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| __NOTOC__ | | __NOTOC__ |
| '''For more information about necrotizing fasciitis click [[necrotizing fasciitis|here]] | | '''For more information about necrotizing fasciitis click [[necrotizing fasciitis|here]] |
| {{SI}} | | '''For patient information, click [[Fournier gangrene (patient information)|here]]''' |
| | {{Fournier gangrene}} |
| {{SCC}}; {{AE}} {{YK}}; {{JH}} | | {{SCC}}; {{AE}} {{YK}}; {{JH}} |
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| | MeshID = D018934 | | | MeshID = D018934 |
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| | ==[[Fournier gangrene overview|Overview]]== |
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| ==Overview== | | ==[[Fournier gangrene historical perspective|Historical Perspective]]== |
| '''Fournier gangrene''' is a type of [[Synergy|synergistic]] polymicrobial [[necrosis|necrotizing]] [[infection]] ([[gangrene]]) of the [[perineal]], [[genital]] or perianal regions usually affecting the male [[genital]]s but can also occur in females and children.<ref name="pmid9523650">{{cite journal| author=Smith GL, Bunker CB, Dinneen MD| title=Fournier's gangrene. | journal=Br J Urol | year= 1998 | volume= 81 | issue= 3 | pages= 347-55 | pmid=9523650 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9523650 }} </ref> It is a [[fulminant]] form of [[necrotizing fasciitis]]. It was first described by Baurienne in 1764 and is named after a French [[venereology|venereologist]], Jean Alfred Fournier following five cases he presented in clinical lectures in 1883.<ref name="pmid9492752">{{cite journal| author=Nathan B| title=Fournier's gangrene: a historical vignette. | journal=Can J Surg | year= 1998 | volume= 41 | issue= 1 | pages= 72 | pmid=9492752 | doi= | pmc=3950066 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9492752 }} </ref><ref name="pmid26445600">{{cite journal| author=Chennamsetty A, Khourdaji I, Burks F, Killinger KA| title=Contemporary diagnosis and management of Fournier's gangrene. | journal=Ther Adv Urol | year= 2015 | volume= 7 | issue= 4 | pages= 203-15 | pmid=26445600 | doi=10.1177/1756287215584740 | pmc=4580094 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26445600 }} </ref>
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| ==Historical Perspective== | | ==[[Fournier gangrene classification scheme|Classification]]== |
| *Fournier gangrene was first described in 1764 by Baurienne.<ref name="pmid9492752">{{cite journal| author=Nathan B| title=Fournier's gangrene: a historical vignette. | journal=Can J Surg | year= 1998 | volume= 41 | issue= 1 | pages= 72 | pmid=9492752 | doi= | pmc=3950066 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9492752 }} </ref>
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| *The detailed description of Fournier gangrene was given by Jean Alfred Fournier, a French [[venereology|venereologist]], in 1883.<ref name="pmid26445600">{{cite journal| author=Chennamsetty A, Khourdaji I, Burks F, Killinger KA| title=Contemporary diagnosis and management of Fournier's gangrene. | journal=Ther Adv Urol | year= 2015 | volume= 7 | issue= 4 | pages= 203-15 | pmid=26445600 | doi=10.1177/1756287215584740 | pmc=4580094 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26445600 }} </ref>
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| ==Classification== | | ==[[Fournier gangrene pathophysiology|Pathophysiology]]== |
| The ICD 10 classification of Fournier gangrene include:<ref name=WHO>Classification http://apps.who.int/classifications/icd10/browse/2016/en#/N49.8 (2016) Accessed on October 14, 2016</ref>
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| *ICD-10: N49.3
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| *Code Classification
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| :*Diseases of the [[genitourinary system]]
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| ::*Diseases of male [[genital]] organs (N40-N53)
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| :::*Inflammatory disorders of male [[genital]] organs, NEC (N49)
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| ==Pathophysiology== | | ==[[Fournier gangrene causes|Causes]]== |
| The transmission of [[pathogens]] occurs through the following routes:<ref name="pmid23251819">{{cite journal| author=Mallikarjuna MN, Vijayakumar A, Patil VS, Shivswamy BS| title=Fournier's Gangrene: Current Practices. | journal=ISRN Surg | year= 2012 | volume= 2012 | issue= | pages= 942437 | pmid=23251819 | doi=10.5402/2012/942437 | pmc=3518952 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23251819 }} </ref>
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| :*External trauma (e.g., [[laceration]], [[abrasion]], [[burn]], insect bite)
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| :*Direct spread from a perforated [[viscus]] (particularly [[colon]], [[rectum]], or [[anus]]) or another surgical procedure (e.g., [[vasectomy]], [[hemorrhoidectomy]])
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| :*[[Urogenital|Urogenital organ]]
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| :*[[Perirectal abscess]]
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| :*[[Decubitus ulcer]]
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| Following transmission, the [[bacteria]] uses the entry site to invade the [[Fascia|fascial planes]] which causes the wide spread [[necrosis]] of [[Fascia|superficial fascia]], [[Fascia|deep fascia]], [[subcutaneous fat]], [[nerves]], [[arteries]], and [[veins]]. Superficial skin and deeper muscles are typically spared. In late stages, lesions develop [[liquefactive necrosis]] at all tissue levels.
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| ===Pathogenesis=== | | ==[[Differentiating Fournier gangrene from other diseases|Differentiating Fournier gangrene from other Diseases]]== |
| The pathogenesis of Fournier gangrene is the result of an imbalance between host and bacterial factors.<ref name="pmid19815967">{{cite journal| author=Morua AG, Lopez JA, Garcia JD, Montelongo RM, Guerra LS| title=Fournier's gangrene: our experience in 5 years, bibliographic review and assessment of the Fournier's gangrene severity index. | journal=Arch Esp Urol | year= 2009 | volume= 62 | issue= 7 | pages= 532-40 | pmid=19815967 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19815967 }} </ref><ref name="pmid23578806">{{cite journal| author=Shyam DC, Rapsang AG| title=Fournier's gangrene. | journal=Surgeon | year= 2013 | volume= 11 | issue= 4 | pages= 222-32 | pmid=23578806 | doi=10.1016/j.surge.2013.02.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23578806 }} </ref><ref name="pmid23251819">{{cite journal| author=Mallikarjuna MN, Vijayakumar A, Patil VS, Shivswamy BS| title=Fournier's Gangrene: Current Practices. | journal=ISRN Surg | year= 2012 | volume= 2012 | issue= | pages= 942437 | pmid=23251819 | doi=10.5402/2012/942437 | pmc=3518952 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23251819 }} </ref> A decrease in host [[immunity]] provides a favorable environment to initiate the [[infection]], while [[Virulence|virulence]] and [[synergy|synergism]] between multiple bacteria promotes rapid spread of [[infection]].
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| The [[aerobic]] and [[anaerobic]] bacteria produce [[exotoxins]] and [[enzymes]], such as [[collagenase]], [[Heparin lyase|heparinase]], and [[hyaluronidase]], which promote the spread of [[infection]]. The [[aerobic]] bacteria accelerate [[coagulation]] by promoting [[platelet aggregation]] and [[complement fixation]]. The [[anaerobic]] bacteria produce [[collagenase]] and [[Heparin lyase|heparinase]] that promote the formation of clots leading to [[Obliterating endarteritis]]. The development of [[cutaneous]] and [[subcutaneous]] [[necrosis|vascular necrosis]] leads to local [[ischemia]] and further bacterial proliferation.
| | ==[[Fournier gangrene epidemiology and demographics|Epidemiology and Demographics]]== |
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| The [[infection]] spreads from superficial ([[Fascia of Colles|colles fascia]]) and deep fascial planes of [[genitalia]] to the overlying skin sparing the muscles. The [[infection]] then spreads from [[Fascia of Colles|colles fascia]] to the [[penis]] and [[scrotum]] via [[buck's fascia|Buck's]] and [[Dartos]] fascia or to the anterior abdominal wall via [[Fascia of Scarpa|Scarpa's fascia]] or vice versa. The [[inferior epigastric artery|inferior epigastric]] and deep [[iliac artery|circumflex iliac]] arteries supply the anterior abdominal wall, and the [[deep external pudendal artery|deep external pudendal]] and [[internal pudendal artery|internal pudendal]] arteries supply the scrotal wall. Except for the [[internal pudendal artery]], each of these vessels travels within [[Fascia of Camper|Camper's fascia]] and can therefore become [[thrombosis|thrombosed]] in the progression of Fournier gangrene.
| | ==[[Fournier gangrene risk factors|Risk Factors]]== |
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| The progression of [[infection]] to the [[perineal body]], [[urogenital diaphragm]] and [[ramus|pubic rami]] is limited due to [[Fascia of perineum|perineal fascia]].<ref name="pmid24707378">{{cite journal| author=Katib A, Al-Adawi M, Dakkak B, Bakhsh A| title=A three-year review of the management of Fournier's gangrene presented in a single Saudi Arabian institute. | journal=Cent European J Urol | year= 2013 | volume= 66 | issue= 3 | pages= 331-4 | pmid=24707378 | doi=10.5173/ceju.2013.03.art22 | pmc=3974467 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24707378 }} </ref> Because of the direct supply of blood from the [[aorta]], [[testes|testicular]] involvement is limited in Fournier gangrene.<ref name="pmid17323114">{{cite journal| author=Gupta A, Dalela D, Sankhwar SN, Goel MM, Kumar S, Goel A et al.| title=Bilateral testicular gangrene: does it occur in Fournier's gangrene? | journal=Int Urol Nephrol | year= 2007 | volume= 39 | issue= 3 | pages= 913-5 | pmid=17323114 | doi=10.1007/s11255-006-9126-1 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17323114 }} </ref> However involvement of [[testis]] suggests retroperitoneal origin or spread of [[infection]].<ref name="pmid12706005">{{cite journal| author=Chawla SN, Gallop C, Mydlo JH| title=Fournier's gangrene: an analysis of repeated surgical debridement. | journal=Eur Urol | year= 2003 | volume= 43 | issue= 5 | pages= 572-5 | pmid=12706005 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12706005 }} </ref> Fournier gangrene of the male genetalia spares [[testes]], [[urethra]] and deep [[penis|penile]] tissues while the skin sloughs off.<ref name="pmid2383054">{{cite journal| author=Campos JA, Martos JA, Gutiérrez del Pozo R, Carretero P| title=Synchronous caverno-spongious thrombosis and Fournier's gangrene. | journal=Arch Esp Urol | year= 1990 | volume= 43 | issue= 4 | pages= 423-6 | pmid=2383054 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2383054 }} </ref>
| | ==[[Fournier gangrene screening|Screening]]== |
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| [[Sepsis]] and multiorgan failure is the most common cause of death in Fournier gangrene.
| | ==[[Fournier gangrene natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
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| ===Common locations===
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| The common locations of Fournier gangrene are:<ref name="pmid23578806">{{cite journal| author=Shyam DC, Rapsang AG| title=Fournier's gangrene. | journal=Surgeon | year= 2013 | volume= 11 | issue= 4 | pages= 222-32 | pmid=23578806 | doi=10.1016/j.surge.2013.02.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23578806 }} </ref>
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| *[[Perineum]]
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| *[[Scrotum]]
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| *[[Penis]]
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| ===Gross pathology===
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| On gross pathology, the characteristic findings of Fournier gangrene include:
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| *[[Subcutaneous]] [[emphysema]]
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| *Swollen scrotal wall
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| *[[Edema]]
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| *[[Erythema]]
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| *Bullae
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| *Skin sloughing
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| ===Microscopic histopathological analysis===
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| On microscopic histopathological analysis, the characteristic findings of Fournier gangrene are:
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| *Early stages
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| :*[[vasculitis|Obliterative vasculitis]] with [[Microvascular disease|microangiopathic thrombosis]]
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| :*Acute [[inflammation]] of [[subcutaneous|subcutaneous tissue]]
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| :*Superficial hyaline [[necrosis]] along with [[edema]] and [[inflammation]] of the [[dermis]] and [[subcutaneous fat]]
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| :*Dense [[neutrophil]]-predominant inflammatory infiltrate
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| *Late stages
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| :*Noninflammatory [[Coagulation|intravascular coagulation]] and [[hemorrhage]]
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| :*[[Myonecrosis]]
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| ==Causes==
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| Fournier gangrene is caused by mixed [[aerobic]] and [[anaerobic]] organisms which normally exist below the [[pelvic diaphragm]] in the [[perineum]] and [[genitalia]].<ref name="pmid10848848">{{cite journal| author=Eke N| title=Fournier's gangrene: a review of 1726 cases. | journal=Br J Surg | year= 2000 | volume= 87 | issue= 6 | pages= 718-28 | pmid=10848848 | doi=10.1046/j.1365-2168.2000.01497.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10848848 }} </ref> Fournier gangrene may be caused by the following organisms:<ref>{{cite journal |author=Thwaini A, Khan A, Malik A, Cherian J, Barua J, Shergill I, Mammen K |title=Fournier's gangrene and its emergency management |journal=Postgrad Med J |volume=82 |issue=970 |pages=516-9 |year=2006 |id=PMID 16891442}}</ref>
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| ===Bacteria===
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| '''Aerobic organisms'''
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| Most common aerobic organisms are:<ref name="pmid1736475">{{cite journal| author=Paty R, Smith AD| title=Gangrene and Fournier's gangrene. | journal=Urol Clin North Am | year= 1992 | volume= 19 | issue= 1 | pages= 149-62 | pmid=1736475 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1736475 }} </ref>
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| *[[Streptococcus|''Group A streptococcus'']]
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| *[[Escherichia coli]]
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| *[[Klebsiella pneumoniae]]
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| *[[Staphylococcus aureus]]
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| '''Anaerobic organisms'''
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| Most common anaerobic organisms are:
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| *[[Bacteroides fragilis]]
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| ===Other organisms===
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| *[[Streptococcus]]
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| *[[Enterococcus]]
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| *[[Corynebacterium]]<ref name="pmid16927060">{{cite journal| author=Yanar H, Taviloglu K, Ertekin C, Guloglu R, Zorba U, Cabioglu N et al.| title=Fournier's gangrene: risk factors and strategies for management. | journal=World J Surg | year= 2006 | volume= 30 | issue= 9 | pages= 1750-4 | pmid=16927060 | doi=10.1007/s00268-005-0777-3 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16927060 }} </ref>
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| *[[Clostridium]]
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| *[[Pseudomonas]]
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| *[[Proteus|proteus species]]
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| *''[[Candida]]'' species<ref name="pmid20574621">{{cite journal| author=Jensen P, Zachariae C, Grønhøj Larsen F| title=Necrotizing soft tissue infection of the glans penis due to atypical Candida species complicated with Fournier's gangrene. | journal=Acta Derm Venereol | year= 2010 | volume= 90 | issue= 4 | pages= 431-2 | pmid=20574621 | doi=10.2340/00015555-0847 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20574621 }} </ref>
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| *''[[Lactobacillus|Lactobacillus gasseri]]''<ref name="pmid15307582">{{cite journal| author=Tleyjeh IM, Routh J, Qutub MO, Lischer G, Liang KV, Baddour LM| title=Lactobacillus gasseri causing Fournier's gangrene. | journal=Scand J Infect Dis | year= 2004 | volume= 36 | issue= 6-7 | pages= 501-3 | pmid=15307582 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15307582 }} </ref>
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| ===Idiopathic===
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| Less than quarter of cases of Fournier gangrene are [[idiopathic]].<ref name="pmid9523650">{{cite journal| author=Smith GL, Bunker CB, Dinneen MD| title=Fournier's gangrene. | journal=Br J Urol | year= 1998 | volume= 81 | issue= 3 | pages= 347-55 | pmid=9523650 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9523650 }} </ref><ref name="pmid10584624">{{cite journal| author=Vick R, Carson CC| title=Fournier's disease. | journal=Urol Clin North Am | year= 1999 | volume= 26 | issue= 4 | pages= 841-9 | pmid=10584624 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10584624 }} </ref>
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| ==Differentiating Fournier gangrene from Other Diseases==
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| Fournier gangrene must be differentiated from other diseases that cause [[pain]], [[swelling]], [[erythema]], [[discharge]] and raised temperature ([[fever]]) such as:<ref name=Fournier's>Fournier's gangrene https://radiopaedia.org/articles/fournier-gangrene (2016) Accessed on October 12, 2016 </ref><ref name="pmid23251819">{{cite journal| author=Mallikarjuna MN, Vijayakumar A, Patil VS, Shivswamy BS| title=Fournier's Gangrene: Current Practices. | journal=ISRN Surg | year= 2012 | volume= 2012 | issue= | pages= 942437 | pmid=23251819 | doi=10.5402/2012/942437 | pmc=3518952 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23251819 }} </ref>
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| *[[abscess|Scrotal abscess]]
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| *[[Herpes simplex]]
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| *[[Cellulitis]]
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| *[[Strangulated hernia]]
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| *[[necrotizing fasciitis|Streptococcal necrotizing fasciitis]]
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| *[[Balanitis|Gonococcal balanitis]] and [[edema]]
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| *Vascular occlusion syndromes
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| *[[Vasculitis|Allergic vasculitis]]
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| *[[Pyoderma gangrenosum]]
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| *[[Necrolytic migratory erythema]]
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| *[[Ecthyma gangrenosum]]
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| *[[Warfarin necrosis]]
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| *[[Polyarteritis nodosa]]
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| ==Epidemiology and Demographics==
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| ===Incidence===
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| [[Incidence]] of Fournier gangrene in the United states:<ref name="pmid27172977">{{cite journal| author=Sorensen MD, Krieger JN| title=Fournier's Gangrene: Epidemiology and Outcomes in the General US Population. | journal=Urol Int | year= 2016 | volume= 97 | issue= 3 | pages= 249-259 | pmid=27172977 | doi=10.1159/000445695 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27172977 }} </ref>
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| *The overall [[incidence]] of Fournier gangrene annually is 1.6 cases per 100,000 males. The [[incidence]] peaked and remained steady after age 50 at 3.3 cases per 100,000 males.
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| *The [[incidence]] of Fournier gangrene increased 0.2 per 100,000 males for each 1% increase in the regional prevalence of [[diabetes]].
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| *The [[incidence rate]] was highest in the southern U.S. and lowest in the western and mid-western U.S.
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| <gallery>
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| Image:Epidemiology.jpg|1000px|Distribution of annual cases per hospital.<ref name="pmid27172977">{{cite journal| author=Sorensen MD, Krieger JN| title=Fournier's Gangrene: Epidemiology and Outcomes in the General US Population. | journal=Urol Int | year= 2016 | volume= 97 | issue= 3 | pages= 249-259 | pmid=27172977 | doi=10.1159/000445695 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27172977 }} </ref>
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| </gallery>
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| ===Age===
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| Fournier gangrene affects individuals of all ages but more commonly affects individuals older than 50 years of age.<ref name="pmid23251819">{{cite journal| author=Mallikarjuna MN, Vijayakumar A, Patil VS, Shivswamy BS| title=Fournier's Gangrene: Current Practices. | journal=ISRN Surg | year= 2012 | volume= 2012 | issue= | pages= 942437 | pmid=23251819 | doi=10.5402/2012/942437 | pmc=3518952 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23251819 }} </ref><ref name="pmid23578806">{{cite journal| author=Shyam DC, Rapsang AG| title=Fournier's gangrene. | journal=Surgeon | year= 2013 | volume= 11 | issue= 4 | pages= 222-32 | pmid=23578806 | doi=10.1016/j.surge.2013.02.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23578806 }} </ref>
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| ===Gender===
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| Men are more commonly affected with Fournier gangrene than women, with a male:female ratio of 10:1.<ref name="pmid26445600">{{cite journal| author=Chennamsetty A, Khourdaji I, Burks F, Killinger KA| title=Contemporary diagnosis and management of Fournier's gangrene. | journal=Ther Adv Urol | year= 2015 | volume= 7 | issue= 4 | pages= 203-15 | pmid=26445600 | doi=10.1177/1756287215584740 | pmc=4580094 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26445600 }} </ref><ref name="pmid23578806">{{cite journal| author=Shyam DC, Rapsang AG| title=Fournier's gangrene. | journal=Surgeon | year= 2013 | volume= 11 | issue= 4 | pages= 222-32 | pmid=23578806 | doi=10.1016/j.surge.2013.02.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23578806 }} </ref>
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| ===Mortality===
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| *Mortality rate decreases with early aggressive treatment.
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| *The mortality rate of Fournier gangrene is between 20% to 80%. Higher mortality rates are found in [[diabetes|daibetics]], alcoholics and those with colorectal sources of [[infection]].<ref name="pmid20062653">{{cite journal| author=Moslemi MK, Sadighi Gilani MA, Moslemi AA, Arabshahi A| title=Fournier gangrene presenting in a patient with undiagnosed rectal adenocarcinoma: a case report. | journal=Cases J | year= 2009 | volume= 2 | issue= | pages= 9136 | pmid=20062653 | doi=10.1186/1757-1626-2-9136 | pmc=2803933 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20062653 }} </ref>
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| ==Risk Factors==
| |
| Common risk factors in the development of Fournier gangrene are:<ref name="pmid2294630">{{cite journal| author=Clayton MD, Fowler JE, Sharifi R, Pearl RK| title=Causes, presentation and survival of fifty-seven patients with necrotizing fasciitis of the male genitalia. | journal=Surg Gynecol Obstet | year= 1990 | volume= 170 | issue= 1 | pages= 49-55 | pmid=2294630 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2294630 }} </ref><ref name="pmid12516849">{{cite journal| author=Morpurgo E, Galandiuk S| title=Fournier's gangrene. | journal=Surg Clin North Am | year= 2002 | volume= 82 | issue= 6 | pages= 1213-24 | pmid=12516849 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12516849 }} </ref><ref name="pmid10584624">{{cite journal| author=Vick R, Carson CC| title=Fournier's disease. | journal=Urol Clin North Am | year= 1999 | volume= 26 | issue= 4 | pages= 841-9 | pmid=10584624 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10584624 }} </ref>
| |
| *Comorbid systemic disorders
| |
| :*Age >50 yrs
| |
| :*Male Gender
| |
| :*[[Diabetes mellitus]]
| |
| :*Alcohol misuse
| |
| :*[[Immunosupression]]
| |
| :*[[Chemotherapy]]
| |
| :*Chronic [[corticosteroid]] use
| |
| :*[[HIV]]
| |
| :*[[Leukemia]]
| |
| :*[[Liver disease]]
| |
| :*Debilitating illness
| |
| :*[[Malignancy]]
| |
| :*[[Cytotoxic drugs]]
| |
| The most common foci of Fournier gangrene include:<ref name="pmid10848848">{{cite journal| author=Eke N| title=Fournier's gangrene: a review of 1726 cases. | journal=Br J Surg | year= 2000 | volume= 87 | issue= 6 | pages= 718-28 | pmid=10848848 | doi=10.1046/j.1365-2168.2000.01497.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10848848 }} </ref><ref name="pmid7950832">{{cite journal| author=Amendola MA, Casillas J, Joseph R, Antun R, Galindez O| title=Fournier's gangrene: CT findings. | journal=Abdom Imaging | year= 1994 | volume= 19 | issue= 5 | pages= 471-4 | pmid=7950832 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7950832 }} </ref>
| |
| {| style="border: 0px; font-size: 90%; margin: 3px;" align=center
| |
| |+
| |
| ! style="background: #4479BA; width: 400px;" | {{fontcolor|#FFF|Anorectal}}
| |
| ! style="background: #4479BA; width: 400px;" | {{fontcolor|#FFF|Genitourinary}}
| |
| ! style="background: #4479BA; width: 400px;" | {{fontcolor|#FFF|Dermatology}}
| |
| ! style="background: #4479BA; width: 400px;" | {{fontcolor|#FFF|Gynaecological}}
| |
| |-
| |
| | style="padding: 5px 5px; background: #F5F5F5;" |
| |
| *Trauma<br>
| |
| *[[Enemas|Steroid enemas]] for [[colitis|radiation proctitis]]<br>
| |
| *[[Hemorrhoidectomy]]<br>
| |
| *[[Anal fissure|Anal fissures excision]]<br>
| |
| *[[Diverticulitis]]<br>
| |
| *[[Colon|Colonic perforations]]<br>
| |
| *[[Ischiorectal fossa|Ischiorectal]], [[perirectal]], or [[perianal abscesses]]<br>
| |
| *[[Appendicitis]]<br>
| |
| *[[Enemas|Steroid enemas]] for [[Colitis|radiation proctitis]]
| |
| | style="padding: 5px 5px; background: #F5F5F5;" |
| |
| *Trauma<br>
| |
| *[[Cancer]] invasion to external genitalia<br>
| |
| *[[Hemipelvectomy]]<br>
| |
| *[[Epididymitis]] or [[orchitis]]<br>
| |
| *[[Penile implant|Penile artificial implant]] or a foreign body<br>
| |
| *[[Hydrocele]] aspiration<br>
| |
| *Genital piercing<br>
| |
| *[[Cavernous sinus|Intracavernosal]] cocaine<br>
| |
| *[[Urethral catheterization]] or instrumentation<br>
| |
| *[[Penile prosthesis|Penile implants]] insertion<br>[[Biopsy|Prostatic biopsy]]<br>
| |
| *[[Vasectomy]]<br>
| |
| *Urethral strictures with urinary extravasation
| |
| | style="padding: 5px 5px; background: #F5F5F5;" |
| |
| *Blunt [[perineal]] trauma<br>
| |
| *[[Intramuscular injection|Intramuscular injections]]<br>
| |
| *Genital piercings<br>
| |
| *[[Furuncle|Scrotal furuncle]]<br>
| |
| *Perineal or pelvic surgery/inguinal [[herniorrhaphy]]<br>
| |
| | style="padding: 5px 5px; background: #F5F5F5;" |
| |
| *[[Episiotomy]] wound<br>
| |
| *Infected [[bartholin's gland]]<br>
| |
| *[[Abortion|Septic abortion]]<br>
| |
| *Genital mutilation<br>
| |
| *Coital injury
| |
| |}
| |
| | |
| '''Neonates and Children'''
| |
| *Trauma<ref name="pmid7950832">{{cite journal| author=Amendola MA, Casillas J, Joseph R, Antun R, Galindez O| title=Fournier's gangrene: CT findings. | journal=Abdom Imaging | year= 1994 | volume= 19 | issue= 5 | pages= 471-4 | pmid=7950832 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7950832 }} </ref>
| |
| *Burns
| |
| *Insect bites
| |
| *Circumcision
| |
| | |
| ==Screening==
| |
| According to the U.S. Preventive Service Task Force (USPSTF), there is insufficient evidence to recommend routine screening for Fournier gangrene.
| |
| | |
| ==Natural History, Complications, and Prognosis==
| |
| ===Natural history===
| |
| If left untreated, the acute inflammatory changes spread quickly, accompanied by [[high fever]] and extreme weakness.<ref name="pmid20542593">{{cite journal| author=Morgan MS| title=Diagnosis and management of necrotising fasciitis: a multiparametric approach. | journal=J Hosp Infect | year= 2010 | volume= 75 | issue= 4 | pages= 249-57 | pmid=20542593 | doi=10.1016/j.jhin.2010.01.028 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20542593 }} </ref><ref name="pmid8436051">{{cite journal| author=Ecker KW, Derouet H, Omlor G, Mast GJ| title=[Fournier's gangrene]. | journal=Chirurg | year= 1993 | volume= 64 | issue= 1 | pages= 58-62 | pmid=8436051 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8436051 }}</ref> The overlying skin becomes smooth, tense and shiny and diffuse [[erythema]] without distinct borders are seen.
| |
| | |
| During the first 1 or 2 days, the lesions develop with progressive color changes from red to purple to blue and then become [[gangrene|gangrenous]], first turning black, then greenish yellow. If the patient has survived, a line of demarcation between viable and [[necrotic]] tissue would become sharply defined from days 7 to 10.
| |
| | |
| [[Sloughing]] of [[necrotic]] skin would reveal the underlying [[pus]] and extensive [[liquefactive necrosis]] of [[Subcutaneous tissue|subcutaneous tissues]], which will be significantly more extensive than would be suspected with the overlying area of [[necrotic]] skin. [[Metastatic]] [[abscesses]] and pulmonary distress may develop as well.
| |
| | |
| ===Complications===
| |
| Common complications of Fournier gangrene include:<ref name="pmid19669962">{{cite journal| author=Akcan A, Sözüer E, Akyildiz H, Yilmaz N, Küçük C, Ok E| title=Necessity of preventive colostomy for Fournier's gangrene of the anorectal region. | journal=Ulus Travma Acil Cerrahi Derg | year= 2009 | volume= 15 | issue= 4 | pages= 342-6 | pmid=19669962 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19669962 }} </ref><ref name="pmid16891442">{{cite journal| author=Thwaini A, Khan A, Malik A, Cherian J, Barua J, Shergill I et al.| title=Fournier's gangrene and its emergency management. | journal=Postgrad Med J | year= 2006 | volume= 82 | issue= 970 | pages= 516-9 | pmid=16891442 | doi=10.1136/pgmj.2005.042069 | pmc=2585703 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16891442 }} </ref>
| |
| | |
| '''Systemic complications'''
| |
| *[[Renal failure]]
| |
| *[[Acute respiratory distress syndrome]]
| |
| *[[Heart failure]]
| |
| *[[Cardiac arrhythmias]]
| |
| *Septic metastasis
| |
| *[[Urinary tract infection]]
| |
| *[[Stroke]]
| |
| *Acute [[thromboembolic]] disease of lower extremities
| |
| | |
| '''Surgical complications'''
| |
| *Wound infection
| |
| *[[Stoma]]-related complications
| |
| *Prolonged [[ileus]] (7 days)
| |
| *Eventration or evisceration
| |
| | |
| '''Long term complications'''
| |
| *Pain (50% of patients)
| |
| *Impaired sexual function (due to penile deviation/torsion, loss of sensitivity of the penile skin or pain during erection)
| |
| *Stool [[incontinence]]
| |
| *Extensive [[Scar|scarring]]
| |
| | |
| ===Prognosis===
| |
| Depending on the underlying comorbidities, the prognosis of Fournier gangrene varies. Some of the prognostic factors include:
| |
| *Severe [[sepsis]]
| |
| *If the affected area calculation/extension of the [[necrosis]] is:
| |
| :*<3% of the body surface area, death is rare
| |
| :*≥5% of the body surface area, the prognosis is worse
| |
|
| |
|
| ==Diagnosis== | | ==Diagnosis== |
| The diagnosis of Fournier gangrene is primarily based on clinical findings. The diagnosis is based on following criteria:<ref name="pmid18087630">{{cite journal| author=Kuo CF, Wang WS, Lee CM, Liu CP, Tseng HK| title=Fournier's gangrene: ten-year experience in a medical center in northern Taiwan. | journal=J Microbiol Immunol Infect | year= 2007 | volume= 40 | issue= 6 | pages= 500-6 | pmid=18087630 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18087630 }} </ref>
| | [[Fournier gangrene diagnostic criteria|Diagnostic criteria]] | [[Fournier gangrene history and symptoms|History and Symptoms]] | [[Fournier gangrene physical examination|Physical Examination]] | [[Fournier gangrene laboratory tests|Laboratory Findings]] | [[Fournier gangrene electrocardiogram|Electrocardiogram]] | [[Fournier gangrene x ray|X-Ray Findings]] | [[Fournier gangrene CT|CT-Scan Findings]] | [[Fournier gangrene MRI|MRI Findings]] | [[Fournier gangrene ultrasound or echocardiography|Echocardiography and Ultrasound]] | [[Fournier gangrene other diagnostic studies|Other Diagnostic Studies]] | [[Fournier gangrene other imaging findings|Other Imaging Findings]] |
| *Soft tissue infections with involvement of the [[scrotum]], [[perineum]] and perianal areas
| |
| *Presence of air infiltrating the [[subcutaneous tissue]] (demonstrated by physical examination or radiological findings)
| |
| *Surgical findings of [[gangrene|gangrenous]] and [[necrosis|necrotic tissue]]
| |
| *Histologically proven [[necrotizing fasciitis]].
| |
| | |
| ===Diagnostic Criteria===
| |
| '''The Uludag Fournier gangrene severity index'''
| |
| {| class="wikitable" style="border: 2; background: none;"
| |
| ! colspan="1" rowspan="2" style="border: 1; background: 1;"| Physiologic Variables
| |
| ! colspan="4" rowspan="1"| High Abnormal Values
| |
| ! colspan="1" rowspan="1"| Normal
| |
| ! colspan="4" rowspan="1"| Low Abnormal Values
| |
| |- colspan="1" rowspan="2" style="border: 1; background: 1;"
| |
| ! +4 || +3 || +2 || +1 || 0 || +1 || +2 || +3 || + 4
| |
| |-
| |
| ! rowspan="1" style="border: 1; background: none;"| Temperature
| |
| | >41 || 39-40.0|| ||38.5-39 || 36-38.4 || 34-35.9 || 32-33.9 || 30-31.9 || <29.9
| |
| |-
| |
| ! rowspan="1" style="border: 1; background: none;"| Heart Rate
| |
| | >180 || 140-179 || 110-139 || || 70-109 || || 55-69 || 40-54 || <39
| |
| |-
| |
| ! rowspan="1" style="border: 1; background: none;"| Respiratory Rate
| |
| | >50 || 35-49 || ||25-34||12-24||10-11||6-9|| || <5
| |
| |-
| |
| ! rowspan="1" style="border: 1; background: none;"| Serum Sodium (mmol/L)
| |
| | >180 ||160-179 ||155-159 ||150-154 ||130-149 || ||120-129 ||111-119 ||<110
| |
| |-
| |
| ! rowspan="1" style="border: 1; background: none;"| Serum Potassium (mmol/L)
| |
| |>7 ||6-6.9 || || 5.5-5.9 ||3.5-5.4 ||3-3.4 ||2.5-2.9 || ||<2.5
| |
| |-
| |
| ! rowspan="1" style="border: 1; background: none;"| Serum Creatinine<br>(mg/100/ml*2 for acute renal failure)
| |
| |>3.5 ||2-3.4 ||1.5-1.9 || ||0.6-1.4 || ||<0.6 || ||
| |
| |-
| |
| ! rowspan="1" style="border: 1; background: none;"| Hematocrit
| |
| | >60|| ||50-59.9 ||46-49.9 ||30-45.9 || ||20-29.9 || ||<20
| |
| |-
| |
| ! rowspan="1" style="border: 1; background: none;"| WBC (Total/mm*1000)
| |
| | >40|| ||20-39.9 ||15-19.9 ||3-14.9 || ||1-2.9 || || <1
| |
| |-
| |
| ! rowspan="1" style="border: 1; background: none;"| Serum Bicarbonate (Venous,mmol/l)
| |
| |>52 ||41-51.9 || ||32-40.9 ||22-31.9 || ||18-21.9 ||15-17.9 || <15
| |
| | |
| |}
| |
| | |
| *Score >10.5 indicates 96% probability of death<ref name="pmid18563618">{{cite journal| author=Kabay S, Yucel M, Yaylak F, Algin MC, Hacioglu A, Kabay B et al.| title=The clinical features of Fournier's gangrene and the predictivity of the Fournier's Gangrene Severity Index on the outcomes. | journal=Int Urol Nephrol | year= 2008 | volume= 40 | issue= 4 | pages= 997-1004 | pmid=18563618 | doi=10.1007/s11255-008-9401-4 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18563618 }} </ref>
| |
| *Score ≤10.5 indicates 96% probability of survival
| |
| According to Loar and colleagues, the severity of Fournier gangrene is:
| |
| *Score ≥9 indicates 46% probability of death
| |
| *Score <9 indicates 96% probability of survival
| |
| | |
| | |
| '''Laboratory risk indicator for necrotizing fasciitis (LRINEC) scoring system'''
| |
| LRINEC is a diagnostic scoring system used to distinguish [[necrotizing fasciitis]] from other soft tissue infections.<ref name="pmid15241098">{{cite journal| author=Wong CH, Khin LW, Heng KS, Tan KC, Low CO| title=The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections. | journal=Crit Care Med | year= 2004 | volume= 32 | issue= 7 | pages= 1535-41 | pmid=15241098 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15241098 }} </ref><ref name="pmid23251819">{{cite journal| author=Mallikarjuna MN, Vijayakumar A, Patil VS, Shivswamy BS| title=Fournier's Gangrene: Current Practices. | journal=ISRN Surg | year= 2012 | volume= 2012 | issue= | pages= 942437 | pmid=23251819 | doi=10.5402/2012/942437 | pmc=3518952 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23251819 }} </ref> It was first established by Wong et al in 2004.
| |
| | |
| {| class="wikitable" style="border: 2; background: none;"
| |
| ! colspan="1" rowspan="2" style="border: 1; background: 1;"| Variable
| |
| ! colspan="5" rowspan="1"| Score
| |
| |- colspan="1" rowspan="2" style="border: 1; background: 1;"
| |
| ! 0 || +1 || +2 || +3 || +4
| |
| |-
| |
| ! rowspan="1" style="border: 1; background: none;"| [[C reactive protein|C-reactive protein]] (mg/dL)
| |
| | <150 || || || || >150
| |
| |-
| |
| ! rowspan="1" style="border: 1; background: none;"| Total [[white blood cell|White Blood Cell]] Count (/mm3)
| |
| | <15 || 15-25 || >25 || ||
| |
| |-
| |
| ! rowspan="1" style="border: 1; background: none;"| [[Hemoglobin]] (g/dL)
| |
| | <13.5 || 11-13.5 || <11 || ||
| |
| |-
| |
| ! rowspan="1" style="border: 1; background: none;"| [[Sodium]] (mmol/L)
| |
| | ≥135 || || <135 || ||
| |
| |-
| |
| ! rowspan="1" style="border: 1; background: none;"| [[Creatinine]] (μmol/L)
| |
| | <141 || || >141 || ||
| |
| |-
| |
| ! rowspan="1" style="border: 1; background: none;"| [[Glucose]] (mmol/L)
| |
| | <10 || >10 || || ||
| |
| |}
| |
| | |
| *Score of ≤5 indicates low risk
| |
| *Score of 6-7 indicates intermediate risk
| |
| *Score of ≥8 indicates high risk
| |
| | |
| ===History===
| |
| A detailed and thorough history from the patient is necessary. Specific areas of focus when obtaining a history from the patient include:<ref name="pmid2294630">{{cite journal| author=Clayton MD, Fowler JE, Sharifi R, Pearl RK| title=Causes, presentation and survival of fifty-seven patients with necrotizing fasciitis of the male genitalia. | journal=Surg Gynecol Obstet | year= 1990 | volume= 170 | issue= 1 | pages= 49-55 | pmid=2294630 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2294630 }} </ref><ref name="pmid12516849">{{cite journal| author=Morpurgo E, Galandiuk S| title=Fournier's gangrene. | journal=Surg Clin North Am | year= 2002 | volume= 82 | issue= 6 | pages= 1213-24 | pmid=12516849 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12516849 }} </ref><ref name="pmid10584624">{{cite journal| author=Vick R, Carson CC| title=Fournier's disease. | journal=Urol Clin North Am | year= 1999 | volume= 26 | issue= 4 | pages= 841-9 | pmid=10584624 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10584624 }} </ref>
| |
| *Trauma
| |
| *Alcohol misuse
| |
| *[[Immunosupression]]
| |
| *[[Chemotherapy]]
| |
| *Chronic [[corticosteroid]] use
| |
| *[[HIV]]
| |
| *[[Leukemia]]
| |
| *Liver disease
| |
| *Debilitating illness
| |
| *[[Malignancy]]
| |
| *[[Cytotoxic drugs]]
| |
| *Abdominal disease
| |
| *Surgery
| |
| *[[Epididymitis]] or [[orchitis]]
| |
| | |
| ===Symptoms===
| |
| The symptoms of Fournier gangrene include:<ref name="pmid23251819">{{cite journal| author=Mallikarjuna MN, Vijayakumar A, Patil VS, Shivswamy BS| title=Fournier's Gangrene: Current Practices. | journal=ISRN Surg | year= 2012 | volume= 2012 | issue= | pages= 942437 | pmid=23251819 | doi=10.5402/2012/942437 | pmc=3518952 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23251819 }} </ref><ref name="pmid15302463">{{cite journal| author=Yeniyol CO, Suelozgen T, Arslan M, Ayder AR| title=Fournier's gangrene: experience with 25 patients and use of Fournier's gangrene severity index score. | journal=Urology | year= 2004 | volume= 64 | issue= 2 | pages= 218-22 | pmid=15302463 | doi=10.1016/j.urology.2004.03.049 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15302463 }} </ref>
| |
| *Pain and swelling in the scrotum
| |
| *[[Erythema]]
| |
| *Discoloration of involved skin
| |
| *[[Purulent|Purulence]] or wound discharge
| |
| *Pallor
| |
| *Fever >38°C
| |
| *[[Crepitus|Crepitation]]
| |
| *[[Prostration]]
| |
| *Fluctuance
| |
| *Fetid odour
| |
| | |
| ===Physical examination===
| |
| The physical examination of Fournier gangrene include:
| |
| | |
| '''Appearance of the Patient'''
| |
| | |
| The patients with Fournier gangrene usually appear to be ill.
| |
| | |
| '''Vitals'''
| |
| | |
| *[[Fever]] (is often absent)
| |
| *[[Tachycardia]]
| |
| *[[Hypotension]]
| |
| *[[Tachypnea]]
| |
| | |
| '''Skin'''
| |
| | |
| *[[Jaundice]]
| |
| *Evidence of trauma, surgery, insect or human bites, or injection sites
| |
| | |
| '''Local examination'''
| |
| | |
| Local examination of patient under [[local anesthesia]] includes palpation of [[genitalia]] and [[perineum]], and [[digital rectal examination]].
| |
| *[[Induration]]
| |
| *Warmth
| |
| *Tenderness beyond margins of [[erythema]]
| |
| *[[Swelling]]
| |
| *Erythema with ill defined margins
| |
| *[[Blister|Blistering]]/bullae
| |
| *Skin discoloration
| |
| *Foul discharge (greyish or brown discharge)
| |
| *Fluctuance
| |
| *[[Crepitus]]
| |
| *Skin sloughing or [[necrosis]]
| |
| *Absence of [[lymphangitis]] or [[lymphadenopathy]] ([[lymphangitis]] is rarely seen in Fournier gangrene)
| |
| *Sensory and motor deficits (e.g. [[Anesthesia|localized anesthesia]])
| |
| | |
| ====Images====
| |
| | |
| '''Genitourinary system'''
| |
| | |
| <gallery>
| |
| | |
| Image:Fourniers_gangrene_1.jpg|Brownish-black discolouration of the penis with [[erythema]] of the scrotum.<ref name="pmid20606995">{{cite journal| author=Talwar A, Puri N, Singh M| title=Fournier's Gangrene of the Penis: A Rare Entity. | journal=J Cutan Aesthet Surg | year= 2010 | volume= 3 | issue= 1 | pages= 41-4 | pmid=20606995 | doi=10.4103/0974-2077.63394 | pmc=2890137 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20606995 }} </ref>
| |
| | |
| Image:Fourniers_gangrene_2.jpg|Discolouration of the penis with [[vesicles]] filled with hemorrhagic fluid.<ref name="pmid20606995">{{cite journal| author=Talwar A, Puri N, Singh M| title=Fournier's Gangrene of the Penis: A Rare Entity. | journal=J Cutan Aesthet Surg | year= 2010 | volume= 3 | issue= 1 | pages= 41-4 | pmid=20606995 | doi=10.4103/0974-2077.63394 | pmc=2890137 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20606995 }} </ref>
| |
| | |
| Image: Fournier's_gangrene_01.jpeg|Fournier gangrene. - Adapted from Dermatology Atlas.<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref>
| |
| | |
| | |
| Image: Fournier's_gangrene_02.jpeg|Fournier gangrene. Adapted from Dermatology Atlas.<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref>
| |
| | |
| Image: Fournier's_gangrene_03.jpeg|Fournier gangrene. Adapted from Dermatology Atlas.<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref>
| |
| | |
| | |
| Image: Fournier's_gangrene_04.jpeg|Fournier gangrene. Adapted from Dermatology Atlas.<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref>
| |
| | |
| | |
| Image: Fournier's_gangrene_05.jpeg|Fournier gangrene. Adapted from Dermatology Atlas.<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref>
| |
| | |
| | |
| </gallery>
| |
| | |
| ===Laboratory Findings===
| |
| Laboratory findings consistent with the diagnosis of Fournier gangrene include:
| |
| *[[CBC]] with differential count
| |
| *Culture of open wound or abscess
| |
| *[[Disseminated intravascular coagulation]] panel
| |
| :*[[Coagulation studies]]([[PT]], [[aPTT]], [[thrombin time]] etc)
| |
| :*[[Fibrinogen]]/[[fibrin degradation product]] levels
| |
| *[[Blood culture]]
| |
| *[[Urine culture]]
| |
| *[[ABG|Arterial blood gas analysis]]
| |
| *Electrolyte panel
| |
| *[[Blood urea nitrogen]] ([[BUN]])
| |
| *[[Creatinine]]
| |
| *[[Blood sugar|Blood glucose levels]]
| |
| | |
| ===Imaging Findings===
| |
| The diagnosis of Fournier gangrene is based on clinical findings. Imaging is used when diagnosis has not been established, to determine the extent of the disease or to detect the underlying cause.<ref name=Fournier's>Fournier's gangrene https://radiopaedia.org/articles/fournier-gangrene (2016) Accessed on October 12, 2016 </ref>
| |
| | |
| ====Radiography====
| |
| *On X-ray, Fournier gangrene is characterized by:<ref name=Fournier's>Fournier's gangrene https://radiopaedia.org/articles/fournier-gangrene (2016) Accessed on October 12, 2016 </ref>
| |
| :*[[Subcutaneous]] gas or [[soft tissue]] swelling (specific x-ray finding) seen extending from [[scrotum]] and [[perineum]] to the [[Inguinal region|inguinal regions]], [[anterior abdominal wall]], and thighs
| |
| :*Increase in the soft tissue thickness and opacity
| |
| *Plain x-ray is a poor screening study for Fournier gangrene because:
| |
| :*[[Emphysema|Subcutaneous emphysema]] is an insensitive finding and is present in a minority of patients
| |
| :*In the early stages the findings are similar to [[cellulitis]]
| |
| | |
| ====Ultrasound====
| |
| On ultrasound, Fournier gangrene is characterized by:<ref name="pmid23251819">{{cite journal| author=Mallikarjuna MN, Vijayakumar A, Patil VS, Shivswamy BS| title=Fournier's Gangrene: Current Practices. | journal=ISRN Surg | year= 2012 | volume= 2012 | issue= | pages= 942437 | pmid=23251819 | doi=10.5402/2012/942437 | pmc=3518952 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23251819 }} </ref><ref name="pmid9423625">{{cite journal| author=Rajan DK, Scharer KA| title=Radiology of Fournier's gangrene. | journal=AJR Am J Roentgenol | year= 1998 | volume= 170 | issue= 1 | pages= 163-8 | pmid=9423625 | doi=10.2214/ajr.170.1.9423625 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9423625 }} </ref>
| |
| *Thickened scrotal wall
| |
| *Echogenic gas foci in scrotum pathognomonic (seen as dirty shadowing)
| |
| *[[Testes]] and [[Epididymis|epididymi]] spared (due to their separate blood supply)
| |
| *Reactive unilateral or bilateral [[Hydrocele|hydroceles]] are present
| |
| *Differentiate Fournier gangrene from inguinoscrotal incarcerated hernia (In inguinoscrotal incarcerated hernia gas is observed in the obstructed bowel lumen, away from the scrotal wall)
| |
| | |
| ====Computed tomography====
| |
| The CT of Fournier gangrene is characterized by:<ref name=Fournier's>Fournier's gangrene https://radiopaedia.org/articles/fournier-gangrene (2016) Accessed on October 12, 2016 </ref>
| |
| *[[Soft tissue]] stranding and fascial thickening
| |
| *Soft tissue gas
| |
| *The extent of disease can be assessed prior to surgery
| |
| *A cause of infection may be apparent (e.g.[[perineal abscess]], [[fistula]])
| |
| | |
| ====MRI====
| |
| On MRI, Fournier gangrene is characterized by:<ref name="pmid11372608">{{cite journal| author=Kickuth R, Adams S, Kirchner J, Pastor J, Simon S, Liermann D| title=Magnetic resonance imaging in the diagnosis of Fournier's gangrene. | journal=Eur Radiol | year= 2001 | volume= 11 | issue= 5 | pages= 787-90 | pmid=11372608 | doi=10.1007/s003300000599 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11372608 }} </ref>
| |
| *[[Edema]] and [[inflammation]] of skin and subcutaneous planes of the scrotum and perineal planes
| |
| *[[Emphysema|Subcutaneous emphysema]]
| |
| | |
| ===Gallery of Imaging Findings===
| |
| | |
| <gallery>
| |
| | |
| Image:Founier-gangrene_X-ray.JPG|200px|X ray of Fournier gangrene - Case courtesy of Dr Chris O'Donnell, Radiopaedia.org, rID: 16849
| |
| | |
| Image:Fournier-gangrene-usg.jpg|200px|Ultrasound of Fournier gangrene - Case courtesy of Dr Chris O'Donnell, Radiopaedia.org, rID: 16849
| |
| | |
| Image:Fournier-gangrene_CT.jpg|200px|CT of Fournier gangrene <ref name=Fournier's>Fournier's gangrene - Case courtesy of Dr Chris O'Donnell, Radiopaedia.org, rID: 16849
| |
| | |
| Image:Fournier-gangrene-spontaneous-perforation-of-rectal-cancer.jpg|200px|CT of Fournier gangrene with spontaneous perforation of rectal cancer - Case courtesy of Dr Chris O'Donnell, Radiopaedia.org, rID: 16849
| |
| | |
| </gallery>
| |
|
| |
|
| ==Treatment== | | ==Treatment== |
| ===Medical Therapy===
| | [[Fournier gangrene medical therapy|Medical Therapy]] | [[Fournier gangrene surgery|Surgery]] | [[Fournier gangrene primary prevention|Primary Prevention]] | [[Fournier gangrene secondary prevention|Secondary Prevention]] | [[Fournier gangrene cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Fournier gangrene future or investigational therapies|Future or Investigational Therapies]] |
| Fournier gangrene is a urological emergency requiring [[intravenous]] antibiotics and [[debridement]] (surgical removal) of [[necrotic]] (dead) tissue. Despite such measures, the mortality rate overall is 40%, but 78% if [[sepsis]] is already present at the time of initial hospital admission.<ref name="pmid16927060">{{cite journal| author=Yanar H, Taviloglu K, Ertekin C, Guloglu R, Zorba U, Cabioglu N et al.| title=Fournier's gangrene: risk factors and strategies for management. | journal=World J Surg | year= 2006 | volume= 30 | issue= 9 | pages= 1750-4 | pmid=16927060 | doi=10.1007/s00268-005-0777-3 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16927060}}</ref> The spread of gangrene is rapid at the rate of 2–3 cm/h, hence early diagnosis and emergency surgical treatment is important.<ref name="pmid1736475">{{cite journal| author=Paty R, Smith AD| title=Gangrene and Fournier's gangrene. | journal=Urol Clin North Am | year= 1992 | volume= 19 | issue= 1 | pages= 149-62 | pmid=1736475 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1736475 }}</ref>
| |
|
| |
|
| ====Antimicrobial Therapy==== | | ==Case Studies== |
| * Fournier gangrene<ref>{{cite book | last = Gilbert | first = David | title = The Sanford guide to antimicrobial therapy | publisher = Antimicrobial Therapy | location = Sperryville, Va | year = 2015 | isbn = 978-1930808843 }}</ref>
| | [[Fournier gangrene case study one|Case #1]] |
| :* '''If caused by streptococcus species or clostridia'''
| | [[Category:Emergency mdicine]] |
| ::* Preferred regimen: [[Penicillin G]]
| | [[Category:Disease]] |
| :* '''Polymicrobial'''
| |
| | |
| ::* Preferred regimen: [[Doripenem]] {{or}} [[imipenem]] {{or}} [[meropenem]]
| |
| :* '''MRSA (methicillin resistant staphylococcus aureus) suspected'''
| |
| | |
| ::* Preferred regimen: [[vancomycin]] {{or}} [[daptomycin]]
| |
| | |
| ===Nutritional Support===
| |
| The metabolic demands of Fournier gangrene patients are similar to those of other major [[trauma]] or [[burns]].<ref name="pmid25593960">{{cite journal| author=Misiakos EP, Bagias G, Patapis P, Sotiropoulos D, Kanavidis P, Machairas A| title=Current concepts in the management of necrotizing fasciitis. | journal=Front Surg | year= 2014 | volume= 1 | issue= | pages= 36 | pmid=25593960 | doi=10.3389/fsurg.2014.00036 | pmc=4286984 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25593960 }}</ref> Nutritional support to replace lost [[proteins]] and fluids from large wounds and/or the result of [[shock]] is required from the first day of a patient's hospital admission.
| |
| | |
| ===Hyperbaric oxygen===
| |
| *Delivery of 100% oxygen ([[hyperbaric]]) at two or three times the atmospheric pressure for 30 to 90 minutes with three to four treatments daily.<ref name="pmid16509286">{{cite journal| author=Escobar SJ, Slade JB, Hunt TK, Cianci P| title=Adjuvant hyperbaric oxygen therapy (HBO2)for treatment of necrotizing fasciitis reduces mortality and amputation rate. | journal=Undersea Hyperb Med | year= 2005 | volume= 32 | issue= 6 | pages= 437-43 | pmid=16509286 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16509286 }} </ref>
| |
| *Hyperbaric oxygen inhibits [[infection]] and [[exotoxin]] release.<ref name="pmid11199291">{{cite journal| author=Korhonen K| title=Hyperbaric oxygen therapy in acute necrotizing infections with a special reference to the effects on tissue gas tensions. | journal=Ann Chir Gynaecol Suppl | year= 2000 | volume= | issue= 214 | pages= 7-36 | pmid=11199291 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11199291 }} </ref>
| |
| *It enhances efficacy of [[antibiotics]] by increasing local oxygen tension in tissue and augment oxidative burst and killing ability of [[leukocytes]].<ref>Hyperbaric oxygen therapy. http://onlinelibrary.wiley.com/doi/10.1080/110241500750008583/abstract (2016) Accessed on September 12, 2016</ref>
| |
| *These effects result in a reduced need for surgical [[debridement]] and improved [[morbidity]] and [[mortality]] in patients with [[necrotizing fasciitis]].
| |
| Contraindications to hyperbaric oxygen are:<ref name="pmid1924583">{{cite journal| author=Kindwall EP, Gottlieb LJ, Larson DL| title=Hyperbaric oxygen therapy in plastic surgery: a review article. | journal=Plast Reconstr Surg | year= 1991 | volume= 88 | issue= 5 | pages= 898-908 | pmid=1924583 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1924583 }} </ref><ref name="pmid10458334">{{cite journal| author=Capelli-Schellpfeffer M, Gerber GS| title=The use of hyperbaric oxygen in urology. | journal=J Urol | year= 1999 | volume= 162 | issue= 3 Pt 1 | pages= 647-54 | pmid=10458334 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10458334 }} </ref>
| |
| *[[Pneumothorax]]
| |
| *[[Cisplatin]] (which decreases the production of [[superoxide dismutase]] which is protective against damaging effects of high partial O2 pressure)
| |
| *[[Doxorubicin]] therapy
| |
| Side effects of hyperbaric oxygen are:
| |
| *[[Barotrauma]] of the middle ear
| |
| *[[Seizures]]
| |
| *Loss of respiratory drive in [[hypercapnia|hypercapnic]] patients (therefore, frequent periods of breathing in room air are interposed when patients are on [[hyperbaric oxygen|HBOT]])
| |
| *[[Vasoconstriction]]
| |
| | |
| ===IV γ-globulin===
| |
| *Use of [[intravenous]] [[immune globulin]] is not FDA approved.
| |
| *If used, this treatment is restricted to critically ill patients with either [[staphylococcal]] or [[streptococcal]] [[infections]].<ref name="pmid16686841">{{cite journal| author=Darabi K, Abdel-Wahab O, Dzik WH| title=Current usage of intravenous immune globulin and the rationale behind it: the Massachusetts General Hospital data and a review of the literature. | journal=Transfusion | year= 2006 | volume= 46 | issue= 5 | pages= 741-53 | pmid=16686841 | doi=10.1111/j.1537-2995.2006.00792.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16686841 }} </ref>
| |
| | |
| ===Surgery===
| |
| '''Radical surgical debridement'''
| |
| | |
| Surgery is the mainstay of treatment for Fournier gangrene.<ref name="pmid25593960">{{cite journal| author=Misiakos EP, Bagias G, Patapis P, Sotiropoulos D, Kanavidis P, Machairas A| title=Current concepts in the management of necrotizing fasciitis. | journal=Front Surg | year= 2014 | volume= 1 | issue= | pages= 36 | pmid=25593960 | doi=10.3389/fsurg.2014.00036 | pmc=4286984 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25593960 }} </ref>
| |
| *Indications include:<ref name="pmid25593960">{{cite journal| author=Misiakos EP, Bagias G, Patapis P, Sotiropoulos D, Kanavidis P, Machairas A| title=Current concepts in the management of necrotizing fasciitis. | journal=Front Surg | year= 2014 | volume= 1 | issue= | pages= 36 | pmid=25593960 | doi=10.3389/fsurg.2014.00036 | pmc=4286984 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25593960 }} </ref>
| |
| :*Patients displaying intense pain and skin color change such as [[edema]] and/or [[ecchymoses]]
| |
| :*Signs of [[ischemia|skin ischemia]] with [[blister|blisters]] and bullae
| |
| :*[[Altered mental status]], [[hypotension]], elevated [[band cell|band forms]] in the differential [[WBC]] count and [[metabolic acidosis]].
| |
| * Immediate surgical referral remains the only method of reducing [[mortality]] and [[morbidity]] in Fournier gangrene patients.<ref name="pmid22196774">{{cite journal| author=Roje Z, Roje Z, Matić D, Librenjak D, Dokuzović S, Varvodić J| title=Necrotizing fasciitis: literature review of contemporary strategies for diagnosing and management with three case reports: torso, abdominal wall, upper and lower limbs. | journal=World J Emerg Surg | year= 2011 | volume= 6 | issue= 1 | pages= 46 | pmid=22196774 | doi=10.1186/1749-7922-6-46 | pmc=3310784 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22196774 }} </ref><ref name="pmid16830885">{{cite journal| author=Mok MY, Wong SY, Chan TM, Tang WM, Wong WS, Lau CS| title=Necrotizing fasciitis in rheumatic diseases. | journal=Lupus | year= 2006 | volume= 15 | issue= 6 | pages= 380-3 | pmid=16830885 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16830885 }} </ref>
| |
| *As the patients are cardiovascularly unstable, immediate [[resuscitation]] with [[intravenous fluids]], [[colloids]] and [[inotropes|inotropic agents]] are usually necessary.<ref name="pmid11097546">{{cite journal| author=Baxter F, McChesney J| title=Severe group A streptococcal infection and streptococcal toxic shock syndrome. | journal=Can J Anaesth | year= 2000 | volume= 47 | issue= 11 | pages= 1129-40 | pmid=11097546 | doi=10.1007/BF03027968 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11097546 }} </ref>
| |
| *Effects of [[analgesia]] can be measured by documenting pain score regularly.
| |
| *Stop any [[NSAID|NSAIDs]] on patient admission.
| |
| | |
| '''Procedure'''
| |
| *Radical debridement of areas of overt [[necrosis|subcutaneous necrosis]] should be done in the operation theater in the [[lithotomy]] position to allow access to all perineal structures.
| |
| *Deep fascia and muscle are rarely involved, thus debridement is usually not required.
| |
| *Separation of the skin and subcutaneous tissue with a hemostat has been recommended to define the limits of excision. Debridement is stopped where these tissues do not separate easily.
| |
| | |
| '''Fecal and urinary diversion'''
| |
| *Urinary or fecal diversion is required to treat an underlying condition or prevent wound contamination.<ref name="pmid1736475">{{cite journal| author=Paty R, Smith AD| title=Gangrene and Fournier's gangrene. | journal=Urol Clin North Am | year= 1992 | volume= 19 | issue= 1 | pages= 149-62 | pmid=1736475 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1736475 }}</ref>
| |
| *When there is gross urinary extravasation or periurethral inflammation, [[suprapubic cystostomy]] is required. A urinary catheter is used in milder cases.
| |
| *[[Colostomy]] is required when there is gross sphincter infection or colonic or rectal perforation.
| |
| *Testes are temporarily implanted into subcutaneous tissue pouch (medial thigh or lower abdomen) until healing or reconstruction is complete.
| |
| *[[Orchidectomy]] is performed if there is any pre-existing [[epididymo-orchitis]] or [[abscess|scrotal abscess]].
| |
| | |
| '''Plastic reconstruction'''
| |
| *The split thickness [[skin graft]] is a commonly used technique for reconstructive surgery. For large defects, rotational or free myocutaneous flaps and omental flaps are used to cover larger defects.<ref name="pmid1736475">{{cite journal| author=Paty R, Smith AD| title=Gangrene and Fournier's gangrene. | journal=Urol Clin North Am | year= 1992 | volume= 19 | issue= 1 | pages= 149-62 | pmid=1736475 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1736475 }} </ref>
| |
| | |
| '''Wound management'''
| |
| *The wound is monitored closely after surgery.
| |
| *Multiple surgical debridement are required with an average of 3.5 procedures per patient.<ref name="pmid12706005">{{cite journal| author=Chawla SN, Gallop C, Mydlo JH| title=Fournier's gangrene: an analysis of repeated surgical debridement. | journal=Eur Urol | year= 2003 | volume= 43 | issue= 5 | pages= 572-5 | pmid=12706005 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12706005 }}</ref>
| |
| *[[Sodium hypochlorite]] or [[hydrogen peroxide]] are used post-operatively for topical application.<ref name="pmid8650874">{{cite journal| author=Hejase MJ, Simonin JE, Bihrle R, Coogan CL| title=Genital Fournier's gangrene: experience with 38 patients. | journal=Urology | year= 1996 | volume= 47 | issue= 5 | pages= 734-9 | pmid=8650874 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8650874 }}</ref>
| |
| *[[Collagenase|Lyophilized collagenase]] (an enzyme that digests and debrides [[necrotic]] tissues) is used for enzymatic debridement twice daily until definite reconstruction can be performed.<ref name="pmid9803004">{{cite journal| author=Aşci R, Sarikaya S, Büyükalpelli R, Yilmaz AF, Yildiz S| title=Fournier's gangrene: risk assessment and enzymatic debridement with lyophilized collagenase application. | journal=Eur Urol | year= 1998 | volume= 34 | issue= 5 | pages= 411-8 | pmid=9803004 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9803004 }} </ref>
| |
| | |
| '''Vacuum-assisted closure device'''
| |
| <br>The vacuum assisted closure device is used for faster and effective wound closure.<ref name="pmid18470279">{{cite journal| author=Silberstein J, Grabowski J, Parsons JK| title=Use of a Vacuum-Assisted Device for Fournier's Gangrene: A New Paradigm. | journal=Rev Urol | year= 2008 | volume= 10 | issue= 1 | pages= 76-80 | pmid=18470279 | doi= | pmc=2312348 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18470279 }}</ref><ref name="pmid25593960">{{cite journal| author=Misiakos EP, Bagias G, Patapis P, Sotiropoulos D, Kanavidis P, Machairas A| title=Current concepts in the management of necrotizing fasciitis. | journal=Front Surg | year= 2014 | volume= 1 | issue= | pages= 36 | pmid=25593960 | doi=10.3389/fsurg.2014.00036 | pmc=4286984 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25593960 }}</ref> This devices helps wound healing by absorbing excess [[exudate|exudates]], reducing localized [[edema]], and finally drawing wound edges together.
| |
| | |
| ===Prevention===
| |
| '''Primary prevention'''
| |
| | |
| Effective measures for the primary prevention of Fournier gangrene include:
| |
| *Prevention of trauma/breaks in skin integrity that act as a portal of entry
| |
| *Treatment of [[cellulitis]] to prevent extension into the [[subcutaneous tissue]]
| |
| *Ensure wounds are cleaned and monitored for signs of infection
| |
| *Do not delay first aid of wounds like [[blister|blisters]], scrapes, or any break in the skin
| |
| *Patients with underlying co-morbidities should watch carefully for any signs of infection
| |
| | |
| | |
| '''Secondary prevention'''
| |
| | |
| Secondary prevention strategies following Fournier gangrene include:
| |
| *Early diagnosis and prompt treatment with either [[antibiotics]] or surgery.
| |
| *This strategy prevents or slows the progression and complications of the disease.
| |
| | |
| ==External links==
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| * {{WhoNamedIt2|synd|2521|Fournier gangrene}} and {{WhoNamedIt|doctor|2209|Jean Alfred Fournier}}
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| ==References==
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| {{reflist|2}}
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| | [[Category:Up-To-Date]] |
| | [[Category:Infectious disease]] |
| | [[Category:Surgery]] |
| | [[Category:Orthopedics]] |
| [[Category:Dermatology]] | | [[Category:Dermatology]] |
| [[Category:Infectious disease]]
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| {{WH}}
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| {{WS}}
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