Pernetti R, Palmieri F, Sagrini E, Negri M, Morisi C, Carbone A, et al. Fournier's gangrene: Clinical case and review of the literature. Arch Ital Urol Androl. 2016 Oct 5. 88 (3):237-238. [QxMD MEDLINE Link].
Khalid A, Devakumar S, Huespe I, Kashyap R, Chisti I. A Comprehensive Literature Review of Fournier's Gangrene in Females. Cureus. 2023 May. 15 (5):e38953. [QxMD MEDLINE Link]. [Full Text].
Ekelius L, Björkman H, Kalin M, Fohlman J. Fournier's gangrene after genital piercing. Scand J Infect Dis. 2004. 36(8):610-2. [QxMD MEDLINE Link].
Laucks SS 2nd. Fournier's gangrene. Surg Clin North Am. 1994 Dec. 74 (6):1339-52. [QxMD MEDLINE Link].
Stephens BJ, Lathrop JC, Rice WT, Gruenberg JC. Fournier's gangrene: historic (1764-1978) versus contemporary (1979-1988) differences in etiology and clinical importance. Am Surg. 1993 Mar. 59 (3):149-54. [QxMD MEDLINE Link].
Furr J, Watts T, Street R, Cross B, Slobodov G, Patel S. Contemporary Trends in the Inpatient Management of Fournier's Gangrene: Predictors of Length of Stay and Mortality Based on Population-Based Sample. Urology. 2016 Sep 27. 382(1):15-8. [QxMD MEDLINE Link].
Corman JM. Classic articles in colonic and rectal surgery. Dis Colon Rectum. 1988. 31:984-8.
Mergenhagen SE, Thonard JC, Scherp HW. Studies on synergistic infections. I. Experimental infections with anaerobic streptococci. J Infect Dis. 1958 Jul-Aug. 103(1):33-44. [QxMD MEDLINE Link].
Meleney FL. Hemolytic Streptococcus gangrene. Arch Surg. 1924. 9:317-21.
Moses AE. Necrotizing fasciitis: flesh-eating microbes. Isr J Med Sci. 1996 Sep. 32(9):781-4. [QxMD MEDLINE Link].
Benizri E, Fabiani P, Migliori G, et al. Gangrene of the perineum. Urology. 1996 Jun. 47(6):935-9. [QxMD MEDLINE Link].
Benchekroun A, Lachkar A, Bjijou Y, et al. [Gangrene of the external genital organs. Apropos of 55 cases]. J Urol (Paris). 1997. 103(1-2):27-31. [QxMD MEDLINE Link].
Ben-Aharon U, Borenstein A, Eisenkraft S, et al. Extensive necrotizing soft tissue infection of the perineum. Isr J Med Sci. 1996 Sep. 32(9):745-9. [QxMD MEDLINE Link].
Basoglu M, Gül O, Yildirgan I, Balik AA, Ozbey I, Oren D. Fournier's gangrene: review of fifteen cases. Am Surg. 1997 Nov. 63(11):1019-21. [QxMD MEDLINE Link].
Goyette M. Group A streptococcal necrotizing fasciitis Fournier's gangrene--Quebec. Can Commun Dis Rep. 1997 Jul 1. 23(13):101-3. [QxMD MEDLINE Link].
Smith GL, Bunker CB, Dinneen MD. Fournier's gangrene. Br J Urol. 1998 Mar. 81(3):347-55. [QxMD MEDLINE Link].
Clayton MD, Fowler JE Jr, Sharifi R, Pearl RK. Causes, presentation and survival of fifty-seven patients with necrotizing fasciitis of the male genitalia. Surg Gynecol Obstet. 1990 Jan. 170(1):49-55. [QxMD MEDLINE Link].
Ossibi PE, Souiki T, Ibn Majdoub K, Toughrai I, Laalim SA, Mazaz K, et al. Fournier gangrene: rare complication of rectal cancer. Pan Afr Med J. 2015. 20:288. [QxMD MEDLINE Link]. [Full Text].
Gould SW, Banwell P, Glazer G. Perforated colonic carcinoma presenting as epididymo-orchitis and Fournier's gangrene. Eur J Surg Oncol. 1997 Aug. 23(4):367-8. [QxMD MEDLINE Link].
Brings HA, Matthews R, Brinkman J, Rotolo J. Crohn's disease presenting with Fournier's gangrene and enterovesical fistula. Am Surg. 1997 May. 63(5):401-5. [QxMD MEDLINE Link].
Kappel C, Piticaru J, Jones G, Goucher G, Cheon P, Fischer M, et al. A case of possible Fournier's gangrene associated with proning in COVID-19 ARDS. Can J Anaesth. 2020 Nov. 67 (11):1697-1698. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America. Clin Infect Dis. 2014 Jul 15. 59 (2):147-59. [QxMD MEDLINE Link]. [Full Text].
Mouraviev VB, Pautler SE, Hayman WP. Fournier's gangrene following penile self-injection with cocaine. Scand J Urol Nephrol. 2002. 36(4):317-8. [QxMD MEDLINE Link].
Abate G, Shirin M, Kandanati V. Fournier gangrene from a thirty-two-centimeter rectosigmoid foreign body. J Emerg Med. 2013 Feb. 44(2):e247-9. [QxMD MEDLINE Link].
Ekingen G, Isken T, Agir H, Oncel S, Günlemez A. Fournier's gangrene in childhood: a report of 3 infant patients. J Pediatr Surg. 2008 Dec. 43 (12):e39-42. [QxMD MEDLINE Link].
Numoto S, Kurahashi H, Azuma Y, Numaguchi A, Nakahara K, Tainaka T, et al. Fournier's gangrene during ACTH therapy. Brain Dev. 2017 May. 39 (5):435-438. [QxMD MEDLINE Link].
Huang CS. Fournier's Gangrene. N Engl J Med. 2017 Mar 23. 376 (12):1158. [QxMD MEDLINE Link]. [Full Text].
Perkins TA, Bieniek JM, Sumfest JM. Solitary Candida albicans Infection Causing Fournier Gangrene and Review of Fungal Etiologies. Rev Urol. 2014. 16 (2):95-8. [QxMD MEDLINE Link].
Jaworski R, Irga-Jaworska N, Naumiuk Ł, Chojnicki M, Haponiuk I. Fournier Gangrene Caused by Candida albicans in an Infant After Cardiac Surgery. Mycopathologia. 2016 Nov 2. [QxMD MEDLINE Link].
Jaworski R, Irga-Jaworska N, Naumiuk Ł, Chojnicki M, Haponiuk I. Fournier Gangrene Caused by Candida albicans in an Infant After Cardiac Surgery. Mycopathologia. 2017 Apr. 182 (3-4):409-412. [QxMD MEDLINE Link]. [Full Text].
Rajbhandari SM, Wilson RM. Unusual infections in diabetes. Diabetes Res Clin Pract. 1998 Feb. 39(2):123-8. [QxMD MEDLINE Link].
Faber HJ, Girbes AR, Daenen S. Fournier's gangrene as first presentation of promyelocytic leukemia. Leuk Res. 1998 May. 22(5):473-6. [QxMD MEDLINE Link].
Martinelli G, Alessandrino EP, Bernasconi P, et al. Fournier's gangrene: a clinical presentation of necrotizing fasciitis after bone marrow transplantation. Bone Marrow Transplant. 1998 Nov. 22(10):1023-6. [QxMD MEDLINE Link].
Kohagura K, Sesoko S, Tozawa M, et al. [A female case of Fournier's gangrene in a patient with lupus nephritis]. Nippon Jinzo Gakkai Shi. 1998 Jul. 40(5):354-8. [QxMD MEDLINE Link].
Roca B, Cuñat E, Simón E. HIV infection presenting with Fournier's gangrene. Neth J Med. 1998 Oct. 53(4):168-71. [QxMD MEDLINE Link].
Gonzaga-López A, Muñoz-Rodriguez J, Ruiz-Casado A. Necrotising fasciitis in a patient treated with FOLFIRI-aflibercept for colorectal cancer: a case report. Ann R Coll Surg Engl. 2017 Nov. 99 (8):e225-e226. [QxMD MEDLINE Link].
Bersoff-Matcha SJ, Chamberlain C, Cao C, Kortepeter C, Chong WH. Fournier Gangrene Associated With Sodium-Glucose Cotransporter-2 Inhibitors: A Review of Spontaneous Postmarketing Cases. Ann Intern Med. 2019 May 7. [QxMD MEDLINE Link].
Paty R, Smith AD. Gangrene and Fournier's gangrene. Urol Clin North Am. 1992 Feb. 19(1):149-62. [QxMD MEDLINE Link].
Eke N. Fournier's gangrene: a review of 1726 cases. Br J Surg. 2000 Jun. 87(6):718-28. [QxMD MEDLINE Link].
Sorensen MD, Krieger JN. Fournier's Gangrene: Epidemiology and Outcomes in the General US Population. Urol Int. 2016. 97 (3):249-259. [QxMD MEDLINE Link]. [Full Text].
Ngugi P, Magoha G, Nyaga P. Fournier's ganrene in the HIV era. Afr Health Sci. 2014 Dec. 14 (4):1063-8. [QxMD MEDLINE Link]. [Full Text].
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. 2008 Feb 19. 148(4):249-57. [QxMD MEDLINE Link].
Corman JM, Moody JA, Aronson WJ. Fournier's gangrene in a modern surgical setting: improved survival with aggressive management. BJU Int. 1999 Jul. 84(1):85-8. [QxMD MEDLINE Link].
Chen CS, Liu KL, Chen HW, Chou CC, Chuang CK, Chu SH. Prognostic factors and strategy of treatment in Fournier's gangrene: a 12-year retrospective study. Changgeng Yi Xue Za Zhi. 1999 Mar. 22(1):31-6. [QxMD MEDLINE Link].
Laor E, Palmer LS, Tolia BM, Reid RE, Winter HI. Outcome prediction in patients with Fournier's gangrene. J Urol. 1995 Jul. 154(1):89-92. [QxMD MEDLINE Link].
Corcoran AT, Smaldone MC, Gibbons EP, Walsh TJ, Davies BJ. Validation of the Fournier's gangrene severity index in a large contemporary series. J Urol. 2008 Sep. 180(3):944-8. [QxMD MEDLINE Link].
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. 2004 Aug. 64(2):218-22. [QxMD MEDLINE Link].
Ulug M, Gedik E, Girgin S, Celen MK, Ayaz C. The evaluation of microbiology and Fournier's gangrene severity index in 27 patients. Int J Infect Dis. 2009 Nov. 13(6):e424-30. [QxMD MEDLINE Link].
Ferretti M, Saji AA, Phillips J. Fournier's Gangrene: A Review and Outcome Comparison from 2009 to 2016. Adv Wound Care (New Rochelle). 2017 Sep 1. 6 (9):289-295. [QxMD MEDLINE Link]. [Full Text].
Yilmazlar T, Ozturk E, Ozguc H, Ercan I, Vuruskan H, Oktay B. Fournier's gangrene: an analysis of 80 patients and a novel scoring system. Tech Coloproctol. 2010 Sep. 14(3):217-23. [QxMD MEDLINE Link].
Morais H, Neves J, Maciel Ribeiro H, Ferreira M, Guimarães N, Azenha N, et al. Case series of Fournier's gangrene: Affected body surface area - The underestimated prognostic factor. Ann Med Surg (Lond). 2017 Apr. 16:19-22. [QxMD MEDLINE Link]. [Full Text].
Norton KS, Johnson LW, Perry T, et al. Management of Fournier's gangrene: an eleven year retrospective analysis of early recognition, diagnosis, and treatment. Am Surg. 2002 Aug. 68(8):709-13. [QxMD MEDLINE Link].
Roghmann F, von Bodman C, Löppenberg B, Hinkel A, Palisaar J, Noldus J. Is there a need for the Fournier's gangrene severity index? Comparison of scoring systems for outcome prediction in patients with Fournier's gangrene. BJU Int. 2012 Nov. 110(9):1359-65. [QxMD MEDLINE Link].
Bozkurt O, Sen V, Demir O, Esen A. Evaluation of the utility of different scoring systems (FGSI, LRINEC and NLR) in the management of Fournier's gangrene. Int Urol Nephrol. 2015 Feb. 47 (2):243-8. [QxMD MEDLINE Link].
Ghodoussipour SB, Gould D, Lifton J, Badash I, Krug A, Miranda G, et al. Surviving Fournier's gangrene: Multivariable analysis and a novel scoring system to predict length of stay. J Plast Reconstr Aesthet Surg. 2017 Dec 14. [QxMD MEDLINE Link].
Rios-Diaz AJ, Lin E, Williams K, Jiang W, Patel V, Shimizu N, et al. The obesity paradox in patients with severe soft tissue infections. Am J Surg. 2017 Sep. 214 (3):385-389. [QxMD MEDLINE Link].
Jones J, US Sanitary Commission. Investigation upon the nature, causes and treatment of hospital gangrene as it prevailed in the Confederate Armies 1861-1865. Surgical Memoirs of the War of the Rebellion. New York, NY: Hurd and Houghton; 1871. 142-580.
Kim SY, Dupree JM, Le BV, Kim DY, Zhao LC, Kundu SD. A contemporary analysis of Fournier gangrene using the National Surgical Quality Improvement Program. Urology. 2015 May. 85 (5):1052-6. [QxMD MEDLINE Link].
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. 2009 Aug. 37(4):306-12. [QxMD MEDLINE Link].
Yilmazlar T, Gulcu B, Isik O, Ozturk E. Microbiological aspects of Fournier's gangrene. Int J Surg. 2017 Apr. 40:135-138. [QxMD MEDLINE Link].
Fan CM, Whitman GJ, Chew FS. Radiologic-Pathologic Conferences of the Massachusetts General Hospital. Necrotizing fasciitis of the scrotum (Fournier's gangrene). AJR Am J Roentgenol. 1996 May. 166(5):1164. [QxMD MEDLINE Link].
Rajan DK, Scharer KA. Radiology of Fournier's gangrene. AJR Am J Roentgenol. 1998 Jan. 170(1):163-8. [QxMD MEDLINE Link].
Sherman J, Solliday M, Paraiso E, Becker J, Mydlo JH. Early CT findings of Fournier's gangrene in a healthy male. Clin Imaging. 1998 Nov-Dec. 22(6):425-7. [QxMD MEDLINE Link].
Wysoki MG, Santora TA, Shah RM, Friedman AC. Necrotizing fasciitis: CT characteristics. Radiology. 1997 Jun. 203(3):859-63. [QxMD MEDLINE Link].
Kane CJ, Nash P, McAninch JW. Ultrasonographic appearance of necrotizing gangrene: aid in early diagnosis. Urology. 1996 Jul. 48(1):142-4. [QxMD MEDLINE Link].
Auerbach J, Bornstein K, Ramzy M, Cabrera J, Montrief T, Long B. Fournier Gangrene in the Emergency Department: Diagnostic Dilemmas, Treatments and Current Perspectives. Open Access Emerg Med. 2020. 12:353-364. [QxMD MEDLINE Link]. [Full Text].
Sugihara T, Yasunaga H, Horiguchi H, Fujimura T, Ohe K, Matsuda S, et al. Impact of surgical intervention timing on the case fatality rate for Fournier's gangrene: an analysis of 379 cases. BJU Int. 2012 Dec. 110(11 Pt C):E1096-100. [QxMD MEDLINE Link].
El-Shazly M, Aziz M, Aboutaleb H, Salem S, El-Sherif E, Selim M, et al. Management of equivocal (early) Fournier's gangrene. Ther Adv Urol. 2016 Oct. 8 (5):297-301. [QxMD MEDLINE Link]. [Full Text].
Stevens DL, Gibbons AE, Bergstrom R, Winn V. The Eagle effect revisited: efficacy of clindamycin, erythromycin, and penicillin in the treatment of streptococcal myositis. J Infect Dis. 1988 Jul. 158(1):23-8. [QxMD MEDLINE Link].
Cawley MJ, Briggs M, Haith LR Jr, et al. Intravenous immunoglobulin as adjunctive treatment for streptococcal toxic shock syndrome associated with necrotizing fasciitis: case report and review. Pharmacotherapy. 1999 Sep. 19(9):1094-8. [QxMD MEDLINE Link].
Karian LS, Chung SY, Lee ES. Reconstruction of Defects After Fournier Gangrene: A Systematic Review. Eplasty. 2015. 15:e18. [QxMD MEDLINE Link]. [Full Text].
Konofaos P, Hickerson WL. A Technique for Improving Cosmesis After Primary Scrotum Reconstruction With Skin Grafts. Ann Plast Surg. 2015 Aug. 75 (2):205-7. [QxMD MEDLINE Link].
Korhonen K, Hirn M, Niinikoski J. Hyperbaric oxygen in the treatment of Fournier's gangrene. Eur J Surg. 1998 Apr. 164(4):251-5. [QxMD MEDLINE Link].
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. 1997 Sep. 158(3 Pt 1):837-40. [QxMD MEDLINE Link].
Hollabaugh RS Jr, Dmochowski RR, Hickerson WL, Cox CE. Fournier's gangrene: therapeutic impact of hyperbaric oxygen. Plast Reconstr Surg. 1998 Jan. 101(1):94-100. [QxMD MEDLINE Link].
Mladenov A, Diehl K, Müller O, von Heymann C, Kopp S, Peitsch WK. Outcome of necrotizing fasciitis and Fournier's gangrene with and without hyperbaric oxygen therapy: a retrospective analysis over 10 years. World J Emerg Surg. 2022 Aug 5. 17 (1):43. [QxMD MEDLINE Link]. [Full Text].
Mindrup SR, Kealey GP, Fallon B. Hyperbaric oxygen for the treatment of fournier's gangrene. J Urol. 2005 Jun. 173(6):1975-7. [QxMD MEDLINE Link].
Nomikos IN. Necrotizing perineal infections (Fournier's disease): old remedies for an old disease. Int J Colorectal Dis. 1998. 13(1):48-51. [QxMD MEDLINE Link].
Asci R, Sarikaya S, Büyükalpelli R, Yilmaz AF, Yildiz S. Fournier's gangrene: risk assessment and enzymatic debridement with lyophilized collagenase application. Eur Urol. 1998. 34(5):411-8. [QxMD MEDLINE Link].
Hersant B, SidAhmed-Mezi M, Bosc R, Meningaud JP. Autologous Platelet-Rich Plasma/Thrombin Gel Combined with Split-Thickness Skin Graft to Manage Postinfectious Skin Defects: A Randomized Controlled Study. Adv Skin Wound Care. 2017 Nov. 30 (11):502-508. [QxMD MEDLINE Link].
Ingraham AM, Jung HS, Liepert AE, Warner-Hillard C, Greenberg CC, Scarborough JE. Effect of transfer status on outcomes for necrotizing soft tissue infections. J Surg Res. 2017 Dec. 220:372-378. [QxMD MEDLINE Link].

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.

of 8

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