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TAU0010.1177/1756287215584740Therapeutic Advances in UrologyA Chennamsetty, I Khourdaji et al.
Correspondence to:
Avinash Chennamsetty,
Introduction 1883 as a fulminant gangrene of the penis and MD
Department of Urology,
Fournier’s gangrene (FG) is a type of necrotizing scrotum [Fournier, 1883]. Over the years, experi- Beaumont Health System,
fasciitis of the perineal, genital and perianal region ence has shown that FG often has an identifiable 3535 West Thirteen Mile
Road, Suite 438, Royal
that has a rapidly progressive and potentially fatal cause and it frequently manifests indolently. Oak, MI 48073, USA
course [Vick and Carson, 1999]. Similar to other Many terms have been used to describe the clini- avinash.chennamsetty@
beaumont.edu
necrotizing soft tissue infections, the inflamma- cal condition including ‘idiopathic gangrene of
Iyad Khourdaji, MD
tion and edema from the polymicrobial infection the scrotum’, ‘periurethral phlegmon’, ‘strepto- Department of Urology,
lead to an obliterative endarteritis of the subcuta- coccal scrotal gangrene’, ‘phagedena’ and ‘syner- Beaumont Health System,
Royal Oak, MI, USA
neous arteries [Korkut et al. 2003]. This impaired gistic necrotizing cellulitis’ [Meleney, 1924; Gray,
Frank Burks, MD
blood supply furthers perifascial dissection with 1960; Shyam and Rapsang, 2013]. Department of Urology,
spread of bacteria and progression to gangrene of Beaumont Health System,
Royal Oak, MI, USA
the overlying subcutaneous tissue and skin. Subjects of both genders and all ages may be Oakland University William
affected [Sorensen et al. 2009a]; however, FG has Beaumont School of
Medicine, Rochester, MI,
Even though FG was first described by Baurienne a predilection for those over the age of 50 with a USA
in 1764 [Nathan, 1998], it is credited to the male to female ration of 10 to 1 [Alonso et al. Kim A. Killinger, MSN
Department of Urology,
French venereologist, Jean Alfred Fournier, who 2000; Eke, 2000]. Early diagnosis remains imper- Beaumont Health System,
provided a detailed description of the disease in ative, as the rate of fascial necrosis has been noted Royal Oak, MI, USA
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Therapeutic Advances in Urology 7(4)
as high as 2–3 cm per hour [Uppot et al. 2003; chronic urinary tract infection, neurogenic blad-
Safioleas et al. 2006]. Treatment of FG entails der, epididymitis and recent instrumentation
treating sepsis, stabilizing medical parameters [Amendola et al. 1994]. In women, additional sites
and urgent surgical debridement. Despite timely of origin include Bartholin gland or vulvar abscess,
and aggressive management, the condition is life episiotomy, hysterectomy and septic abortion
threatening as most studies report mortality rates [Morua et al. 2009]. Insect bites, burns, trauma
of between 20% and 40% with a range of 4–88% and circumcision have also been reported as
[Morpurgo and Galandiuk, 2002; Sorensen et al. causes of pediatric FG [Amendola et al. 1994].
2009b]. Interestingly, the mortality has been
shown to be higher in technologically advanced
countries such as the United States, Canada and Pathogenesis and organisms involved
Europe than in underdeveloped countries [Eke, The predisposing and etiologic factors of FG pro-
2000]. vide a favorable environment for the infection by
decreasing the host immunity and allowing a por-
tal of entry for the microorganism into the peri-
Predisposing factors neum. The incident leading to the inoculation
Primarily an infective condition, FG has several may be so trivial that the patient or physician may
predisposing factors and theoretically, any condi- fail to notice. Characteristically, FG exists due to
tion that decreases the host immunity may predis- synergism between multiple bacteria that theo-
pose a person to the development of FG. The retically are not highly aggressive when presented
most common predisposing factors are diabetes alone. The polymicrobial nature of FG with con-
mellitus and alcohol overindulgence, which are tributions by both aerobic and anaerobic bacteria
reported to be present in 20–70% and 20–50% of is necessary to create the production of various
patients, respectively [Clayton et al. 1990; exotoxins and enzymes like collagenase, hepari-
Morpurgo and Galandiuk, 2002]. The relatively nase, hyaluronidase, streptokinase and strepto-
high incidence of FG in patients with diabetes has dornase, which promote rapid multiplication and
been attributed to their small vessel disease, spread of infection. The aerobic bacteria cause
defective phagocytosis, diabetic neuropathy and platelet aggregation and induce complement fixa-
immunosuppression, all of which can be exacer- tion, thereby causing acceleration of coagulation.
bated by poor hygiene when present [Vick and The anaerobic bacteria promote the formation of
Carson, 1999]. Other risk factors include clots by producing collagenase and heparinase.
extremes in age, malignancy, chronic steroid use, Other organisms like Bacteroides inhibit the
cytotoxic drugs, lymphoproliferative disease, mal- phagocytosis of aerobic bacteria, aiding in further
nutrition and human immunodeficiency virus spread of the infection [Morua et al. 2009; Shyam
(HIV) infection [Mallikarjuna et al. 2012]. In cer- and Rapsang, 2013].
tain countries, near epidemic proportions of HIV
places a large population at risk for developing The organisms that tend to be found in FG are
FG [Elem and Ranjan, 1995]. species that normally exist below the pelvic dia-
phragm in the perineum and genitalia [Eke, 2000].
The most commonly isolated aerobic microorgan-
Etiology isms are Escherichia coli, Klebsiella pneumoniae and
FG was initially defined as an idiopathic entity, Staphylococcus aureus, while the most commonly
but recent research has shown that less than a isolated anaerobic microorganism is Bacteroides
quarter of FG cases are now considered idiopathic fragilis [Paty and Smith, 1992]. Other organisms
[Smith et al. 1998; Vick and Carson, 1999]. include Streptococcus, Enterococcus, Clostridium,
Colorectal sources (30–50% of cases), urogenital Pseudomonas and Proteus species. In some series,
sources (20–40% of cases), cutaneous infections an average of more than three organisms were cul-
(20% of cases) and local trauma are frequently tured from each patient [Addison et al. 1984;
identified as the cause of FG [Eke, 2000]. Thwaini et al. 2006]. Group A streptococcal is the
Colorectal sources include local infection, most common cause of monomicrobial necrotiz-
abscesses (particularly in the perianal, perirectal ing fasciitis [Ekelius et al. 2004]. Although rare,
and ischiorectal regions), anal fissures, colonic necrotizing fasciitis due to Candida species as well
perforations, diverticulitis, hemorrhoidectomy as Lactobacillus gasseri has also been reported
and rectal carcinoma [Ash and Hale, 2005]. [Tleyjeh et al. 2004; Jensen et al. 2010]. Ultimately,
Urologic sources of FG include urethral strictures, the microorganism’s virulence promotes the rapid
204 http://tau.sagepub.com
A Chennamsetty, I Khourdaji et al.
Clinical features
The clinical features of FG include sudden pain Diagnosis
and swelling in the scrotum, purulence or wound The diagnosis of FG is primarily based on clinical
discharge, crepitation, fluctuance, prostration, findings of fluctuance, crepitus, localized tender-
pallor and fever greater than 38°C (Figure 1) ness and wounds of the genitalia and perineum.
[Yeniyol et al. 2004]. Usually the infection starts Although diagnosis is straightforward when the
as a cellulitis adjacent to the portal of entry, com- lesions are found, failure to examine the genitals,
monly in the perineum or perineal region, with an especially in the older or obtunded patient, can
insidious presentation. The affected area is often result in misdiagnosis. The common laboratory
swollen, dusky and covered by macerated skin findings are nonspecific and may show anemia,
and presents with a characteristic feculent odor, leukocytosis, thrombocytopenia, electrolyte
which is attributed to the role of anaerobes in the abnormalities, hyperglycemia, elevated serum
infection [Alonso et al. 2000]. Patients also may creatinine level, azotemia and hypoalbuminemia
have pronounced systemic signs, usually out of [Shyam and Rapsang, 2013]. The diagnosis of FG
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Therapeutic Advances in Urology 7(4)
is primarily clinical, and in most cases imaging is disease extent than does radiography, US or even
neither necessary nor desirable. Under no cir- physical examination [Rajan and Scharer, 1998].
cumstances should surgery be delayed signifi-
cantly for imaging of any kind. However, imaging Magnetic resonance imaging (MRI) offers an
modalities may be useful in cases when the pres- important diagnostic adjunct in the management
entation is atypical or when there is concern of FG as it is more useful than conventional radi-
regarding the true extent of the disease. ography and US for specifying range of infection.
Some argue that MRI is even more helpful than
Conventional radiography can be used to detect CT in planning any operative intervention [Sharif
the presence of soft tissue air in the area overlying et al. 1990; Yoneda et al. 2010].
the scrotum and perineum before clinical crepitus
is detected. In addition to demonstrating signifi-
cant swelling of the scrotal soft tissue, radiographs Investigations
may also detect subcutaneous emphysema Despite timely and aggressive treatment, the mor-
extending from the scrotum and perineum to the tality rate for FG remains high [Morpurgo and
inguinal regions, anterior abdominal wall and Galandiuk, 2002; Sorensen et al. 2009b]. Various
thighs. However, the absence of subcutaneous air, comorbidities are known to be associated with
which is demonstrated in 10% of patients, does FG, of which DM is most common. However, its
not exclude the diagnosis of FG [Sherman et al. association with increased mortality is debatable
1998]. A significant weakness of radiography in [Kabay et al. 2008; Unalp et al. 2008; Kara et al.
the diagnosis and evaluation of FG is the lack of 2009; Ersoz et al. 2012]. Similarly, there is uncer-
detection of deep fascial gas [Wysoki et al. 1997]. tainty about the association of age and mortality
in FG [Yeniyol et al. 2004; Tuncel et al. 2006;
Ultrasound (US) findings in FG include a thick- Lujan et al. 2010]. However, two comorbidities
ened, edematous scrotal wall containing hypere- associated with increased mortality in FG are
choic foci that demonstrate reverberation artifacts, ischemic heart disease and hemodialysis-depend-
causing ‘dirty’ shadowing which represents gas ent renal failure [Jeong et al. 2005; Altarac et al.
within the scrotal wall [Levenson et al. 2008]. In 2012; Ersoz et al. 2012].
addition, US can demonstrate paratesticular fluid,
which is seen prior to clinical crepitus. This imag- The presence of severe sepsis on admission has
ing modality is also useful in differentiating FG been significantly associated with mortality [Kara
from inguinoscrotal hernias. Overall, US is con- et al. 2009; Altarac et al. 2012]. Additionally, the
sidered superior to conventional radiography as volume of necrosis appears to be a prognostic fac-
soft tissue air is more obvious and scrotal con- tor as some studies show patients with a gangre-
tents along with Doppler blood flow can be nous area less than 3% of the body surface rarely
examined. die, whereas patients presenting with a gangre-
nous area of 5% body surface area or more have a
Computed tomography (CT) plays an important worse prognosis [Dahm et al. 2000; Horta et al.
role in the diagnosis of FG as well as the evalua- 2009; Janane et al. 2011]. However, the associa-
tion of the extent of the disease to guide appropri- tion between larger gangrenous areas and worse
ate surgical treatment. CT findings include prognosis is not universally accepted [Clayton
asymmetric fascial thickening, fluid collections, et al. 1990; Laor et al. 1995].
abscess formation, fat stranding around involved
structures and subcutaneous emphysema [Rajan Abnormal laboratory parameters at admission
and Scharer, 1998; Sherman et al. 1998; Levenson have also been noted to have a significant impact
et al. 2008]. The underlying cause of FG, such as on mortality. The laboratory values most often
a perianal abscess, a fistulous tract, or an intraab- predictive of worse prognosis include increased
dominal or retroperitoneal infectious process, leukocyte counts, creatinine, creatine kinase,
may also be demonstrated by CT [Rajan and urea, lactate dehydrogenase, alkaline phos-
Scharer, 1998]. It can help to evaluate both the phatase, and decreased levels of hematocrit,
superficial and the deep fascia, and to differenti- bicarbonate, sodium, potassium, calcium, total
ate FG from less aggressive entities such as soft- protein and albumin [Clayton et al. 1990; Laor
tissue edema or cellulitis, which may appear et al. 1995; Chawla et al. 2003; Yeniyol et al. 2004;
similar to FG on physical examination. As a Jeong et al. 2005; Tuncel et al. 2006; Altarac et al.
whole, CT has greater specificity for evaluating 2012; Vyas et al. 2013]. Using a weighted point
206 http://tau.sagepub.com
A Chennamsetty, I Khourdaji et al.
system of multiple laboratory markers, the et al. 2013]. As the rate of fascial necrosis has
Laboratory Risk Indicator for Necrotizing been noted as high as 2–3 cm per hour, FG is
Fasciitis (LRINEC) score is often used to stratify considered a surgical emergency with prompt,
patients into low, moderate or high risk for pragmatic and individualized therapy being the
necrotizing soft tissue infections [Wong et al. cornerstone for effective treatment [Eke, 2000;
2004; Wolf and Wolf, 2010]. A LRINEC score of Safioleas et al. 2006; Akilov et al. 2013].
more than 6 should raise the suspicion of
necrotizing fasciitis among patients with severe
soft tissue infections, and a score greater than 8 is Broad-spectrum antibiotic coverage
strongly predictive of FG. Broad-spectrum parental antibiotic therapy is
administered empirically upon diagnosis of FG
A prognostic index known, as the Fournier’s and then subsequently tailored based on culture
Gangrene Severity Index (FGSI), was created by results. It is imperative that the antibiotic regi-
Laor and colleagues to determine the severity and men chosen is effective against staphylococcal,
prognosis of FG in patients [Laor et al. 1995]. By streptococcal and gram-negative bacteria, coli-
quantifying the severity of infection using com- forms, Pseudomonas, Bacteroides and Clostridium
mon vital signs (temperature, heart rate, respira- [Mallikarjuna et al. 2012]. Triple antibiotic ther-
tory rate) and laboratory data (serum sodium, apy consisting of a broad-spectrum penicillin or
serum potassium, serum creatinine, serum bicar- third-generation cephalosporins, an aminoglyco-
bonate, hematocrit and white blood cell count), side (e.g. gentamicin) and metronidazole or clin-
the FGSI score helps prognosticate progression damycin is typically instituted empirically
and predict the mortality. The degree of deviation [Mallikarjuna et al. 2012; Benjelloun et al. 2013;
from normal is graded from 0 to 4, and individual Wroblewska et al. 2014]. Moreover, many have
values are summed to obtain the FGSI score. A suggested adding penicillin for treatment of
score greater than 9 is suggested to have a 75% streptococci and, in particular, when Clostridia is
probability of death, and index score up to 9 is suspected. Alternatively, clindamycin and chlo-
associated with a 78% probability of survival. ramphenicol can be substituted empirically to
FGSI has been validated by several studies facilitate coverage of gram-positive cocci and
[Chawla et al. 2003; Yeniyol et al. 2004; Kabay anaerobes until culture results return [Martinez-
et al. 2008; Unalp et al. 2008; Kara et al. 2009; Rodriguez et al. 2009]. In patients infected with
Altarac et al. 2012]. Kabay and colleagues ana- methicillin-resistant S. aureus, vancomycin
lyzed patients using this index and showed those should be utilized. Amphotericin B or caspo-
with FGSI greater than 10.5 had 96% mortality fungin should be added to the empiric regimen
whereas those with a score less than 10.5 had should fungi be detected in tissue cultures [Pais
96% survival [Kabay et al. 2008]. Kara and col- et al. 2013; Wroblewska et al. 2014].
leagues found that FGSI scores of at least 7
affected mortality rates with statistical signifi-
cance (p < 0.05) and Altarac and colleagues Radical surgical debridement
noted that FGSI scores were significantly higher In addition to broad-spectrum parental antibiot-
among nonsurvivors (11 versus 5, p < 0.0001) ics, early and aggressive surgical debridement has
[Kara et al. 2009; Altarac et al. 2012]. However, been shown to improve survival in patients pre-
controversy exists regarding the accuracy of senting with FG as patients often undergo more
FGSI, as Tuncel and colleagues and Janane and than one debridement during their hospitaliza-
colleagues argued the index cannot be relied upon tion [Corman et al. 1999; Chawla et al. 2003;
to predict survival [Tuncel et al. 2006; Janane Sorensen et al. 2009b]. In a retrospective study of
et al. 2011]. 219 patients presenting with a diagnosis of FG,
Proud and colleagues found that there was no sta-
tistically significant difference in mortality
Management of FG between patients who underwent debridement
The management of FG is underscored by three before transfer or within 24 h of presentation to
main principles: rapid and aggressive surgical those who had not. The authors attributed this
debridement of necrotized tissue, hemodynamic seemingly counterintuitive observation to the
support with urgent resuscitation with fluids, and range in severity of necrotizing soft tissue infec-
broad-spectrum parental antibiotics [Corman tions and to the notion that patients are less likely
et al. 1999; Eke, 2000; Chen et al. 2010; Akilov to succumb to localized infections. Regardless,
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Therapeutic Advances in Urology 7(4)
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A Chennamsetty, I Khourdaji et al.
50 and 125 mmHg. The negative pressure in increases morbidity. The estimated percentage of
NPWT leads to an increased blood supply and patients requiring colostomy after debridement of
thus encourages migration of inflammatory cells FG is approximately 15%, and an increased mor-
into the wound region. Also, this promotes and tality has been noted in patients requiring diver-
accelerates the formation of granulation tissue by sion [Yanar et al. 2006; Mallikarjuna et al. 2012].
removing bacterial contamination, end products, In their study of 44 patients presenting with FG,
exudates and debris compared with traditional Ozturk and colleagues found that in 18 patients
dressing [Ozkan et al. 2014]. Czymek and col- that required temporary stoma formation, signifi-
leagues prospectively collected data on 35 patients cant increases in healthcare costs were observed
diagnosed with FG to assess the effectiveness of without an effect on outcomes. Overall, stoma
VAC therapy versus daily antiseptic (polyhexa- creation and closure increased costs by approxi-
dine) dressings. Patients treated with VAC ther- mately $6650. Therefore, it is recommended that
apy had significantly longer hospitalization and stoma formation be reserved for patients with
lower mortality. However, significantly more fecal incontinence caused by extensive damage to
patients required fecal diversion in the group the anal sphincter [Ozturk et al. 2011].
receiving VAC therapy because of the need to Nevertheless, the potential need for colostomy
reapply the vacuum dressing after each bowel underscores the importance of a multidisciplinary
movement. Fecal diversions may have be partially approach to the management of the patient pre-
responsible for a higher mean number of surgical senting with FG [Gurdal et al. 2003]. In a series
procedures in patients treated with VAC therapy of 28 consecutive patients with FG, Corman and
compared with those whose wounds were treated colleagues found that general surgical service was
with conventional dressings that were more easily involved in 52% of the initial operations to per-
changed on the wards. Overall, the authors state form perianal and sometimes perirectal debride-
that VAC is not superior to conventional dressings ment [Corman et al. 1999]. Alternatively, the
in terms of length of hospital stay or clinical out- Flexi-Seal Fecal Management System has been
come. However, they are still clinically effective introduced for fecal diversion, which can be uti-
and successfully used in the management of large lized as an alternative method to colostomy as it
wounds [Czymek et al. 2009]. successfully prevents fecal contamination of the
wound [Ozkan et al. 2014]. In regards to urinary
diversion, some authors suggest cystostomy,
Hyperbaric oxygen therapy although most suggest that urinary catheteriza-
A modality that has shown some promise as an tion provides satisfactory diversion [Yanar et al.
adjunct to treatment of FG is hyperbaric oxygen 2006]. In a review of 26 cases of FG treated at a
(HBO) therapy, which entails exposing the patient university medical center, Hollabaugh and col-
to increased ambient pressure while breathing leagues utilized suprapubic diversion in 16 cases
100% oxygen [Mallikarjuna et al. 2012]. The with 15 of those patients receiving diversion at the
physiological effects are believed to be enhanced time of initial debridement. Indications for
leukocyte ability to kill aerobic bacteria, stimula- suprapubic urinary diversion included patients
tion of collagen formation and increased levels of with extensive penile and perineal debridement,
superoxide dismutase resulting in better tissue or periurethral abscesses [Hollabaugh et al. 1998].
survival. Several case reports have demonstrated In 74 patients presenting with FG at an Egyptian
enhanced patient survival with the use of HBO in medical center, adequate urinary diversion was
the setting of necrotizing fasciitis when combined accomplished with the use of a urethral Foley
with surgical debridement [Jallali et al. 2005]. catheter in all but one patient who had experi-
enced a urethral injury. In this series, suprapubic
cystostomy was recommended in patients experi-
Fecal and urinary diversion encing urethral disruption or stricture [Ghnnam,
Colostomy has been used for fecal diversion in 2008].
cases of severe perineal involvement. Indications
for colostomy include anal sphincter involvement,
fecal incontinence and continued fecal contami- Reconstructive surgery
nation of the wound’s margins. Although colos- After extensive debridement, many patients sus-
tomy can be beneficial with regard to wound tain significant defects of the skin and soft tissue,
healing by avoiding fecal contamination, it should creating a need for reconstructive surgery for
be performed only in selected cases because it wound coverage as well as satisfactory functional
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Therapeutic Advances in Urology 7(4)
Figure 3. Fournier’s gangrene extending from the Figure 4. Debrided scrotum with testicular thigh
scrotum into the inguinal region after debridement. pouches.
Source: Frank Burks, MD. Source: Frank Burks, MD.
and cosmetic results (Figure 3). As a result of reconstruction in the acute setting (Figure 4)
these defects, ensuing exposure of the testicles in [Akilov et al. 2013]. Chan and collages state that
the male patient presents a substantial challenge implantation of the exposed testicle into an adja-
for reconstruction. The primary goal of recon- cent subcutaneous thigh flap can provide a
struction in patients who have undergone genital shorter hospital stay and reduce recovery time.
skin loss due to necrotizing fasciitis is simple and However, this technique is only temporizing,
efficient coverage. Additional goals are good cos- allowing the patient more time to recover until
mesis and the preservation of penile function, definitive scrotal reconstruction can be under-
including erection, ejaculation and micturition. taken [Chan et al. 2013].
Coverage has to be achieved in a way that restores
function quickly with a good cosmetic outcome The best functional and cosmetic results are
and low associated morbidity and mortality. achieved with primary closure of any remaining
Salvaging the testes is usually achieved by using scrotum, though this is only possible with small
techniques such as thigh pouches, skin grafts and defects (Figures 5 and 6). Closure via secondary
use of fasciocutaneous or musculocutaneous flaps intention, particularly of large defects, prolongs
[Corman et al. 1999; Maguina et al. 2003; Black healing time but also leads to contraction and
et al. 2004; Chen et al. 2010; Lee et al. 2012]. deformity of the scrotum [Maguina et al. 2003]. In
a retrospective study of 28 male patients present-
As mentioned previously, testicular involvement ing with FG, Akilov and colleagues evaluated the
in FG is rare and suggests an intraabdominal or outcomes of early loose scrotal approximation and
retroperitoneal source [Eke, 2000]. Though found that approximation of the scrotal wound at
orchiectomy is rarely required, it may be neces- the time of surgical debridement in patients with
sary in situations of extensive tissue damage in up to 50% involvement may be safely performed
the surrounding scrotum, groin and perineum with successful prevention of ipsilateral testis
leading to difficult dressing changes [Ghnnam, exposure. Loose wound edge closure was achieved
2008]. Temporary thigh pouches to harbor the with a nonabsorbable monofilament suture by
testicles may be utilized in scenarios when sig- U-stitch approximation of the scrotal or perineal
nificant tissue loss may preclude complex scrotal wound edges [Akilov et al. 2013].
210 http://tau.sagepub.com
A Chennamsetty, I Khourdaji et al.
Figure 5. Extensive defect from Fournier’s gangrene Figure 7. Significant scrotal skin loss after Fournier’s
debridement prior to primary closure. gangrene debridement with meshed split-thickness
Photo credit D. Rosenstein. skin graft.
Photo credit D. Rosenstein.
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