Fournier Gangrene Clinical Presentation

Updated: Nov 12, 2016
  • Author: Vernon M Pais, Jr, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
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Presentation

History

The hallmark of Fournier gangrene is intense pain and tenderness in the genitalia. The clinical course usually progresses through the following phases:

  1. Prodromal symptoms of fever and lethargy, which may be present for 2-7 days
  2. Intense genital pain and tenderness that is usually associated with edema of the overlying skin; pruritus may also be present
  3. Increasing genital pain and tenderness with progressive erythema of the overlying skin
  4. Dusky appearance of the overlying skin; subcutaneous crepitation
  5. Obvious gangrene of a portion of the genitalia; purulent drainage from wounds

Early in the course of the disease, pain may be out of proportion to physical findings. As gangrene develops, pain may actually subside as nerve tissue becomes necrotic.

Systemic effects of this process vary from local tenderness with no toxicity to florid septic shock. In general, the greater the degree of necrosis, the more profound the systemic effects.

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Physical Examination

The physician should direct particular attention to palpation of the genitalia and perineum and to the digital rectal examination, to assess for signs of the disease and to seek a potential portal of entry. Fluctuance, soft-tissue crepitation, localizing tenderness, or occult wounds in any of these sites should alert the examiner to possible Fournier disease. See image below.

Photograph of a morbidly obese male with long-stan 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.

Skin overlying the affected region may be normal, erythematous, edematous, cyanotic, bronzed, indurated, blistered, and/or frankly gangrenous. Skin appearance often underestimates the degree of underlying disease.

A feculent odor may be present secondary to infection with anaerobic bacteria. Crepitus may be present, but its absence does not exclude the presence of Clostridium species or other gas-producing organisms.

Systemic symptoms (eg, fever, tachycardia, hypotension) may be present.

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