fourniers gangrene- Surgery

1. Fournier’s gangrene
By: DR Darayus P.Gazder

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

6. 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

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

8. Etiology (contd.)
3. Dermatologic 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

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. 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

11. 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

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

13. 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)

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

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

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

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

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

19. 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

20. 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

21. Treatment
• Medical
• Surgical

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

23. 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)

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

26. Questions ?

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