Larva Terapia.com.ecDr. C.A. Vincent M.D.INTERNISTAManuel Galecio 1208 y Av. del Ejército (Centro Guayaquil)Bálsamos #629 e/ Ficus y Las Monjas (Urdesa)Telf.: 2280008 / 2320936 Cel.: 0981137366 / 097226405Guayas - Ecuador
Necrotizing Gangrene of the Genitalia and Perineumfrom Infections in Urology ®Maxwell V. Meng, MD, Jack W. McAninch, MD, University of California School of Medicine, SanFrancisco.Abstract and IntroductionAbstractNecrotizing gangrene of the genitalia and perineum is a fulminant, life-threatening infection. The infectionmay spread along subcutaneous planes and result in tissue necrosis. Infections are usuallypolymicrobial. The organisms most commonly isolated from wound cultures include Bacteroides,coliforms, Streptococcus, Staphylococcus, and Peptostreptococcus.Anorectal infections, genitourinary infections, and cutaneous injuries are the most frequent sources ofinfection in necrotizing genital gangrene. Despite increased experience in treating this condition, patientssuffer significant morbidity and mortality. Early diagnosis and complete debridement of all necrotic tissueare essential for improved outcomes.IntroductionNecrotizing soft-tissue infections of the genitalia and perineum present diagnostic and therapeuticchallenges. Although uncommon, these infections can progress rapidly and cause significant morbidityand mortality. Therefore, they must be promptly diagnosed and aggressively treated to achieve anoptimal outcome.The first reported case of such an infection was by Baurienne in 1764. In 1883, the French venereologistFournier described a syndrome of abrupt, idiopathic onset of genital gangrene in 5 young, previouslyhealthy men. Although the condition currently is recognized to afflict an older population of both gendersand has identifiable risk factors, "Fourniers gangrene" still constitutes a urologic emergency. Because ofa greater understanding of the etiology and pathogenesis of this disorder, improved therapy has resultedin improved outcomes.EtiologyFournier was unable to identify the cause of infection in his patients, but the etiology can be discerned inmost cases today (Table). Anorectal infections, genitourinary infections, and cutaneous injuries are themost frequent sources of infection in necrotizing genital gangrene.Among gastrointestinal causes (30% to 50%), ischiorectal, perianal, and intrasphincteric abscessesaccount for approximately 70%. Nec-rotizing gangrene has also been reported to be secondary to minoranorectal procedures such as rectal mucosal biopsy, anal dilation, and hemorrhoidectomy as well asappendicitis, colorectal malignancy, and diverticulitis.[5-7]Genitourinary foci comprise the second major source of initial infection (20% to 40%); underlying urethralstricture and periurethral infection are most common. Urologic conditions also associated includeurethral trauma and instrumentation, indwelling urethral catheters, urethral calculi, epididymitis, prostatebiopsy and massage, and bladder cancer extension.[8-10]Cutaneous injuries and infection account for 20% of cases. Often the dermal source is minor, such ashuman and insect bites. Other reported etiologies involving trauma to the superficial soft tissues includevasectomy, circumcision, genital infections (balanoposthitis), and penile prosthesis insertion.[8,11]
Necrotizing gangrene is less common in women. In 1 literature review of 449 cases, 14% involvedwomen. Typically, abscesses of the vulva or Bartholins glands initiate the gangrene of the perineum.Episiotomy, septic abortion, pudendal nerve block, and coital injury are recognized factors in femalenecrotizing soft-tissue infections.[12,13]Additional host factors affect the development of necrotizing gangrene. Increased prevalence ofcomorbidities such as diabetes (30% to 60%) and alcoholism (40% to 50%) have been reported.[9,14] It ispostulated that susceptibility to infection from decreased defense mechanisms and impaired activeimmune response contribute to the increased incidence. Malnutrition, AIDS, malignancy, renal failure, andimmunosuppressive chemotherapy are other risk factors.[3,15,16] However, outcomes have not correlatedwith presence or absence of the comorbid states.[9,14]AnatomyThe patterns of spread in genital and perineal necrotizing soft-tissue infection can be explained by thefascial anatomy of the perineum, external genitalia, and abdominal wall. The superficial perineal fascia(Colles fascia) is attached laterally to the pubic rami and fascia lata of the thighs, and posteriorly to theurogenital diaphragm and perineal membrane. The anterior extensions of Colles fascia include the tunicadartos of the penis and scrotum and Scarpas fascia of the anterior abdominal wall. Bucks fascia of thepenis, deep to the tunica dartos, is bound by adherence to the tunica albuginea distally at the coronalsulcus of the glans and proximally at the crus and suspensory ligament of the penis.Infections originating in the ano-rectal region first penetrate the sphincteric musculature. Then, theinfection spreads along the perianal region and may extend along Colles fascia. While lateral spread isprevented by attachments of Colles fascia, anterior and superior extension along dartos and Scarpasfasciae is unhindered. Alternatively, anorectal infection may spread through the urogenital diaphragm tothe perivesical space, then to the scrotum via the spermatic fascia.Urethral infections are initially limited by Bucks fascia, surrounding the corpora spongiosum andcavernosa. Once Bucks fascia is traversed, the infection spreads along the overlying tunica dartos andthe contiguous layers of Scarpa and Colles. In general, necrotizing gangrene of urethral origin does notspread to the anal triangle, because Colles fascia is attached to the peri-neal membrane posteriorly;however, if Colles fascia or the urogenital diaphragm is violated, the infection can involve the ischiorectaland perivesical spaces.Clinical FeaturesMost cases of necrotizing gangrene, regardless of location, begin insidiously. Patients initially complain ofscrotal discomfort and associated malaise. As the infection worsens, fever and chills develop with genitalskin changes. Scrotal swelling is usually present with erythema and increased pain (Fig. 1). However, theskin can appear relatively normal, which may account for the delay in presentation after the onset ofsymptoms, usually averaging 5 days. In addition, the pain may subside as pressure necrosis and infectionof cutaneous nerves take place. Signs and symptoms frequently found at presentation include pain(100%), swelling (80% to 100%), fever (60% to 80%), and crepitus (60% to 70%).[7,9,14,27] Systemicmanifestations, such as overt shock and altered mental status, do not often correlate with the physicalfindings and must be recognized early. (click image to zoom) Figure 1. Preoperative photograph of patient with ne gangrene of perineum demonstrating scrotal edema with minimal skin changes.Careful history can elucidate the etiology. Symptoms of urgency, frequency, decreased force of stream,and a history of perineal trauma, instrumentation, or urethral stricture point to a urologic diagnosis.Because of the increased frequency of gastrointestinal foci, a history of rectal pain and bleeding,hemorrhoids, and anal fissures can often be elicited. Acute and chronic skin infection of the scrotum orpenis or a history of injection suggest a dermal source. Together with the risk factors discussed above,the presence of these signs, symptoms, and histories should raise a suspicion of necrotizing soft-tissueinfections.
Often nonspecific, abnormal laboratory values are present as the consequence of sepsis. Leukocytosis>15,000/µL is found at presentation in more than 80% of patients. Anemia frequently develops secondaryto decreased production of RBCs and thrombosis. Hyponatremia, hyperglycemia, hypocalcemia, elevatedcreatinine, coagulopathy, and hypoalbuminemia can be present initially and may provide diagnostic cluesto early necrotizing soft-tissue infections.[9,14,28,29]Due to the nonspecific symptoms, its indolent course, and often unremarkable cutaneous appearance,necrotizing gangrene of the perineum may be confused with other scrotal and intrascrotal pathology suchas scrotal cellulitis or balanoposthitis. More serious conditions that mimic Fourniers gangrene includescrotal abscesses or incarcerated hernia. Finally, scrotal or penile gangrene may be primarily due tovessel occlusion from vasculitis, rather than infection. These conditions include IgE-positivehypersensitivity vasculitis, poly-arteritis nodosa, and pyoderma gangrenosum.[30,31] It is important todistinguish these conditions from Fourniers, because appropriate treatment in these patients may includecorticosteroids and local wound care, not radical excision.ImagingNecrotizing gangrene of the genitalia and perineum is primarily a clinical diagnosis. Nevertheless,imaging modalities that have demonstrated utility in confirming the disease, evaluating extent, anddetermining the etiology include radiography, ultrasonography, and computed tomography (CT).Plain radiographs of the abdomen and pelvis can demonstrate subcutaneous air before crepitus ispalpable (Fig. 2). In addition, plain films may aid in defining an intra-abdominal source of the infection.[33,34]One retrospective review reported that plain films were more sensitive in detecting soft-tissue gas thanphysical examination; gas was visualized in all diabetics with necrotizing gangrene. However, theabsence of subcutaneous air in the perineum or scrotum should not exclude the diagnosis. (click image to zoom) Figure 2. Plain radiograph of pelvis at presentation, demo air within soft tissues.Ultrasonography has also proven useful in cases of necrotizing infections.[35,36] Gas can be detected evenwhen not clinically evident, and the ultrasonographic appearance is striking -- the air appears as discrete,bright, hyperechoic areas with posterior acoustic shadowing (Fig. 3). Ultrasound can examine thescrotum, testes and epididymides, perirectal area, and abdomen, helping to differentiate necrotizinginfections from other causes of scrotal pain. Typically, the testes and intrascrotal structures are normal insize and architecture within a thickened scrotal wall. (click image to zoom) Figure 3. Ultrasound of scrotum, demonstrating char hyperechoic appearance of subcutaneous gas.CT of the abdomen and pelvis has not been well studied in necrotizing infections; however, it appears tohave potential. One study described characteristic CT findings in necrotizing fasciitis associated withgangrene of the perineum. The soft tissues are thickened with surrounding fat stranding and gasdissecting along fascial planes. Delineation of gas margins and identification of infected fluid collectionsby CT can suggest the extent of the gangrene. In addition, CT provides excellent anatomic detail of peri-neal, pelvic, and retroperitoneal structures and may diagnose the initial source of infection. MRI providesthe same advantages as CT with improved soft-tissue resolution and multiplanar images.TreatmentNecrotizing infection of the genitalia and perineum is a surgical disease where medical therapy has alimited role. After diagnosis, initial management is aimed at preparation for surgery. Because sepsis maybe present, hemodynamic stabilization via aggressive fluid resuscitation is necessary. In addition,transfusion of blood products may be required to correct anemia and coagulopathy. Need for invasivemonitoring and ventilatory support should be addressed and promptly administered.
Empiric, broad-spectrum antibiotic therapy should be instituted. Typical regimens include penicillin forstreptococci, clostridia, and certain anaerobes, gentamicin for gram-negative rods, and clindamycin forbacteroides and other anaerobes. More recently, semisynthetic penicillins and third-generationcephalosporins have emerged as alternatives to aminoglycosides.Surgical debridement should not be delayed by uncertainty in diagnosis or radiologic studies.Examination under anesthesia and exploration can be performed easily if any doubt exists. One studyreported the utility of intraoperative frozen section in confirming the early diagnosis of necrotizinggangrene. These biopsies, although rarely required, also can demonstrate evidence of the vascularimmune disorders that can be misdiagnosed as necrotizing infections.Operative management consists of radical debridement of all areas with overt necrosis. Recent reportsindicate that incision and drainage are insufficient.[21,40] We have found outcomes to be correlated withadequacy of initial debridement. Mortality was 100% in 4 patients treated with incision and drainage, butonly 8% in 12 patients undergoing complete debridement. Intraoperative findings include edema,liquefactive necrosis of the subcutaneous tissues, and watery pus.Skin changes greatly underestimate the severity of the underlying tissue damage. Thus, extensiveunroofing of the involved areas is needed (Fig. 4). If the fascia separates easily from the skin andsubcutaneous tissues above, necrosis is generally present and debridement is continued. Deep fasciaand muscle are seldom involved. The challenge is to determine tissue viability and the extent ofnecessary debridement, maintaining a balance between inadequate excision and preservation ofthreatened but nonischemic tissue. Drains can be placed in areas of questionable viability to prevent fluidcollections and early skin closure. (click image to zoom) Figure 4. Intraoperative photograph after debridement of al tissue, with extensive skin loss but preservation of testes.Even after satisfactory initial debridement, subsequent procedures are likely to be necessary; reportshave documented a mean of 2 to 4 procedures per patient.[9,29,41] Reexamination of the wound in theoperating room is helpful to completely evaluate wound progress, comfortably change extensivedressings, and determine need for further debridement. If the patient does not improve clinically afterinitial surgery, with resolving fever and leukocytosis, then inadequate debridement should be suspected.Diversion, either fecal or urinary, is occasionally required. Controversy exists regarding the need forcolostomy. While some advocate diverting colostomy in most cases of perineal necrotizing gangrene,others believe this to be unnecessary, even with significant gangrene of perirectal tissues. Generally,colostomy is indicated if the sphincter is grossly infected, rectal or colonic perforation has occurred,incontinence is present, or if the rectal wound is large.[42,43]Criteria for urinary drainage are likewise unclear. Many patients are safely managed with an indwellingcatheter, although some recommend routine suprapubic diversion in all patients. Indications for supra-pubic catheterizations include stricture disease and urinary extravasation or phlegmon. Intraoperativecystourethroscopy and retrograde urethrography can be performed to evaluate urethral integrity.Despite extensive tissue involvement and radical debridement, the testicles are routinely spared. This ispresumed to be due to the copious and independent blood supply. Orchiectomy is performed whenconditions such as scrotal abscesses or severe epididymo-orchitis affect testicular viability. Coverage ofthe testes is important to prevent dessication. Initially, moist dressings and gauze impregnated withpetroleum jelly provide sufficient protection. Delayed closure of the scrotum is often an option because ofthe redundant nature of scrotal skin. If this is not possible, the testes can be placed in temporarysubcutaneous pouches of the medial thighs or lower abdominal wall for later scrotal reconstruction.[9,44]The large defects in the scrotum, perineum, and abdominal wall after debridement often necessitate laterreconstruction. We have a significant experience in treatment of genital skin defects and have foundexcellent results using skin grafts.[9,44,45] Once the patient has improved and local wound healing is
complete, reconstruction can be considered. The testes are covered with meshed, split-thickness skingrafts, creating a neoscrotum, and the penile shaft is covered with unmeshed split-thickness skin grafts(Fig. 5). Alternative methods of skin coverage include rotational or free myocutaneous flaps and omentalflaps.(click image to zoom)Figure 5. (A) Appearance of genitalia after reconstruction of scrotum withsplit-thickness skin graft. (B) The penis has been covered with unmeshed, split-thickness skin graOther issues in treating patients with perineal necrotizing gangrene include nutritional support and thepotential utility of hyperbaric oxygen and topical agents. Calorie balance is important in critically illpatients with large open wounds and preexisting malnutrition. Enteral or parenteral supplementation whenthe patient has insufficient intake, prolonged intubation, or compromised gastrointestinal function isbeneficial.Because of the importance of anaerobic organisms in necrotizing infections, hyperbaric oxygen has beenproposed as an adjunctive therapy.[46,47] Although experimental studies have demonstrated increasedleukocyte phagocytic function, fibroblast proliferation, and decreased endotoxin with the use of hyperbaricoxygen, the clinical evidence supporting its utility is inconclusive. Routine wound care, consisting of salineor Dakins soaked dressings, is important after debridement. However, some investigators have proposedthe use of unprocessed honey not only as part of postoperative wound care, but as initial, definitivetherapy.[48,49] The studies, although encouraging, involve small numbers of patients and do not providesufficient evidence to pursue nonoperative management of necrotizing infections.OutcomesReported mortality rates from genital and perineal necrotizing soft-tissue infections range from 0% to80%.[3,7] In 2 series with 57 and 29 patients, mortality was 18% and 21%, respectively.[8,9] One review of449 cases (1979-1988) reported overall mortality of 22%. Patients were typically hospitalized 40 days.Determinants of outcome have not been clearly defined. In numerous studies, factors such as age,source of infection, delay in diagnosis, comorbidities, and extent of infection and debridement are notconsistently associated with prognosis. It is clear, however, that delay in adequate surgical interventionleads to increased mortality. An objective index has been developed in order to quantify "deviations fromhomeostasis," the parameter that best predicts outcome. Variables in the classification system includesigns of sepsis (temperature, heart rate, respiratory rate) and laboratory values (sodium, potassium,creatinine, hematocrit, WBC count, bicarbonate).Morbidity from necrotizing infections is significant. Early complications include sepsis, respiratory andrenal failure, and coagulopathy; delayed complications that have been reported include fistulae, infertility,and urethral strictures.[9,14]SummaryNecrotizing soft-tissue infections of the genitalia and perineum represent a diverse collection of rapidlyprogressive, potentially lethal diseases. Patients at risk include those with increased susceptibility toinfections from gastrointestinal, genitourinary, and cutaneous sources. The clinical picture is not alwaysclear; therefore, a high index of suspicion must be maintained in order to make an early diagnosis.Radiologic clues may provide additional information. Prompt surgical excision of necrotic tissue, alongwith broad-spectrum antibiotics and aggressive supportive care, is paramount to improved survival.Despite advances in understanding the disease, imaging techniques, and modern medicine, necrotizinggangrene of the genitalia and perineum carries significant morbidity and mortality.Teamwork Is the Key
This is an excellent review of a disease entity that continues to perplex and frustrate managingphysicians. Aggressive teamwork is the key to the successful treatment of these patients with complexproblems. The use of a multidisciplinary approach using the expertise of the urologist, the reconstructivesurgeon, and either a general surgeon or colon/rectal surgeon as an operative team is critical to thesuccessful management. Furthermore, general support through nutrition, intensive care, hyperbaricoxygen, and infectious disease specialists have all helped lower the mortality rate. The cosmeticappearance of most of these men is dramatically better today through some of the reconstructivetechniques currently used.S. Lee Guice III, MDDepartment of UrologyNalle ClinicCharlotte, N.C.
Case ReportFungal Fournier Gangrenefrom Infections in Urology®Posted 08/12/2003Scott Rutchik, MD, Melinda Sanders, MDAbstract and IntroductionAbstractA diagnosis of Fournier gangrene always calls for prompt medical and often surgical action. The additionof a fungal infection can only enhance the possibility of increased morbidity. Treatment options forpatients with this rare combination are discussed.IntroductionFournier gangrene, a necrotizing fasciitis that originates in the perineum, represents one of the few trueemergencies in urology practice. Typically, the infection involves anaerobic bacteria. Fungal infection,however, has only been implicated in a single case report in the medical literature. We describe hereperhaps only the second case of Fournier gangrene with a fungal organism.Fungal Fournier Gangrenefrom Infections in Urology®Case ReportA 74-year-old man presented to the urology clinic with a 10-day history of fever accompanied by scrotalswelling and pain. He had been undergoing treatment from his primary care physician with an oralfluoroquinolone for presumed epididymo-orchitis. His medical history was significant for poorly controlleddiabetes and severe peripheral vascular disease that had necessitated bilateral above-knee amputations.Physical examination revealed a hemodynamically stable patient with a tender discolored scrotum andswelling extending into the suprapubic area with palpable crepitus throughout. A clinical diagnosis ofFournier gangrene was made, and emergent debridement was undertaken.The initial incision into the scrotum yielded watery pus with a fungal odor. Approximately 350 mL of puswas aspirated from the wound. Extensive debridement of the scrotum and base of the penis wasperformed, exposing necrosis of the scrotum that tracked into the inguinal and suprapubic area. The righttesticle was absent; the left testicle did not appear to be grossly infected and was spared. The skin overthe suprapubic area appeared viable and was not excised.A suprapubic tube was placed, and the wound was packed with a sterile dressing. Gram stain of thewound fluid demonstrated yeast, and intravenous therapy with a third-generation cephalosporin andfluconazole was begun pending results of final wound cultures. A second debridement procedure wasperformed 48 hours later.Aerobic and anaerobic cultures of material obtained from the primary debridement demonstrated onlyCandida albicans; blood cultures were negative. Pathologic examination of the debrided tissue showedacute suppurative inflammation (Figure). Daily whirlpool therapy was initiated, as were wet-to-drydressing changes. The patient was discharged from the hospital on postoperative day 4, witharrangements made for outpatient wound care.
Figure. (click image to zoom) Photomicrograph demonstrates an area of intact striking underlying edema and inflammation (hematoxylin-eosin, ×200). (Photogra Walz.)DiscussionFournier gangrene is somewhat of a misnomer for this disease, because true myonecrosis is uncommon.Nonetheless, this does not detract from the seriousness of the illness, because the infection tends tofollow the distribution of Scarpa fascia, thereby allowing for extension as far cephalad as the clavicles andas far caudad as the fascia lata. Although the disease was classically described in patients withperiurethral abscess, more contemporary presentations occur in the diabetic or immunocompromisedhost.[2,3]Modern interventions have greatly improved the prognosis for patients with Fournier gangrene, but thedisease still is capable of producing grave morbidity, because large areas of tissue debridement may berequired for disease control. Dahm and associates reported a 20% mortality rate in their contemporarycase series, with depth of invasion, extent of infection, and treatment with hyperbaric oxygen observed asthe most important prognostic variables. It should be noted, however, that the use of hyperbaric oxygen isa controversial treatment for patients with Fournier gangrene, although it may be a useful adjunct todebridement and antibiotic therapy in severe circumstances.The extensive tissue infarction and destruction seen in Fournier gangrene is usually the result ofanaerobic bacterial infection. In many cases, this infection may begin as a primary infection with lessvirulent organisms, with anaerobic infection occurring as a secondary phenomenon. Thus, initial antibiotictherapy should consist of broad-spectrum coverage that includes agents active against anaerobes.Because of the rarity of fungal infection in this scenario, antifungal agents are probably not required inmost cases.Because our patients solitary testicle appeared viable at surgery, we believe that the most likely scenarioto explain his clinical course was a misdiagnosed scrotal abscess that was managed with a broad-spectrum antibiotic, resulting in selection for yeast. Thus, we cannot rule out the possibility that a bacterialinfection had been the initial inciting event. Nevertheless, in this patient, fungal sepsis did not develop,and he did not require extensive hospitalization, perhaps emphasizing the importance of early recognitionand intervention in the management of all types of Fournier gangrene.