History

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

Prodromal symptoms of fever and lethargy, which may be present for 2-7 days
Intense genital pain and tenderness that is usually associated with edema of the overlying skin; pruritus may also be present
Increasing genital pain and tenderness with progressive erythema of the overlying skin
Dusky appearance of the overlying skin; subcutaneous crepitation
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.

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 gangrene. See the image below.

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.

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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.

Differential Diagnoses

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Media Gallery

Necrotizing infection results when the pathogen is extremely virulent or, most commonly, when a combination of microorganisms act 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.
Patient with Fournier gangrene following radical debridement. 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. Familiarity with this fascial anatomy, along with recognition that necrotizing fasciitis tends to spread along fascial planes, makes it easy to understand how a process that starts 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.
In a man with alcoholism and known cirrhosis who presented with exquisite pain limited to the scrotum, opening of the scrotum along the median raphe liberated foul-smelling brown purulence and exposed necrotic tissue throughout the mid scrotum. The testicles were not involved. Courtesy of Thomas A. Santora, MD.
The same patient depicted in Images 6 and 7. 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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Author

Vernon M Pais, Jr, MD Associate Professor, Department of Surgery, Section of Urology, Geisel School of Medicine at Dartmouth

Vernon M Pais, Jr, MD is a member of the following medical societies: Alpha Omega Alpha, American Urological Association, Endourological Society, Sigma Xi, The Scientific Research Honor Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: consultant -- Boston Scientific.

Coauthor(s)

Thomas A Santora, MD Professor, Vice-Chair for Informatics and Business Affairs, Department of Surgery, Lewis Katz School of Medicine at Temple University

Thomas A 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, Eastern Association for the Surgery of Trauma

Disclosure: Nothing to disclose.

Daniel B Rukstalis, MD Professor of Urology, Wake Forest Baptist Health System, Wake Forest University School of Medicine

Daniel B Rukstalis, MD is a member of the following medical societies: American Association for the Advancement of Science, American Urological Association

Disclosure: Nothing to disclose.

Grace E Sollender, MD Resident Physician, Department of Urology, University of California, Los Angeles, David Geffen School of Medicine

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 Laparoscopic and Robotic Surgeons, Society of University Urologists

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Endourological Society Board of Directors; President Elect North Central Section of the American Urological Association<br/>Serve(d) as a speaker or a member of a speakers bureau for: Cook Medical.

Acknowledgements

Andrew A Aronson, MD, FACEP Vice President, Physician Practices, Bravo Health Advanced Care Center; Consulting Staff, Department of Emergency Medicine, Taylor Hospital

Andrew A Aronson, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, Massachusetts Medical Society, and Society of Hospital Medicine