Fournier’s gangrene

What is is a Fournier’s gangrene?

Fournier’s Gangrene is an acute fulminant polymicrobial necrotising fascitis or gangrene affecting the scrotum and sometimes extending to the perineum, penis and lower abdomen.
It is also called idiopathic gangrene of the scrotum.
The synergistic infections of anaerobic and aerobic bacteria coupled with obliterative arteritis results in the extensive gangrene.
The risk factors include diabetes mellitus, HIV/Immunosuppression, perineal abscess/ infection of scrotum and contents, trauma, extravasation of urine, periurethral abscess and urethral stricture/calculi.
The complications of Fournier’s gangrene include septicaemia, extravasation of urine, exposure of testes and fistula formation.

Causes of Fournier’s Gangrene

  1. Staphylococcus spp
  2. Microaerophilic Streptococcus
  3. E. coli
  4. Fusibacteria
  5. Clostridium welchii
  6. Bacteroides

Symptoms of Fournier’s Gangrene

  1. Acute onset of painful anterior scrotal swelling in previously healthy tissue Fever
  2. Pain in affected scrotum
  3. General malaise

Signs

  1. Fever
  2. Prostration
  3. Rapidly progressing gangrene
  4. Foetid odour
  5. Sharp demarcation between ‘dead’ tissue and healthy tissue
  6. Crepitus on palpation of affected tissue
  7. Testis is usually spared
  8. Urinary extravasation.
  9. Presence of risk or predisposing factors

Investigations

  • Wound culture and sensitivity
  • Serum culture and sensitivity
  • Urinalysis FBC and ESR
  • Grouping and cross-matching
  • Fasting blood glucose
  • HIV screening
  • Plain X-ray of pelvis will reveal gas in affected tissue

Treatment for Fournier’s Gangrene

Treatment objectives

  1. To resuscitate patient
  2. To treat the infection
  3. To manage concomitant risk factors
  4. To salvage the testes
  5. To prevent/treat complications

Non-pharmacological treatment

  1. Surgical intervention
  2. Reconstructive surgery: Testis buried in upper thigh temporarily to prevent dessication
  3. Skin grafting and reconstruction of scrotum (scrotoplasty)
  4. Radical debridement
  5. Myocutaneous flaps
  6. Nutrition supplement
  7. Wound care Management of diabetes mellitus if present
  8. Management of HIV/AIDS if present

Pharmacological treatment

Evidence Rating: [C]

A. IV fluids, haemotransfusion and hyperbaric oxygen

  • As required for patients clinical state

B. Antibiotics

Gentamicin, IV, 80 mg 8 hourly

And

Ampicillin, IV, 500 mg 6 hourly

And

Metronidazole, IV, 500 mg 8 hourly

Or

Amoxicillin +Clavulanic Acid, IV, 1 g 12 hourly

And

Metronidazole, IV, 500 mg 8 hourly.

Or

Cefuroxime, IV, 750 mg 8 hourly

And

Metronidazole, IV, 500 mg 8 hourly

Referral Criteria

Refer all cases with septic shock after resuscitation and all those who require reconstructive surgery to a urologist or surgical specialist.