Management of Fournier's gangrene: an eleven year retrospective analysis of early recognition,diagnosis, and treatment

Fournier's gangrene is an infectious necrotizing fasciitis of the perineum and genital regions. It is a synergistic infection caused by a mixture of aerobic and anaerobic organisms. The mortality rate from this infection ranges from 0 to 67 per cent. One of the most important determinants of overall outcome is early recognition and extensive surgical debridement upon initial diagnosis. This is followed by aggressive antibiotic therapy combined with other precautionary and resuscitative measures. Our hypothesis is that early aggressive surgical debridement combined with broad-spectrum antibiotic coverage results in decreased mortality from Fournier gangrene. The objective of this study was to determine our morbidity and mortality as compared with other institutions. This was a retrospective review of 200 charts of patients from 1990 through 2001. The charts reviewed included patients with a diagnosis of male and female genital abscesses, cellulitis, necrotizing fasciitis, and vascular disorders. This resulted in 33 patients who had a final diagnosis of Fournier's gangrene. There were 26 (79%) males and seven (21%) females with a diagnosis of Fournier's gangrene. The patients ranged in age from 30 to 85 years (mean age 51.5). There were a number of predisposing factors that were examined. Thirteen patients (39%) were diabetic, 18 (55%) suffered from hypertension, 18 (55%) were obese, and 18 (55%) were cigarette smokers. Four patients (12%) had no predisposing factors. The treatment consisted of wide surgical debridement which was performed in all 33 patients. Most patients received multiple debridements ranging from one surgery to seven (mean 3.25) per hospital stay. The majority of patients received broad-spectrum antibiotic coverage. Three patients died, which resulted in a mortality rate of 9 per cent. Early recognition and aggressive surgical debridement is the most essential intervention in stopping the rapidly progressing infectious process of Fournier's gangrene. This intervention should be combined with aggressive triple-antibiotic therapy and other precautionary measures for supporting the patient who has the systemic effects of Fournier's gangrene. Our data do not reach statistical significance with regard to the use of triple-antibiotic therapy. However, we believe that it is an important part of the treatment regimen. The combination of aggressive surgical therapy and appropriate antibiotic coverage results in a reduction in mortality.     

Fournier's gangrene: a retrospective clinical study on forty-one patients

BACKGROUND: Fournier's gangrene, first described by Dr Jean Alfred Fournier in 1883, still has a high mortality rate. The prognosis and outcome of such patients were analysed. METHODS: Forty-one patients with Fournier's gangrene were reviewed on the parameters of age, sex, aetiological agents, predisposing factors, treatment modalities and outcomes. RESULTS: Although early intervention and careful treatment was carried out, nine of 41 patients (21.9%) died as a result of complications of septicemia. Among the treatment modalities, there were extensive debridement, drainage, excisions of the skin and fascia, colostomy procedure, extensive antibiotic treatment and hyperbaric oxygen therapy. Although a combination of different treatment modalities were used, the mortality rate was 21.9%. CONCLUSIONS: Fournier's gangrene is still a severe disease. Today, hyperbaric oxygen treatment is very effective in the treatment of this disease.     

Factors affecting mortality of Fournier's gangrene: review of 70 patients

BACKGROUND: Fournier's disease is a potentially fatal, acute, gangrenous infection of the scrotum, penis or perineum associated with a synergistic bacterial infection of the subcutaneous fat and superficial fascia. METHODS: The clinical records of 70 patients treated for Fournier's gangrene were evaluated retrospectively to determine prognostic indices and to stress Fournier's Severity Index (FSI), influencing outcome. RESULTS: The mortality rate in this study was 22.8%. Length of the hospitalization time and FSI were detected as effective factors on mortality of Fournier's gangrene (P < 0.05) by Binary Logistic Regression analysis and the area under the receiver operating characteristic curve of these variables was also found to be significant (P < 0.001). The average FSI was determined as 4.66 +/- 2.31 in survivors and 11.56 +/- 2.68 in non-survivors and 5.11 +/- 2.83 in patients with primary genito-urinary infection but 7.56 +/- 4.35 in primary anorectal infection. The FSI was also found predictive of hospitalization time and number of debridements among survivors. CONCLUSION: Fournier's Severity Index is a simplified way of comparing patients with this disease and may also have some significance in predicting outcome. The FSI is a more significant and predictive tool that should be popularized to predict the prognosis in Fournier's gangrene.     

Fournier's gangrene of the scrotum following anorectal disorders

Five cases of Fournier's gangrene of the scrotum following anorectal disorders were encountered in a period of 2 years. Perirectal abscess was the most common associated underlying condition occurring in three patients.E. coli was the predominant organism cultured in all cases. A chronic debilitating condition was encountered in 3 patients. The mortality rate was 20%, but serious life threatening complications occurred in 4 of our patients. Error in diagnosis and delay in initiating medical treatment were the main causes of the high mortality rate associated with the disease. We advocate thorough rectal examination including proctoscopy in all cases of Fournier's gangrene, especially when no obvious source is apparent.     

Predisposing factors and treatment outcome in Fournier's gangrene. Analysis of 28 cases

OBJECTIVES: To evaluate the etiologic factors and the effects of surgical debridement and adjunctive therapies on morbidity and mortality of Fournier's gangrene. METHODS: 27 males, 1 female, a total of 28 patients with a mean age of 58 years treated for Fournier's gangrene were evaluated retrospectively. RESULTS: Predisposing factors including diabetes, alcohol abuse, paraplegia and renal insufficiency were identifiable in 54% of the patients. Etiologic origin of the gangrene was urogenital, cutaneous and anorectal in 43, 25 and 11% of the patients, respectively. The pathology was limited to genitalia in 10, extending to perineum in 8, the umbilicus in 7 and even up to the axilla in 3 patients. Suprapubic cystostomy and colostomy were necessary in 18 and 2 cases, respectively. We used hyperbaric oxygen therapy in 2 and honey in 6 patients to accelerate wound healing. A repeat debridement was necessary in 39% of the cases. Plastic surgery and grafting were done in 14 patients. Our mortality rate was 7%. CONCLUSION: Early recognition of the pathology and aggressive surgical debridement are the mainstay of the management of Fournier's gangrene. Additional strategies to improve wound healing and increase patient survival are also needed.     

Fournier's gangrene. A case report

Fournier's gangrene is a rare pathology, whose aetiopathogenesis is very varied and much debated. In most cases, it occurs in debilitated patients with chronic diseases involving tissue ischaemia. Despite substantial progress in scientific research, it carries a high mortality rate because of the rapidity with which it sets in and evolves, presenting therefore as a medical and surgical emergency. Although this syndrome has long beenknown, it is still difficult to treat and the subject of considerable debate. The authors report a case of Fournier's gangrene of an idiopathic nature, not corresponding to any of the forms described in the literature, which gave rise to a number of medical and surgical considerations, demonstrating the importance of prompt treatment capable of arresting its course and preparing the affected areas for reconstructive surgery.     

Hyperbaric oxygen for the treatment of fournier's gangrene

PURPOSE: Fournier's gangrene is a necrotizing fasciitis of the genitalia that is associated with high morbidity and mortality. Groups at many institutions have initiated routine adjuvant hyperbaric oxygen (HBO) therapy. We examined whether HBO has made a difference in the morbidity, mortality and costs associated with treating this disease. We also analyzed predictors of extended hospital stay and mortality. MATERIALS AND METHODS: The records of patients with the hospital discharge diagnoses of Fournier's gangrene, necrotizing fasciitis, gangrene of the genitalia and scrotal gangrene from 1993 to 2002 were reviewed. Data concerning clinical presentation characteristics, hospital stay, complications, hospital charges and outcomes, including graft failure and death, were analyzed. RESULTS: A total of 42 patients were identified and followed a median 4.2 years. Of the patients 16 underwent surgical debridement and antibiotic therapy alone, and 26 were treated with HBO plus surgery and antibiotics. Overall disease specific mortality was 21.4%, that is 12.5% in the nonHBO group and 26.9% in the HBO group. Three or more complications occurred in 13% of nonHBO and in 19% of HBO cases, of which the most common was myocardial infarction. The skin graft failure rate was 6% (nonHBO) and 8% (HBO). Physical disability was a statistically significant predictor of extended hospital stay (p <0.01). There was a trend toward a correlation between known coronary artery disease and death (p = 0.2). A statistically significant difference was noted in average daily hospital charges in nonHBO vs HBO cases ($2,552 vs $3,384 daily, p <0.01). CONCLUSIONS: These data do not support routine HBO in the treatment of Fournier's gangrene. There was a trend toward higher morbidity and mortality in the HBO group, suggesting that treatment may have been given to patients who were more ill.     

Fournier's gangrene: early diagnosis is the best remedy

Despite the broadening knowledge about Fournier's gangrene, its mortality rate is still considered very high. The authors describe the etiology, pathomechanism, the possible pathways of progression, and the causes and predisposing factors of the disease. Besides the traditional--surgical and antibiotic--therapy, complementary ways of treatment are described. Between 1994 and 2000, ten patients were treated for Fournier's gangrene in our department. We present our experience, the early signs and the way clinical symptoms develop. It is important to observe the early severe general condition and initially minimal local changes for early diagnosis in improved survival.     

Fournier's gangrene presenting as gas-forming subcutaneous infection of the scrotum

Two cases of gas-forming Fournier's gangrene were recently treated in a urology department. The etiology, pathology, bacteriology and treatment of Fournier's gangrene are discussed. An aggressive attitude with respect to both surgery and antibiotic therapy is recommended as possible means of reducing the high mortality associated with the condition.     

Impact of immunodeficiency virus (HIV) on Fournier's gangrene: observations in Zambia.

The results of a prospective study in the University Teaching Hospital, Lusaka, Zambia, on the impact of Human Immunodeficiency Virus on the incidence and prognosis of Fournier's gangrene is presented; Zambia has been in the grip of an HIV epidemic since the early 1980s. A total of 10 patients with an average age of 32 years was observed during a 14-month period (March 1992-April 1993); eight patients had associated HIV infection. A contributory factor to the development of Fournier's gangrene was also present in seven patients, of which six involved the urinary tract. All patients were managed by early surgical débridement under antibiotic cover. Two patients died, only one of whom had associated HIV disease. This study has recorded a significant rise in the prevalence of Fournier's gangrene in Zambia since the advent of the HIV epidemic. It has also been documented that provided aggressive treatment along established lines is initiated without delay, the coexisting HIV infection does not adversely affect the prognosis of Fournier's gangrene.     

Fournier's gangrene. Report of three cases and review of the literature

Fournier's gangrene, or synergistic gangrene of the male external genitalia is a rapidly spreading necrotising infection of the penis and scrotum. Although not so frequent in our civilized world it is by no means rare. In early days it was characterised by a high mortality. Aggressive surgical debridement, broad spectrum antibiotics and plastic reconstructive technics have all contributed to a better survival of the patients.     

Treatment and complications of Fournier's gangrene

Ten patients with Fournier's gangrene were seen over an 11-month period; 3 had indwelling urethral catheters, 3 had preceding perineal infection and 6 had a history of alcohol abuse. An average of 2.1 operations was required per patient and the average hospital stay was 41 days. The mortality rate was 20%; 7 patients developed acute renal failure and 5 developed adult respiratory distress syndrome. Early treatment of these complications should help to reduce the mortality of this disease.     

预后评分系统在Fournier坏疽诊治中的应用

目的 比较两种预后评分系统在我国Fournier坏疽患者死亡风险预测中的适用情况.方法 回顾性分析15例Fournier坏疽患者的临床特点及治疗转归,将研究对象分为存活组(A组)和死亡组(B组),并应用Fournier坏疽严重程度指数(FGSI)和Uludag FGSI进行死亡风险评估,采用受试者工作特征曲线(ROC)进行评分表效果评估,并利用Z检验比较FGSI和UFGSI之间准确性的差异.结果 存活组(A组)11例,死亡组(B组)4例.平均年龄(P =0.024)及术前美国麻醉师协会(ASA)评分(P =0.04)B组均显著高于A组.A组患者接受的清创次数明显多于B组患者.FGSI评分A组低于B组[(1.6±0.9)vs (3.8±1.7),P＜0.05].ROC曲线下面积(AUR) =0.886.UFGSI评分A组明显低于B组[(3.6±1.5)vs(6.0±2.2),P＜0.05],ROC AUR=0.852.UFGSI和FGSI的AUC比较差异无统计学意义.结论 FGSI和UFGSI均可有效预测我国Fournier坏疽患者的死亡风险,并且两种评分系统差异无显著统计学意义,但适合我国患者的死亡评估阈值还需要进一步大样本研究重新确定.     

A case of Fournier's gangrene reconstructed using a rectus abdominis muscle flap

We encountered a case of Fournier's gangrene complicated with vesicorectocutaneous fistula that was treated with a pedicled rectus abdominis muscle flap (pedicled RA m-c flap). A 75-year-old man was admitted with consciousness disorder and swelling of the scrotum. The patient had noticed swelling of the scrotum 4 days before admission, but he had ignored this condition. The scrotum and the penis appeared necrotic. On the basis of clinical and radiological findings, we diagnosed this condition as Fournier's gangrene. Surgical debridement was performed in conjunction with the use of broad-spectrum antibiotics. After the patient's general condition was improved, the broad defect in the perineal tissue was covered with a pedicled rectus abdominis muscle flap. The flap was successful. In Japan, this is the first case of Fournier's gangrene complicated with vesicorectocutaneous fistula that was treated with a pedicled RA m-c flap. In order to determine whether plastic surgery after debridement shortens the duration of hospitalization, we reviewed the cases of 120 patients with Fournier's gangrene in Japan. We conclude that plastic surgery after debridement does not shorten the duration of hospitalization, however, this procedures is very useful to deep and broad defects by Fournier's gangrene.     

Fournier's gangrene: Can aggressive treatment save life?

Fournier's gangrene (FG) is a rapidly progressive, fulminant infection of the scrotum, perineum and the abdominal wall. FG is caused by synergic aerobic and anaerobic organisms. Modern surgical series report mortality of up to 67% [2, 3]. This originally rare disease has become more frequent. Aggressive treatment including antibiotics, antigangrenous serum, and treatment of all accompanied diseases and disorders can be successful. Treatment also includes debridement and plastic corrections. Authors describe management of 8 patients with FG. Treatment of FG and all accompanied diseases was in all cases successful. Treatment costs of this kind of patients were approximately 20 times higher than treatment of patients with other urologic diseases.     

Fournier's gangrene

Over a 5-year period 43 men with severe classic Fournier's gangrene of the scrotum and perineum and in some cases of the abdominal wall were treated at King Edward VIII Hospital, Durban. There were 8 deaths, an overall mortality rate of 18,6%. The mortality rate was high (33%) when associated with diabetes mellitus and lower (14,7%) among non-diabetic patients. There was also an increased mortality rate when there was a delay in presentation (of over 6 days in the case of all the patients who later died). We have adopted a policy of aggressive surgical debridement and frequent revision, coupled with the use of broad-spectrum antibiotics.     

Fournier's disease

Fournier's gangrene is an aggressive synergistic fasciitis of the perineum. The disease can no longer be considered to be idiopathic; in most cases a urologic, colorectal, or cutaneous source can be identified. Despite antibiotics and aggressive debridement, the mortality rate remains high, particularly in the elderly, in patients with renal failure, and in patients with extensive disease. The presentation is highly variable, necessitating a high index of suspicion. High-risk patients include diabetics, alcoholics, and debilitated and immunosuppressed individuals. As the AIDS population increases, the incidence of Fournier's gangrene may increase as well. In questionable cases, imaging modalities should be performed to allow early diagnosis and to reduce missed diagnoses. Broad-spectrum antibiotics and aggressive debridement remain the hallmarks of treatment. Hyperbaric oxygen therapy and improved local wound care may decrease the extent of tissue destruction. Reconstructive techniques afford better cosmetic results. With early recognition, prompt treatment, improved wound care, and reconstructive efforts, the mortality rates and cosmetic results should continue to improve.     

Fournier's gangrene in childhood: a report of 3 infant patients

Fournier's gangrene is uncommon in pediatric age group, and little is known about the disease in the newborn period and infancy.Three patients, aged 10 days, 14, and 17 months, with Fournier's gangrene, were treated in our hospital. The predisposing factors were prematurity, a diaper rash, and varicella infection, respectively.Especially, prematurity and diaper rash are rare predisposing factors in the pediatric population; therefore, high index of suspicion, prompt diagnosis, conservative surgery, and multidisciplinary approach are the mainstays of management in children with Fournier's gangrene.     

Delayed recognition of an intersphincteric abscess as the underlying cause of Fournier's scrotal gangrene

It has recently become increasingly clear that Fournier's gangrene, far from being 'idiopathic' as initially thought, often originates from preexisting perianal or periurethral sepsis. The aetiology is discussed and an example quoted where the associated intersphincteric abscess was not recognised until some 3 months after the initial presentation. It is recommended that all patients presenting with Fournier's gangrene be examined by an experienced rectal surgeon early in the course of their illness.