Fourniers Gangrene

Necrotizing ascending infection of the scrotal wall, or Fournier's gangrene, is a urologic emergency requiring immediate diagnosis and expedient treatment, as delayed diagnosis and treatment can result in a 50 % mortality in high-risk patients such as older diabetic patients. It involves the skin, subcutaneous fat, and superficial fascia of the external genitalia and perineum. This disease process is characterized by a polymicrobial fas-ciitis involving the perineum and external genitalia. This infective process was first reported by Baurienne in 1764, and later by Fournier in 1883, whose name is eponymous with the disease. Although initially thought to be a fulminant disease restricted to young men, it has now been found to involve all ages and genders, and in some cases, to follow an indolent course.

The origin is most often from a genitourinary source, such as a periurethral abscess, or from a colorectal source, such as a perirectal abscess. Additionally, surgery or local trauma to the genitalia are additional risk factors. In presentation of the patient in the classic form, there is an acute onset of spreading cellulitis adjacent to the site of injury and very often frank necrosis (Fig. 12.9). Genital and scrotal pain out of proportion to the exam, swelling, and erythema are the most common symptoms. Interval examination usually shows rapid progression of the disease. Radiographic studies may be valuable when the physical examination is in doubt. While CT scans may be most sensitive at determining the presence of subcutaneous gas, bedside ultrasound maybe more rapid, depending on the institutional capabilities (Morrison et al. 2005). Occasionally, subcutaneous and deep tissue gas can be observed on a KUB by an observant radiographer. The identification of subcutaneous gas should prompt immediate surgery. Incidentally, if a urethral source is suspected, retrograde urethrography will be helpful in determining whether the patient needs a suprapubic tube to drain the bladder.

12.9. Fournier's Gangrene. This patient, a diabetic male aged 65, sustained minor trauma to his scrotum while zipping his trousers 21 h prior to presentation. Note the necrotic, large amount of scrotum that is affected. A large amount of purulent material was also found in the perineum, which can be seen to be swollen in the picture

12.9. Fournier's Gangrene. This patient, a diabetic male aged 65, sustained minor trauma to his scrotum while zipping his trousers 21 h prior to presentation. Note the necrotic, large amount of scrotum that is affected. A large amount of purulent material was also found in the perineum, which can be seen to be swollen in the picture

Management is emergent (Baskin et al. 1990). Rapid recognition, speedy resuscitation with fluids and oxygen, administration of broad-spectrum antibiotics, and wide debridement of all necrotic tissue are the cornerstones of treatment, along with the recognized need for a second trip to the operating room for a second look within 24 h. Many times additional surgery is required beyond the second surgery. Support in an intensive care unit may be required, including a large amount of fluid resuscitation, ventilatory support, and vasopres-sor support. Antibiotic coverage should include metro-nidazole or clindamycin for anaerobes, a third-generation cephalosporin or aminoglycoside for Gram-negative infections and penicillin for Gram-positive bacteria. Debridement should extend to fresh, vital tissue at every surgical margin. The glans, corpus spongiosum, corpora cavernosa and testes are almost always unin-fected and preserved because of their deep blood supply. However, if the tunica vaginalis is violated during the course of debridement, the testis may become su-perinfected and require orchiectomy at a later time. Primary removal of the testicle should be performed at the time of surgical debridement if the etiology of the necrotizing infection is epididymo-orchitis. Cystosco-py and rigid sigmoidoscopy should be performed to find the primary source of infection. Fecal diversion via end colostomy is rarely required unless there is massive contamination of the wound by feces or simultaneous colorectal and urinary tract involvement. Testicles can be places in subcutaneous thigh pouches.

After the patient is stabilized in the operating room, debrided wounds are managed with moist gauze dressings and repeat debridement. Secondary coverage takes place via split thickness skin grafting only after the primary infective process has been eradicated.

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