1. Fournier’s gangrene
Dr. Vinod Jain

2. Fournier’s gangrene Definition Etiology & risk factors
Pathogenesis & pathology
Incidence
Clinical features
Differential diagnosis
Investigations
Treatment –
- Medical
- Surgical
Complications

4. Definition
Named after French venereologist Jean Alfred Fournier (1883). Fournier gangrene is defined as a polymicrobial necrotizing fasciitis of the perineal, perianal, or genital areas.

5. Etiology & risk factors
Initially described as idiopathic
Now in more than 75% cases inciting cause in known
Necrotizing process commonly originates from infection in anorectum, urogenital tract or skin of genitalia

6. Etiology Ano-rectal causes – infection in the perineal glands
Manifestation of colorectal injury, malignancy or diverticulitis
Uro-genital causes –
infection in the bulbourethral glands
urethral injury
Iatrogenic injury
Lower urinary tract infections

7. Etiology (contd.) Dermatologic causes – 4. Other less common causes –
Hidradenitis suppurativa
Ulceration from scrotal pressure
Trauma to scrotum or perineum
4. Other less common causes –
Consequence of bone marrow malignancy
Systemic lupus erythematosus
Crohn’s diseases

8. Risk factors Diabetes mellitus Alcoholism Malignancies Cirrhosis Liver
Chronic steroid use
HIV infection
Malnutrition
Morbid Obesity

9. Causative Bacteria Polymicrobial infection
Minimum of four isolates per case
Most common aerobe – E. coli
Most common anaerobes – Bacteroids
Others – Streptococcus, Staphylococcus, MRSA – Methicillin Resistant Staphylococcus aureus, Klebsiella Pseudomonas, Proteus & Clostridium.

10. Pathogenesis
Bacteria act synergistically causing obliterative endarteritis & production of various enzymes causing destruction
There is imbalance between host immunity & virulence of organism

11. Mechanism of spread Entry of bacteria (act through synergism)
Fibrinoid coagulation of nutrient vessels
Decreased locally blood supply to skin
Decreased tissue oxygen tension
Growth of anaerobes & microaerophilic organisms
Production of enzyme (Collagenase, Lecithinase, Hyaluronidase )
Digestion of fascial barrier
Rapid spread of infection

12. Pathognomonic findings on pathological evaluation of tissue are :-
Pathology
Pathognomonic findings on pathological evaluation of tissue are :-
Necrosis of superficial & deep fascial planes
Fibrinoid coagulation of the nutrient arterioles
Polymorphonuclear cell infiltration
Presence of micro organisms with in the involved tissues
Air in the perineal tissue

13. Incidence Age – 30 – 60 years Sex – 10 times more common in males
Social habits – More common in male homosexuals (more prone for Rectal injury)

14. Clinical features
Begins with insidious onset of pruritus and discomfort of external genitalia
Prodromal symptoms of fever and lethargy, which may be present for 2-7 days before gangrene
The hallmark of Fournier gangrene is out of proportion pain and tenderness in the genitalia.
Increasing genital pain and tenderness with progressive erythema of the overlying skin
Dusky appearance of the overlying skin; subcutaneous crepitation; feculent odor
Obvious gangrene of a portion of the genitalia; purulent discharge from wounds
As gangrene develops, pain subsides (Nerve necrosis)

15. Differential diagnosis
Balanitis
Cellulitis
Epididymitis
Gas gangrene
Compicated hernias
Complicated hydrocele
Necrotizing fasciitis
Orchitis
Testicular torsion

16. Other Problems to be Considered
Testicular fracture
Testicular hematoma
Testicular abscess
Scrotal abscess
Vasculitis
Warfarin gangrenosum
Polyarteritis nodosum
Wegener’s granulomatosis

17. Investigations (CBC) Complete blood count Electrolytes
BUN / Serum creatinine
Blood Sugar
ABG
Blood and urine culture with sensitivity
Coagulation profile for DIC

18. Investigations (contd.)
Imaging-
Conventional radiography
Ultrasonography
C.T. Scanning
MRI

19. Conventional radiography
Consider where clinical findings are inconclusive
Presence of gas in soft tissue

20. Ultrasonography Can be used to detect fluid or gas in soft tissue
“Sonographic hallmark” – Presence of gas in scrotal tissue
Excludes other conditions
Testicular blood flow - N
Limitations – Direct pressure on involved tissue causes inconvenience

21. C.T. Scanning Can detect smaller amount of soft tissue gas
Defines extent more specifically
Identifies underlying causes eg. Small perineal abscess
MRI
Yields greater soft tissue details
Create logistic challenges, especially in critically ill patients

22. Treatment
Medical
Surgical

23. Medical Treatment Restoration of normal organ perfusion
Reduction of systemic toxicity
Broad spectrum antibiotics to cover anaerobes as well (cipro+clinda+metro)
Vancomycin for MRSA
Tetanus prophylaxis
Irrigation with super oxidised water
Hyperbaric oxygen therapy
IV immunoglobulins to neutralize super antigen as streptotoxin A & B (as adjuvant)
Antifungal – if required
Non – conventional
- Unprocessed honey – enzyme action
- dressing with gauge soaked with zinc per oxide

24. Surgical treatment Repeated aggressive debridement
Preservation of testes (subcutaneous pocket from desiccation)
Reconstruction after infection is over
Fecal diversion
Urinary diversion
Vacuum assisted closure (VAC)

26. Complications ARF ARDS Septicemia and gram negative shock MSOF Tetanus
Death

27. Questions ?

28. Let us revise Definition Etiology & risk factors
Pathogenesis & pathology
Incidence
Clinical features
Differential diagnosis
Investigations
Treatment –
- Medical
- Surgical
Complications