eMedicine Specialties > Emergency Medicine > Genitourinary

Fournier Gangrene: Follow-up

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: Mar 4, 2008

Follow-up

Further Inpatient Care

  • The consulting urologist or surgeon may order further diagnostic tests, including cystourethroscopy, retrograde urethrography, sigmoidoscopy, barium enema, tissue biopsy, and examination under anesthesia.
  • Urinary and/or fecal diversion (eg, suprapubic catheterization, colostomy) may be required depending on the source of infection.
  • Multiple debridements in the operating room may be required to effectively remove all necrotic tissue. Patients with Fournier gangrene undergo an average of 2-4 operative procedures during their initial hospitalization.
  • Orchidectomy and/or penectomy rarely are required.
  • Hyperbaric oxygen therapy (HBO) has been used as an adjuvant to surgical and antimicrobial therapy, especially in patients for whom conventional treatment has failed, in those with documented clostridial involvement, or in those with myonecrosis or deep tissue involvement. HBO is postulated to reduce systemic toxicity, prevent extension of necrotizing infection, and inhibit growth of anaerobic bacteria. However, in one series, there was actually a trend toward increased mortality in patients undergoing HBO therapy.2 (This trend may have been related to selection bias). Decisions regarding hyperbaric therapy must be made on an individual basis and should be an adjuvant to debridement and antimicrobial therapy.
  • A Fournier gangrene severity index score has been developed, which has been shown to aid in prognosis. A score from 0 to 4 is assigned to each of the following parameters3 : temperature; heart rate; respiratory rate; serum sodium, potassium, bicarbonate, and creatinine levels; hematocrit; and white blood cell count. Mortality is associated with a total score >9.
  • Unprocessed honey, applied directly to the surface of the wounds, has been reported by some authors to enzymatically debride, sterilize, and dehydrate wounds and to improve local tissue oxygenation and re-epithelialization. This treatment is controversial, and no current studies support this practice.
  • One published case report advocates irrigation of the perineum with superoxidized water as well as application of gauze soaked in zinc peroxide and hydrogen peroxide.

Transfer

  • Fournier gangrene is a true surgical emergency. If the initial facility does not have the capability to provide operative therapy in a timely fashion, arrange for transfer once the patient has been stabilized and resuscitative efforts have begun.
  • Patients often require a multidisciplinary team, including a urologist, general surgeon, and intensivist. Transfer to a tertiary facility may be required if these resources are not available at the initial facility.

Complications

  • Progression to single-organ or multiorgan failure may occur, usually as a result of gram-negative sepsis and typically is the cause of death. Examples include acute renal failure and adult respiratory distress syndrome.
  • Large scrotal, perineal, penile, and abdominal wall skin defects may require reconstructive procedures.
  • Fatal tetanus associated with Fournier gangrene has been reported in the literature.

Prognosis

  • Factors associated with an improved prognosis include age younger than 60 years, localized clinical disease, absence of systemic toxicity, and sterile blood cultures.
  • Surprisingly, diabetes and HIV infection are not associated with higher mortality.
  • The scrotum has a remarkable ability to heal and regenerate once the infection and necrosis have subsided.

Patient Education

Encourage diligent hygiene of the perineum, especially in immunocompromised patients or those with other risk factors for the disease. 

Miscellaneous

Medicolegal Pitfalls

  • Failure to realize that cutaneous findings often underestimate the extent of underlying disease
  • Failure to initiate early broad-spectrum antibiotics
  • Failure to obtain immediate urologic consultation or to transfer the patient to an appropriate facility if such resources are not available at the current facility
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors, Todd Thomsen, MD, and Eric Legome, MD, to the development and writing of this article.



More on Fournier Gangrene

Overview: Fournier Gangrene
Differential Diagnoses & Workup: Fournier Gangrene
Treatment & Medication: Fournier Gangrene
Follow-up: Fournier Gangrene
References
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References

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

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

  3. 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].

  4. 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].

  5. Basoglu M, Gül 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].

  6. 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].

  7. 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].

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

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

  10. 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].

  11. Diep BA, Chambers HF, Graber CJ, Szumowski JD, Miller LG, Han LL, 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].

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

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

  14. 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].

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

  16. 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].

  17. 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].

  18. 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].

  19. 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].

  20. 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].

  21. 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].

  22. 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].

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

  24. 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].

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

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

  27. 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].

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

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

  30. 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].

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

  32. 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].

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Further Reading

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Keywords

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

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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: Nothing to disclose.

Managing Editor

Richard 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 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

Jonathan Adler, MD, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital; Division of Emergency Medicine, Harvard Medical School
Jonathan Adler, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: eMedicine.com, Inc. Consulting fee Consulting

 
 
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