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FOURNIER’S 
GANGRENE 
DR BASHIR YUNUS 
SURGERY RESIDENT 
AKTH 
bbinyunus2002@gmail.com 11/29/2014 1
DEFINITION 
Fournier’s gangrene is a synergistic polymicrobial necrotizing fasciitis of the 
perineum and genitalia. 
bbin...
ANATOMY 
The five fascial 
planes that can be 
affected are: 
Colles’fascia, 
dartos fascia, 
Buck’s fascia, 
Scarpa’s fas...
ANATOMY 
Colles’ fascia is the fascia of the anterior 
triangle of the perineum. 
It prevents the spread of infection in a...
ANATOMY 
• Urogenital causes of Fournier’s gangrene 
lead to initial involvement of the anterior 
triangle, whereas anorec...
bbinyunus2002@gmail.com 11/29/2014 6
bbinyunus2002@gmail.com 11/29/2014 7
CAUSES 
UROGENITAL 
•Urethral stricture 
•Indwelling transurethral catheter 
•Prolonged or neglected use of condom cathete...
CAUSES 
ANORECTAL 
Ischiorectal or perianal or 
intersphincteric abscess 
Rectal mucosal biopsy 
Banding of hemorrhoids 
A...
• Iatrogenic trauma 
• Cauterization of genital warts 
• Circumcision 
• Manipulation of longstanding paraphimosis 
• Noni...
CUTANEOUS 
•Hidradenitis suppurativa 
•Folliculitis 
•Scrotal pressure sore 
•Post-scrotal surgery wound infection 
•Cellu...
RETROPERITONEAL 
CAUSES 
Others 
Inguinal hernia repair 
Filariasis in endemic areas 
Strangulated Richter hernia 
•Psoas ...
PREDISPOSING 
FACTORS 
• Diabetes mellitus 
• Chronic alcoholism 
• Malnutrition 
• Obesity 
• Liver cirrhosis 
• Poor per...
RISK FACTORS 
• Circumcision 
• Episiotomy 
• Extravasations of urine (periurethrally or through 
cutaneous fistula) 
• He...
MOST COMMON 
CAUSATIVE ORGANISMS 
• Gram-negative 
• E. coli 
• Klebsiella pneumoniae 
• Pseudomonas aeruginosa 
• Proteus...
PATHOGENESIS 
• The pathogenesis of Fournier’s gangrene is 
characterized by polymicrobial infection with 
subsequent vasc...
PATHOGENESIS 
• Aerobic organisms cause intravascular coagulation 
by inducing platelet aggregation and complement 
fixati...
PATHOGENESIS 
• Hypoxic tissue leads to the formation of oxygen free 
radicals (superoxide anions, hydrogen peroxide, 
hyd...
PATHOGENESIS 
• Anaerobic organisms secrete various enzymes and 
toxins. Lecithinase, collagenase, and hyaluronidase 
caus...
PATHOGENESIS 
• Endotoxins are released from the cell walls of Gram 
negative bacteria. 
• Macrophage activation and subse...
CLINICAL 
PRESENTATION 
1-Prodromal 
symptoms of 
fever and 
lethargy, 
which may be 
present for 2-7 
days 
2-Intense 
ge...
CLINICAL 
PRESENTATION 
• Fournier’s gangrene shows vast heterogeneity in 
clinical presentation, 
o from insidious onset ...
INVESTIGATION 
Laboratory Studies 
full blood count, clotting profile, urea, creatinine and 
electrolytes, liver function ...
• Imaging Studies 
o Radiography 
o Ultrasonography 
o CT scanning 
o MRI 
bbinyunus2002@gmail.com 11/29/2014 24
TREATMENT 
• Medical 
o Aggressive resuscitation 
o Antibiotics with broad-spectrum coverage 
• Surgical 
o Emergent surgi...
TREATMENT 
• Reconstruction 
o Primary closure of the skin, if possible. 
o Local skin flap coverage. 
o Split-thickness s...
COMPLICATION 
• Unresolved sepsis 
• Unrecognized cause of the infection 
o (perforated peptic ulcer disease, appendicitis...
DIFFERENTIAL 
DIAGNOSIS 
• Cellulitis 
• Strangulated hernia 
• Scrotal abscess 
• Streptococcal necrotising fascitis 
• V...
PROGNOSIS 
• In the pre-antibiotic era, Fournier’s gangrene was 
commonly fatal; even today, it poses a significant 
risk ...
PROGNOSIS 
• Delays in diagnosis or treatment increase the mortality 
rate. 
o A 24-hour delay in radical debridement incr...
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UROLOGIC EMERGENCY, NACROTISING INFECTION OF THE MALE EXTERNAL GENITALIA

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FOURNIER'S GANGRENE

  1. 1. FOURNIER’S GANGRENE DR BASHIR YUNUS SURGERY RESIDENT AKTH bbinyunus2002@gmail.com 11/29/2014 1
  2. 2. DEFINITION Fournier’s gangrene is a synergistic polymicrobial necrotizing fasciitis of the perineum and genitalia. bbinyunus2002@gmail.com 11/29/2014 2
  3. 3. ANATOMY The five fascial planes that can be affected are: Colles’fascia, dartos fascia, Buck’s fascia, Scarpa’s fascia, and Camper’s fascia. bbinyunus2002@gmail.com 11/29/2014 3
  4. 4. ANATOMY Colles’ fascia is the fascia of the anterior triangle of the perineum. It prevents the spread of infection in a posterior or lateral direction, but provides no resistance to spread in an anterosuperior direction towards the abdominal wall. Posterior spread to the anal region will be limited by the termination of Colles’ fascia in the posterior edge of the perineal membrane Dartos fascia is the continuation of Colles’ fascia over the scrotum and penis. Buck’s fascia lies deep to the dartos fascia, covering the penile corpora. Camper’s fascia is the loose areolar fascial layer deep to the skin of the abdominal wall, but superficial to Scarpa’s fascia. Together with Scarpa’s fascia it is continuous with Colles’ fascia inferomedially. bbinyunus2002@gmail.com 11/29/2014 4
  5. 5. ANATOMY • Urogenital causes of Fournier’s gangrene lead to initial involvement of the anterior triangle, whereas anorectal causes primarily involve the posterior triangle. • Blood supply to the testis, bladder, and rectum originates directly from the aorta and not from the perineal vasculature, and for this reason they are rarely affected in Fournier’s gangrene. bbinyunus2002@gmail.com 11/29/2014 5
  6. 6. bbinyunus2002@gmail.com 11/29/2014 6
  7. 7. bbinyunus2002@gmail.com 11/29/2014 7
  8. 8. CAUSES UROGENITAL •Urethral stricture •Indwelling transurethral catheter •Prolonged or neglected use of condom catheter •Urethral calculi •Urethritis •Transurethral surgery •Infection of periurethral glands and paraurethral abscess •Urogenital tuberculosis •Urethral cancer •Prostate biopsy •Prostatic massage •Prostate abscess •Insertion of penile prosthesis •Constriction ring device for management of ED bbinyunus2002@gmail.com 11/29/2014 8
  9. 9. CAUSES ANORECTAL Ischiorectal or perianal or intersphincteric abscess Rectal mucosal biopsy Banding of hemorrhoids Anal dilatation Cancer of sigmoid or rectum Diverticulitis Rectal perforation by foreign body Ischemic colitis Anal stenosis bbinyunus2002@gmail.com 11/29/2014 9
  10. 10. • Iatrogenic trauma • Cauterization of genital warts • Circumcision • Manipulation of longstanding paraphimosis • Noniatrogenic trauma • Animal, insect, or human bite • Scrotal abscess • Infected hydrocele • Hydrocelectomy • Vasectomy • Balanitis • Phimosis bbinyunus2002@gmail.com 11/29/2014 10
  11. 11. CUTANEOUS •Hidradenitis suppurativa •Folliculitis •Scrotal pressure sore •Post-scrotal surgery wound infection •Cellulitis of scrotum •Pyoderma gangrenosum •Femoral access for intravenous drug users bbinyunus2002@gmail.com 11/29/2014 11
  12. 12. RETROPERITONEAL CAUSES Others Inguinal hernia repair Filariasis in endemic areas Strangulated Richter hernia •Psoas abscess •Perinephric abscess •Appendicitis and appendix abscess •Pancreatitis with retroperitoneal fat necrosis bbinyunus2002@gmail.com 11/29/2014 12
  13. 13. PREDISPOSING FACTORS • Diabetes mellitus • Chronic alcoholism • Malnutrition • Obesity • Liver cirrhosis • Poor personal hygiene • Immunosuppression: • Chronic steroid use • Organ transplantation • Chemotherapy for malignancy • HIV/AIDS • Tuberculosis • Syphilis bbinyunus2002@gmail.com 11/29/2014 13
  14. 14. RISK FACTORS • Circumcision • Episiotomy • Extravasations of urine (periurethrally or through cutaneous fistula) • Hernioplasty • Hysterectomy • Local trauma or instrumentation to the perineum • Paraphimosis • Septic abortion • Urethral stricture caused by sexually transmitted diseases bbinyunus2002@gmail.com 11/29/2014 14
  15. 15. MOST COMMON CAUSATIVE ORGANISMS • Gram-negative • E. coli • Klebsiella pneumoniae • Pseudomonas aeruginosa • Proteus mirabilis • Enterobacteria • Gram-positive • Staphylococcus aureus • Beta-hemolytic streptococci • Streptococcus faecalis • Staphylococcus epidermidis • Anaerobes • Bacteroides fragilis • Peptococcus • Fusobacterium • Clostridium perfringens • Mycobacteria • Mycobacterium tuberculosis • Yeasts • Candida albicans bbinyunus2002@gmail.com 11/29/2014 15
  16. 16. PATHOGENESIS • The pathogenesis of Fournier’s gangrene is characterized by polymicrobial infection with subsequent vascular thrombosis and tissue necrosis, aggravated by poor host defense due to one or more underlying systemic disorders. bbinyunus2002@gmail.com 11/29/2014 16
  17. 17. PATHOGENESIS • Aerobic organisms cause intravascular coagulation by inducing platelet aggregation and complement fixation, while anaerobes produce heparinase. bbinyunus2002@gmail.com 11/29/2014 17
  18. 18. PATHOGENESIS • Hypoxic tissue leads to the formation of oxygen free radicals (superoxide anions, hydrogen peroxide, hydroxyl radicals) • This lead to cell membrane disruption, decreased ATP production, and DNA damage, which leads to decreased protein production bbinyunus2002@gmail.com 11/29/2014 18
  19. 19. PATHOGENESIS • Anaerobic organisms secrete various enzymes and toxins. Lecithinase, collagenase, and hyaluronidase cause digestion of the fascial planes. • They produce insoluble hydrogen and nitrogen, leading to the formation of gas in the subcutaneous tissues, clinically palpable as crepitus. bbinyunus2002@gmail.com 11/29/2014 19
  20. 20. PATHOGENESIS • Endotoxins are released from the cell walls of Gram negative bacteria. • Macrophage activation and subsequent complement activation ensues with release of pro-inflammatory cytokines and eventual development of septic shock bbinyunus2002@gmail.com 11/29/2014 20
  21. 21. CLINICAL PRESENTATION 1-Prodromal symptoms of fever and lethargy, which may be present for 2-7 days 2-Intense genital pain and tenderness that is usually associated with edema of the overlying skin 3-Increasing genital pain and tenderness with progressive erythema of the overlying skin. 4-Dusky appearance of the overlying skin; subcutaneous crepitation 5-Obvious gangrene of a portion of the genitalia; purulent drainage from wounds bbinyunus2002@gmail.com 11/29/2014 21
  22. 22. CLINICAL PRESENTATION • Fournier’s gangrene shows vast heterogeneity in clinical presentation, o from insidious onset and slow progression to o rapid onset and fulminant course, • the latter being the more common presentation. • the • disease tends to present more in elderly men(6-7th decade) and also has been reported in women and children bbinyunus2002@gmail.com 11/29/2014 22
  23. 23. INVESTIGATION Laboratory Studies full blood count, clotting profile, urea, creatinine and electrolytes, liver function tests, blood glucose, blood gases, group and screen, HIV and VDRL. Abnormal findings include anemia, thrombocytopenia, coagulopathy, hyponatremia, and raised urea and creatinine. Hypocalcaemia may occur in some cases, subsequent to the chelation of ionized calcium by triglycerides liberated by bacterial lipases. bbinyunus2002@gmail.com 11/29/2014 23
  24. 24. • Imaging Studies o Radiography o Ultrasonography o CT scanning o MRI bbinyunus2002@gmail.com 11/29/2014 24
  25. 25. TREATMENT • Medical o Aggressive resuscitation o Antibiotics with broad-spectrum coverage • Surgical o Emergent surgical excision of all necrotic tissue o The skin should be wide opened o Re-debridement o Fecal diversion o Urinary diversion o Orchiectomy? bbinyunus2002@gmail.com 11/29/2014 25
  26. 26. TREATMENT • Reconstruction o Primary closure of the skin, if possible. o Local skin flap coverage. o Split-thickness skin grafts. o Muscular flaps, which are used to fill a cavity. bbinyunus2002@gmail.com 11/29/2014 26
  27. 27. COMPLICATION • Unresolved sepsis • Unrecognized cause of the infection o (perforated peptic ulcer disease, appendicitis, diverticulitis) or extension of the necrotizing process outside the obvious wound. • Complication of severe acute illness. o (bacterial endocarditis, pneumonia) • The plethora of comorbid conditions. o (acute myocardial infarction, respiratory failure, pressure ulcerations, delirium) or the bed-rest conditions imposed on patients who are acutely ill (pulmonary embolus, deep venous thrombosis, atelectasis, pneumonia) bbinyunus2002@gmail.com 11/29/2014 27
  28. 28. DIFFERENTIAL DIAGNOSIS • Cellulitis • Strangulated hernia • Scrotal abscess • Streptococcal necrotising fascitis • Vascular occlusion syndromes • Herpes simplex • Gonococcal balanitis and oedema • Pyoderma gangrenousm • Allergic vasculitis • Polyarteritis nodosa • Necrolytic migratory erythema • Warfarin necrosis • Ecthyma gangrenosum bbinyunus2002@gmail.com 11/29/2014 28
  29. 29. PROGNOSIS • In the pre-antibiotic era, Fournier’s gangrene was commonly fatal; even today, it poses a significant risk of morbidity and mortality. • Despite aggressive therapy, the mortality rate for patients with Fournier’s gangrene is nearly 50% because of the aggressive nature of the infection and the presence of underlying comorbidities. bbinyunus2002@gmail.com 11/29/2014 29
  30. 30. PROGNOSIS • Delays in diagnosis or treatment increase the mortality rate. o A 24-hour delay in radical debridement increases the mortality rate by 11.5%; o A 6-day delay is associated with a mortality rate of 76%. • Additional factors associated with high mortality include: o Anorectal origin o Advanced age. o Extensive disease o Shock o Sepsis at presentation, o Renal failure o Hepatic dysfunction. • Multiorgan system failure secondary to gram-negative sepsis is the most common cause of death bbinyunus2002@gmail.com 11/29/2014 30
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UROLOGIC EMERGENCY, NACROTISING INFECTION OF THE MALE EXTERNAL GENITALIA

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