure: RFA Medical None Director; MRC Biotec None Director

J Stuart Wolf Jr, MD, FACS  The David A Bloom Professor of Urology, Director, Division of Endourology and Stone Disease, Department of Urology, University of Michigan Medical School

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: Nothing to disclose.

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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Necrotizing infection results from infection with an extremely virulent microorganism or, most commonly, from a combination of microorganisms acting synergistically in a susceptible immunocompromised host.
Photomicrograph of Fournier gangrene (necrotizing fasciitis), oil immersion at 1000X magnification. Note the acute inflammatory cells in the necrotic tissue. Bacteria are located in the haziness of their cytoplasm. Courtesy of Billie Fife, MD, and Thomas A. Santora, MD.
Photograph of a morbidly obese male with long-standing phimosis. This condition led to urinary incontinence, perineal diaper rash–like dermatitis, and urinary tract infection. Ultimately, he presented with exquisite perineal pain. An examination with the patient under anesthesia was necessary to discover the necrotizing infection that appeared to originate in the right bulbourethral gland. Courtesy of Thomas A. Santora, MD.
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.
Fascial envelopment of the perineum (male). Note how Colles fascia completely envelops the scrotum and penis. Colles fascia is in continuity cephalad to the level of the clavicles. In the inguinal region, this fascial layer is known as Scarpa fascia. Understanding the tendency of necrotizing fasciitis to spread along fascial planes and the fascial anatomy, one can see how a process that initiates in the perineum can spread to the abdominal wall, the flank, and even the chest wall.
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.
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.
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.
 
 
 
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