eMedicine Specialties > Emergency Medicine > Genitourinary

Fournier Gangrene: Differential Diagnoses & Workup

Author: Michael T Marynowski, DO, Staff Physician, Department of Emergency Medicine/Internal Medicine, Allegheny General Hospital
Coauthor(s): Andrew A Aronson, MD, Assistant Professor of Emergency Medicine, Drexel University School of Medicine; Consulting Staff, Department of Emergency Medicine, Allegheny General Hospital
Contributor Information and Disclosures

Updated: Dec 11, 2009

Differential Diagnoses

Balanitis
Hydrocele
Cellulitis
Necrotizing Fasciitis
Epididymitis
Orchitis
Gas Gangrene
Testicular Torsion
Hernias

Other Problems to Be Considered

Testicular fracture
Testicular hematoma
Testicular abscess
Scrotal abscess
Vasculitis
Warfarin gangrenosum
Polyarteritis nodosum
Wegener granulomatosis

Workup

Laboratory Studies

The following studies are indicated in patients Fournier gangrene:

  • CBC count
  • Electrolytes, BUN, creatinine, blood glucose levels
    • Acidosis with hyperglycemia or hypoglycemia may be present.
    • Dehydration occurs as the disease progresses.
  • ABG sampling to provide a more accurate assessment of acid/base disturbance
  • Blood and urine cultures
  • Disseminated intravascular coagulation (DIC) panel (coagulation studies, fibrinogen/fibrin degradation product levels) to find evidence of severe sepsis
  • Cultures of any open wound or abscess

Imaging Studies

Diagnosis of Fournier gangrene primarily is based on clinical findings. Sensitivities and specificities of different radiologic modalities are not established.

  • Conventional radiography
    • Conventional radiography may demonstrate soft-tissue gas collections (manifest as areas of hyperlucency), even before they are clinically apparent.
    • Scrotal tissue edema may be observed on radiographs.
    • Absence of air on plain films does not exclude the diagnosis.
  • Ultrasonography
    • Ultrasonography may reveal other causes of acute scrotal pain, including intratesticular injury, scrotal cellulitis, epididymoorchitis, testicular torsion, and inguinal hernia.
    • Gas in the scrotal wall is the "sonographic hallmark" of Fournier gangrene.
    • Air may be appreciated in perineal and/or perirectal areas.
    • Scrotal wall edema may be seen.
    • Testes and epididymides are usually normal.
  • Computed tomography
    • Findings include soft-tissue and fascial thickening, fat stranding, and soft-tissue gas collections.
    • CT scan defines the extent of the disease more specifically than plain films or ultrasound.
    • CT scan often identifies the underlying cause of the infection (eg, perirectal abscess).
    • This modality may assist in surgical planning.
  • Magnetic resonance imaging
    • MRI use is not well described in the literature.
    • MRI may define soft-tissue pathology more distinctly than CT scan but should not delay operative intervention if the diagnosis is highly suspected.

More on Fournier Gangrene

Overview: Fournier Gangrene
Differential Diagnoses & Workup: Fournier Gangrene
Treatment & Medication: Fournier Gangrene
Follow-up: Fournier Gangrene
Multimedia: Fournier Gangrene
References
[ CLOSE WINDOW ]

References

  1. Eke N. Fournier's gangrene: a review of 1726 cases. Br J Surg. Jun 2000;87(6):718-28. [Medline].

  2. 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. Aug 2009;37(4):306-12. [Medline].

  3. [Guideline] Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft-tissue infections. Clin Infect Dis. Nov 15 2005;41(10):1373-406. [Medline].

  4. 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. Feb 19 2008;148(4):249-57. [Medline].

  5. Akcan A, Sozuer E, Akyildiz H, Yilmaz N, Kucuk C, Ok E. Necessity of preventive colostomy for Fournier's gangrene of the anorectal region. Ulus Travma Acil Cerrahi Derg. Jul 2009;15(4):342-6. [Medline].

  6. Mindrup SR, Kealey GP, Fallon B. Hyperbaric oxygen for the treatment of fournier's gangrene. J Urol. Jun 2005;173(6):1975-7. [Medline].

  7. 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. Aug 2004;64(2):218-22. [Medline].

  8. Ameh EA, Dauda MM, Sabiu L, Mshelbwala PM, Mbibu HN, Nmadu PT. Fournier's gangrene in neonates and infants. Eur J Pediatr Surg. Dec 2004;14(6):418-21. [Medline].

  9. Basoglu M, Gul O, Yildirgan I, Balik AA, Ozbey I, Oren D. Fournier's gangrene: review of fifteen cases. Am Surg. Nov 1997;63(11):1019-21. [Medline].

  10. Bayar S, Unal AE, Demirkan A, Atasoy C, Karayalcin K. Fournier's gangrene complicating blunt thoracic trauma. Surgery. Jun 2004;135(6):693-4. [Medline].

  11. Benizri E, Fabiani P, Migliori G, Chevallier D, Peyrottes A, Raucoules M, et al. Gangrene of the perineum. Urology. Jun 1996;47(6):935-9. [Medline].

  12. Biyani CS, Mayor PE, Powell CS. Case report: Fournier's gangrene--roentgenographic and sonographic findings. Clin Radiol. Oct 1995;50(10):728-9. [Medline].

  13. Capelli-Schellpfeffer M, Gerber GS. The use of hyperbaric oxygen in urology. J Urol. Sep 1999;162(3 Pt 1):647-54. [Medline].

  14. Corman JM, Moody JA, Aronson WJ. Fournier's gangrene in a modern surgical setting: improved survival with aggressive management. BJU Int. Jul 1999;84(1):85-8. [Medline].

  15. Ekelius L, Bjorkman H, Kalin M, Fohlman J. Fournier's gangrene after genital piercing. Scand J Infect Dis. 2004;36(8):610-2. [Medline].

  16. Erikoglu M, Tavli S, Turk S. Fournier's gangrene after renal transplantation. Nephrol Dial Transplant. Feb 2005;20(2):449-50. [Medline].

  17. Grayson DE, Abbott RM, Levy AD, Sherman PM. Emphysematous infections of the abdomen and pelvis: a pictorial review. Radiographics. May-Jun 2002;22(3):543-61. [Medline].

  18. Hejase MJ, Simonin JE, Bihrle R, Coogan CL. Genital Fournier's gangrene: experience with 38 patients. Urology. May 1996;47(5):734-9. [Medline].

  19. Hollabaugh RS Jr, Dmochowski RR, Hickerson WL, Cox CE. Fournier's gangrene: therapeutic impact of hyperbaric oxygen. Plast Reconstr Surg. Jan 1998;101(1):94-100. [Medline].

  20. Horita Y, Miyazaki M, Noguchi M, Tadokoro M, Taura K, Ozono Y, et al. Healing of Fournier's gangrene of the scrotum in a haemodialysis patient after conservative therapy alone. Nephrol Dial Transplant. Mar 2000;15(3):419-21. [Medline].

  21. Korhonen K, Hirn M, Niinikoski J. Hyperbaric oxygen in the treatment of Fournier's gangrene. Eur J Surg. Apr 1998;164(4):251-5. [Medline].

  22. 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].

  23. Nabha KS, Badwan K, Kerfoot BP. Fournier's gangrene as a complication of steroid enema use for treatment of radiation proctitis. Urology. Sep 2004;64(3):587-8. [Medline].

  24. Nadel ES, Brown DF, Wiencek JG. Change in mental status in a patient with lung cancer. J Emerg Med. Jan-Feb 1998;16(1):111-4. [Medline].

  25. Olsofka JN, Carrillo EH, Spain DA, Polk HC Jr. The continuing challenge of Fournier's gangrene in the 1990s. Am Surg. Dec 1999;65(12):1156-9. [Medline].

  26. Patankar SP, Lalwani SK. Fourniers gangrene. Indian Pediatr. May 2004;41(5):511. [Medline].

  27. 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. Sep 1997;158(3 Pt 1):837-40. [Medline].

  28. Quatan N, Kirby RS. Improving outcomes in Fournier's gangrene. BJU Int. Apr 2004;93(6):691-2. [Medline].

  29. Rajan DK, Scharer KA. Radiology of Fournier's gangrene. AJR Am J Roentgenol. Jan 1998;170(1):163-8. [Medline].

  30. Rehman J, Kaynan A, Samadi D, Fleischmann J. Air on radiography of perineal necrotizing fasciitis indicates testis involvement. J Urol. Dec 1999;162(6):2101. [Medline].

  31. Riviello RJ, Harris AT, Perez S. Scrotal pain and swelling. Acad Emerg Med. Mar 1997;4(3):223-4, 233-5. [Medline].

  32. Smith GL, Bunker CB, Dinneen MD. Fournier's gangrene. Br J Urol. Mar 1998;81(3):347-55. [Medline].

  33. Vaidyanathan S, Soni BM, Hughes PL, Mansour P, Singh G, Darroch J. Localised necrosis of scrotum (Fournier's gangrene) in a spinal cord injury patient - a case report. BMC Fam Pract. Dec 5 2002;3:20. [Medline].

  34. Vick R, Carson CC 3rd. Fournier's disease. Urol Clin North Am. Nov 1999;26(4):841-9. [Medline].

  35. Yaghan RJ, Al-Jaberi TM, Bani-Hani I. Fournier's gangrene: changing face of the disease. Dis Colon Rectum. Sep 2000;43(9):1300-8. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

Fournier gangrene, Fournier's gangrene, gangrene of the penis and scrotum, polymicrobial necrotizing fasciitis, infection of superficial perineal fascia, treatment, diagnosis, symptoms

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Michael T Marynowski, DO, Staff Physician, Department of Emergency Medicine/Internal Medicine, Allegheny General Hospital
Disclosure: Nothing to disclose.

Coauthor(s)

Andrew A Aronson, MD, Assistant Professor of Emergency Medicine, Drexel University School of Medicine; Consulting Staff, Department of Emergency Medicine, Allegheny General Hospital
Andrew A Aronson, MD is a member of the following medical societies: American College of Emergency Physicians, Massachusetts Medical Society, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Richard Lavely, MD, JD, MS, MPH, Lecturer in Health Policy and Administration, Department of Public Health, Yale University School of Medicine
Richard Lavely, MD, JD, MS, MPH is a member of the following medical societies: American College of Emergency Physicians, American College of Legal Medicine, and American Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Richard H Sinert, DO, Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center
Richard H Sinert, DO is a member of the following medical societies: American College of Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Erik D Schraga, MD, Consulting Staff, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates; Consulting Staff, Permanente Medical Group, Kaiser Permanente, Santa Clara Medical Center
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.