A case of severe Fournier's gangrene in which the testicles and the anus left without any surrounding support tissue.

1. Presented by:
Dr. Majd Al Haddadin. MD, MRCS, FACS, General and Laparoscopic Surgeon .
Supervised by:
Dr. Mohammad Eftaiha. MD, FACS, FASCRS, Consultant Colon & Rectal Surgeon.
Dr. Imad Sammodi. MD, MBchB, General Surgeon.

2. Fournier's gangrene (FG) is a rare but life threatening
disease. Although originally thought to be an idiopathic
process, FG has been shown to have a predilection for
patients with diabetes as well as long term alcohol misuse;
however, it can also affect patients with non‐obvious
immune compromise
Development and progression of the gangrene is often
fulminating and can rapidly cause multiple organ failure
and death.
Because of potential complications, it is important to
diagnose the disease process as early as possible.

3. Case Presentation
We present our experience of severe necrotizing soft
tissue infection involving the rare destruction of
anatomic support in the perineum resulting in what is
termed “ floating or free standing testicles”

4. Case # 1:
 Name: H.A.O
 File number: 411625
 Date of admission: 07/07/2013
 A 70-year-old male patient from Yemen, medically free,
presented to the emergency department with a complaint of
perineal pain ,radiated to scrotum and groins associated with
purulent discharge and bad odor.
 His history had started 7 days prior to admission in our
center when he U/W surgical treatment of perianal fistula
and abscess which was complicated by severe perineal
infection.
 He was treated by scrotal debridement and drainage of the
perineum.

5. Physical examination:
 Afebrile.
 Skin and mucosa:
pale and diaphoresis,
 Respiratory system:
Good bilateral air entry.RR:21/min
 Cardiovascular system:
S1 S2 normal,no murmur. HR: 100 bpm
BP: 120/65mmhg,capillary refill: 3 sec,

6.  Urogenital system:
 severe necrosis and tissue loss of perineum and
scrotum, with free exposure of the testicles(floating).
 Frank purulence from RT inguinal canal.
 multiple anterior abdominal wall collections.
 CNS:
Conscious, oriented ,alert.

7. Laboratory investigation:
 HB: 10.6 mg/dl
 WBC: 11.4 X 10^9/L
 PLT: 383 X 10^9/L
 KFT: normal
 HBA1C: 5.6%
 CRP: 92
 INR: 1.3 PT: 16.8 PTT: 30.4

8. Anesthesia and Urology consultations were obtained.
A proper consent was signed and patient was taken to the
operating room for proper examination and debridement.
Patient was taken to the operating room on
07/07/2013

9. Viable
floating
testicles
Drained horse-
shoe perirectal
abscess

10. Incision and
counter
drainage of
anterior
abdominal
fluid
collections

11. Sphincteroplasty with closure of perineal
wounds and scrotal skin graft were done
(07/08/2013)
Diverting colostomy done on 13/07/2013

12. Split thickness
skin graft

13. One week after surgery patient was discharged in a
good general condition.
He was readmitted on 22/02/2014 for colostomy
closure and discharged on 27/02/2014 without
any complication.

14. Case # 2:
 Name: Sami.A.Hababseh
 File number: 550551
 Date of admission: 02/05/2015
 A 38-year-old male with a past medical history significant for
hypertension, diabetes mellitus and congestive heart failure
secondary to congenital VSD.
 presented to the emergency department with a complaint of
perineal pain and swelling radiated to scrotum and groins
associated with perianal purulent discharge, nausea,
diaphoresis and severe fatigue.
 His symptoms had started seven days prior to presentation
after incision and drainage of perianal abscess but had
progressed rapidly in the preceding twenty-four hours.

15. Physical examination:
 Skin and mucosa:
severe pallor and diaphoresis, perioral and extremities
cyanosis.
 Respiratory system:
moderate decrease in air entry and bilateral
crackles.RR:28/min
 Cardiovascular system:
Muffled heart sounds, irregular. HR: 115 bpm
BP: 90/60 mmhg,capillary refill: 6 sec, weak distal pulses,
distended cervical veins.

16. Physical examination:
 Urogenital system:
severe perineal and scrotal swelling, extended to
groins and proximal part of ventral aspect of penis,
severe tenderness and pain with crepitus on palpation.
 CNS:
Conscious, oriented ,alert.

17. Laboratory investigation:
 HB: 16.7 mg/dl
 WBC: 23.5 X 10^9/L
 PLT: 135 X 10^9/L
 KFT: normal
 HBA1C: 6.6%
 ABGs: PH: 7.46 Hco3:17.9 PCo2: 25.3 Po2:40.8
 CRP: 373
 INR: 1.9 PT: 21.8 PTT: 29.9

18. Echo-Cardiogram:
paradoxical septal motility
E/F: unrecordable
Enlarged right ventricle and right atrium
P.A.P > 100mmhg
ECG:
L.B.B.B, Tachycardia, ischemic changes

19. An urgent cardiology, anesthesia and urology consultations
were obtained. After evaluation, the condition was discussed
with patient and family and a proper consent was obtained
( perioperative mortality of 80%).
After resuscitation patient was taken to
OR for extensive debridement
(02/05/2015)

20. Day 0
Foley catheterization for
diversion of urinary
stream
Debridement
along the left
groin crease
directed
towards
perineum
Bilateral
testicles,
floating,
viable, after
debridement
of necrotic
scrotal tissue

21. Incision and
counter incision
of perianal
abscess with
penrose placed
for assurance of
adequate
drainage

22. Day 7
Testicle
implanted on
the thigh fat
Testicle
Attempted re-
approximation
of skin for
coverage

23. Vacuum Suction Device

24. Flexi Seal

25. On 19/05/2015 patient underwent
diverting colostomy

26. Day 21

27.  Patient was discharged on 3/6/2015 with colostomy
and vacuum suction.
 He was readmitted weekly for dressing under sedation.

28. Day 40
Vac change
in OR with
good tissue
filling and
healthy
granulation

29. Day 60
Vac treatment with
excellent tissue filling and
granulation, near
complete perineal
reconstitution
Patient will continue wound
rehabilitation and reversal of
colostomy, pending anal
manometry studies for strength
of anal sphincters

30. Day 75

31. Perianal and perineal wounds
completely healed
Day 90

32. Historical Background
 Fournier's gangrene (FG) is a fulminant form of
infective necrotising fascitis of the perineal, genital, or
perianal regions.
 It is credited to the Parisian venerologist Jean‐Alfred
Fournier, who described it as a fulminant gangrene of
the penis and scrotum in young men in 1883.
 Baurienne in 1764 and Avicenna in 1877 had described
the same disease earlier.

33. Loss of Anatomical Architecture
Anorectal suppurations are relatively common and if
adequately treated usually result in uncomplicated
recovery with minimal morbidity. However, an
occasional anorectal abscess may cause extensive and
life-threatining suppuration associated with massive
tissue necrosis.The tissue destruction may be limited
to one side of the anorectum, may cross the midline as
an advanced form of horse-shoe abscess or may be
circumferential. In such a case, the anus is left without
anatomic support on one side, bilaterally or
circumferentially, thus resulting in a floating or free-
standing anus. (Abcarian & Eftaiha, 1983)

34. Etiology:
1. Ano-rectal causes –
 Perianal abscess
 Infected hemorrhoids
 Perianal fistula
 Manifestation of colorectal injury, malignancy or
diverticulitis
2. Uro-genital causes –
 infection in the bulbourethral glands
 urethral injury
 Iatrogenic injury
 Lower urinary tract infections

35. 3. Dermatologic causes –
 Hidradenitis suppurativa
 cellulitits
 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
 AIDS

36. Pathogenesis:
 Localized infection adjacent to a portal of entry is the
inciting event in the development of Fournier
gangrene. Ultimately, an obliterative endarteritis
develops, and the ensuing cutaneous and
subcutaneous vascular necrosis leads to localized
ischemia and further bacterial proliferation. Rates of
fascial destruction as high as 2-3 cm/h have been
described.

37. Pathogenesis:
 Infection of superficial perineal fascia (Colles fascia)
may spread to the penis and scrotum via Buck and
dartos fascia, or to the anterior abdominal wall via
Scarpa fascia, or vice versa. Colles fascia is attached to
the perineal body and urogenital diaphragm
posteriorly and to the pubic rami laterally, thus
limiting progression in these directions. Testicular
involvement is rare, as the testicular arteries originate
directly from the aorta and thus have a blood supply
separate from the affected region.

38. Does the imaging studies have any
value in the diagnosis of FG ??
 Pelvic imaging studies can be extremely valuable
when the diagnosis is uncertain, although sensitivities
and specificities of different radiologic modalities are
not established.
 computed tomography (CT) should be considered the
imaging study of choice

39. Conventional radiography
Hyperlucency in the soft tissue indicative of subcutaneous emphysema
Plain radiographs will show air in soft tissue before clinical crepitus (6)
Deep fascial gas is rarely seen on plain radiography, making this imaging choice disadvantageous if
there is a need to evaluate extension

40. Ultrasonography
 Patients presenting to ED with scrotal pain and erythema will inevitably get an
ultrasound of the genitalia
 Ultrasound will show gas in soft tissue before crepitus is appreciated on physical exam.
 More sensitive than radiography in demonstration of subcutaneous emphysema.
 In patients with scrotal pain presenting to ED, ultrasound will easily differentiate an
incarcerated hernia from Fournier’s gangrene

41. CT-Scan
Subcutanous Air

42. MRI

43. Treatment:
Medical:
• ABC resuscitation
• Restoration of tissue perfusion
• Reduction of systemic toxicity
• Broad spectrum antibiotics
• Tetanus prophylaxis
• Irrigation
• Hyperbaric oxygen therapy
• IV immunoglobulins

45. !!controversy!!
Extensive VS Minimal debridement in
the treatment of
Massive Perianal Infection

46. All the surgeons agree that the treatment of the
disease remains surgical despite the availability of
modern antibiotics.

47. There is no role for non-
operative management.
Incision and counter -
incision are not advised.

48. In a retrospective study done by freeza in 9 patients with
fournier gangrene over 2 years, he said:
“wide drainage with minimal debridement resulted in similar
morbidity and shorter hospital stay when compared with
extensive debridement”.
 The average hospital stay was 45+/-10 days for minimal
debridement with wide drainage in comparison with
65+/-12 days with extensive debridement.

49. A retrospective study of 24 patients with massive
perirectal suppuration causing floating free satnding
anus, treated at the colon and rectal surgery service of
cook county hospital by Dr.Abcarian and Dr. Eftaiha
showed that:
Drainage of the abscess cavity through a generous radial
perianal incision with multiple counter-drainage incisions
varying from five to ten in number made by excising ellipses
of skin measuring 2 to 3cm in diameter offered a great
results, preventing anal retraction and step-off deformity
which greatly delayed the healing process.

50. Surgical Treatment
Debridement of underlying necrotic
tissue characterized by generous radial
incisions (devoid of circumanal incisions
to prevent anal deformity and step-off)
with parallel counter incisions to ensure
dependant drainage of abscess cavity .
Radial counter-incisions
to ensure adequate
drainage
Debridement and drainage of
abscess

52. 1983
Dr.Eftaiha; 1983

53. 2015
Case # 3
Dr. Eftaiha; 2015

54.  The average hospital stay in those patients was 2 weeks
for uncomplicated cases and up to six weeks in patients
who developed postoperative complications and the
perineal wounds healed within 8 to 12 weeks.

55. Incision and Counter-Incision

56. Conclusions
 Fournier’s Gangrene is an uncommon and aggressive
form of massive perineal infection ,which may bring
the patient to death.
 The rate of fascial destruction is very high. So, it
should be diagnosed as early as possible.
 FG is a true surgical emergency but the mortality rate
remains high.
 Minimal debridement with incision and counter-
incision resulted in similar morbidity and shorter
hospital stay than extensive debridement.

57. :
References
1) Sabiston, et al: Fournier’s gangrene, a urologic and surgical emergency: Presentation of a multi
institutional experience with 45 cases. Urol Int. 2011: 167-172.
2) Fournier AJ. Gangrene foudroyante de la verge. Sem Med 1883.
3) Thwaini, et al. Fournier's gangrene and its emergency management. Postgrad Med J. 2006 Aug;
82(970): 516–519.
4) Abcarian H, Eftaiha M. Floating free-standing anus. A complication of massive anorectal infection.
1983. Disease Colon & Rectum. 26(8) 516-521.
5) Chan et al. Abdominal Implantation of Testicles in the Management of Intractable testicular pain
in Fournier’s Gangrene. Surg. 2013. 98(4)
6) Kane C, et al. Ultrasonographic appearance of necrotizing gangrene:
aid in early diagnosis. Urology. 1996.
7) Levenson R, et al. Fournier gangrene: role of imaging. Radiographics. 2008. 28(2):519-28.
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