Precept in diagnosis and effective management of Fournier's gangrene

1. By DR
Moses Cletus G
Moderator ; Dr Hamza B.K
Dept. Of Surgery
Barau Dikko Teaching Hospital Kaduna, Nigeria
2/15/2023 1

2. OUTLINE
 INTRODUCTION
 ANATOMY
 CAUSES
 PREDISPOSING FACTOR
 RISK FACTOR
 PATHOGENESIS
 CLINICAL PRESENTATION
 INVESTIGATION
 TREATMENT
 COMPLICATION
 PROGNOSIS
2/15/2023 2

3. INTRO
 Named after French venerologist
Jean Alfred Fournier in 1883 as a polymicrobial
infection of the genitals
 Fourniers gangrene is a synergistic polymicrobial
necrotizing fasciitis of the perineum and genitalia
 It’s a surgical emergency
2/15/2023 3

4. 2/15/2023 4

5. ANATOMY
 Five fascia plane affected
Colles
Dartos
Busks
Campers and Scarpers
2/15/2023 5

6. 2/15/2023 6

7. 2/15/2023 7

8. Causes
 Urogenital causes
 Anorectal causes
 Iatrogenic causes
 Cutaneous causes
 Retroperitoneal causes
2/15/2023 8

9.  Urogenital causes;
-Urethritis
-urethral calculi
-urethral stricture
-urogenital TB
2/15/2023 9

10.  Anorectal causes;
-perianal abscess
-diverticulitis
-ischemic colitis
-rectal mucosa biopsy
2/15/2023 10

11.  Iatrogenic causes;
-circumcision
-cauterization of warts
non iatrogenic trauma
-animal/insect or human bite
-infected hydrocele
-scrotal
2/15/2023 11

12.  Cutaneuos causes;
-hidradenitis suppurativa
-folliculitis
-scrotal pressure abscess
-post scrotal SSI
2/15/2023 12

13.  Retroperitoneal causes;
-psoas abscess
-perinephric abscess
-inguinal hernia repair
-strangulated richter hernia
2/15/2023 13

14. Predisposing factors
 DM
 Chronic alcoholism
 Malnutrition
 Poor personal hygiene
 Obesity
 Liver cirrhosis
Immunosuppression;HIV/AIDS,organ
transplant,chemotherapy,chronic steroids
 TB
2/15/2023 14

15. Risk Factors
 Circumcision
 Episiotomy
 Urethral fistula
 Hysterectomy
 Hernioplasty
 Paraphimosis
 Septic abortion
 Urethral stricture
2/15/2023 15

16. Most Common causative
organisms
 Anaerobes; Bacteriodes fragilis,C-Perfringens,
peptococcus
 Gram negative; E-coli, klep-pneumo,psedomo,p-
mirabilis
 Gram positive; Staph aures and epidermidis, B-hemol
strep and strep feacalis,
 Mycobacterium TB
 Yeast; C-A
2/15/2023 16

17. Pathogenesis
 The pathogenesis of fourniers is characterized by poly
microbial infection with subsequent vascular
thrombosis and tissue necrosis aggravated by poor
host defence due to one or more systemic disorders
 Aerobic organisms causes intravascular coagulation by
inducing platelet aggregation and complement
fixation while anaerobes produce heparinase
2/15/2023 17

18.  Hypoxic tissue leads to the formation of oxygen free
radicals(HO,H2O2,)
 Leading to cell membrane disruption and decreased
ATP production and DNA damage which leads to
decrease protein production
2/15/2023 18

19.  Anaerobic organisms secrete various enzymes and
toxins-lecithinase,collagenase and hyaluronidase
which digest fascia planes
 They produce insoluble hydrogen and nitrogen
leading to formation of gas in sucutaneuos tissue
clinically palpated as crepitus
2/15/2023 19

20.  Endotoxins are released from cell wall of gram
negatives bacteria
 Macrophages activation and subsequent complement
activation ensues with release of pro-inflammatory
cytokines and eventual development of septic shock
2/15/2023 20

21. Clinical Presentation
 Prodromal; fever and lethargy , 2-7days
 Intense genital pain and tenderness with edema of
overlying skin
 Increasing genital pain with erythema of overlying
skin
 Dusky appearance of overlying skin and subcutaneous
crepitation
 Obvious gangrene +-purulent drainage
2/15/2023 21

22. 2/15/2023 22

23. investigation
 Lab;
fbc+d, clotting profile, eucr, lft, fbs, hiv screening,
serum calcium
 Imaging ; Radiography and ultrasonography
2/15/2023 23

24. Treatment
 Medical;
-Aggressive resuscitation
-Antibiotics broad spectrum
 Surgical
-emergent surgical debridement+- re-debridement
-feacal or urinary diversion
 Reconstruction
2/15/2023 24

25. Reconstruction
-local skin flap coverage
-STSG
-muscular flap to fill a cavity
2/15/2023 25

26. 2/15/2023 26

27. 2/15/2023 27

28. Complication
 Unresolved sepsis/gram negative shock
 ARF, ARDS
 MOF
 Tetanus
 Death
2/15/2023 28

29. Differetial Diagnosis
 Cellulitis
 Scrotal abscess
 Strangulated hernia
 Allergic vasculitis
 Hidradenitis suppurtiva
 Vascular occlusion syndrome
2/15/2023 29

30. Prognosis
 In the pre- antibiotic era, fourniers gangrene was
commonly fatal; even today it poses a significant risk
of morbidity and mortality
 Despite aggressive therapy, the mortality rate ranges
from 25%-40% because of its aggressive nature and
presence of underlying comorbidities
2/15/2023 30

31. Reference
 Badoe 4ed. “ microbial infection” chptr 2 pg 16-18
 Schwarts principle 10th ed. Skin and soft tissue
infection” Chpter 16 pg 471-478
 Fourniers gangrene ppt (slideshare) by Dr B-Yunus
2014
2/15/2023 31

32. 32
THANKS
FOR
YOUR
ATTENTI
ON
2/15/2023