Fournier gangrene

1. FOURNIER GANGRENE
Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai
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2. Moderators:
Professors:
• Prof. Dr. G. Sivasankar, M.S., M.Ch.,
• Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
• Dr. J. Sivabalan, M.S., M.Ch.,
• Dr. R. Bhargavi, M.S., M.Ch.,
• Dr. S. Raju, M.S., M.Ch.,
• Dr. K. Muthurathinam, M.S., M.Ch.,
• Dr. D. Tamilselvan, M.S., M.Ch.,
• Dr. K. Senthilkumar, M.S., M.Ch.
Dept of Urology, GRH and KMC, Chennai. 2

3. • Named after French venereologist Jean
Alfred Fournier (1883).
• Fournier gangrene is defined as a
polymicrobial necrotizing fasciitis of the
perineal, perianal, or genital areas.
3
Dept of Urology, GRH and KMC, Chennai.

4. Risk factors
• Diabetes mellitus
• Alcoholism
• Malignancies
• Cirrhosis Liver
• Chronic steroid use
• HIV infection
• Malnutrition
• Morbid Obesity
4
Dept of Urology, GRH and KMC, Chennai.

5. • 80% have a history of previous
trauma/infection
• over 60% commence in the lower extremities
5
Dept of Urology, GRH and KMC, Chennai.

6. Clinical features
• Begins with insidious onset of pruritus and discomfort of external
genitalia
• Prodromal symptoms of fever and lethargy, which may be present
for 2-7 days before gangrene
• The hallmark of Fournier gangrene is out of proportion pain and
tenderness in the genitalia.
• Increasing genital pain and tenderness with progressive erythema
of the overlying skin
• Dusky appearance of the overlying skin; subcutaneous crepitation;
feculent odor
• Obvious gangrene of a portion of the genitalia; purulent discharge
from wounds
• As gangrene develops, pain subsides (Nerve necrosis)
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Dept of Urology, GRH and KMC, Chennai.

7. clinical signs
• Oedema stretching skin
• Erythema
• a woody-hard texture to the subcutaneous
tissues
• inability to distinguish fascial planes and muscle
groups on palpation
• disproportionate pain in relation to the affected
area,
• skin vesicles
• soft- tissue crepitus
7
Dept of Urology, GRH and KMC, Chennai.

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Dept of Urology, GRH and KMC, Chennai.

9. Causes
1. Ano-rectal causes –
• infection in the perineal glands
• Colorectal injury,
• Malignancy or diverticulitis
2. Uro-genital causes –
• Infection in the bulbourethral glands
• Urethral injury
• Iatrogenic injury
• Lower urinary tract infections
9
Dept of Urology, GRH and KMC, Chennai.

10. 3. Dermatologic causes –
• Hidradenitis suppurativa
• 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
10
Dept of Urology, GRH and KMC, Chennai.

11. Causative Bacteria
• Polymicrobial infection
• streptococcal species (Group A β-
haemolytic) in combination with
Staphylococcus, Esch erichia coli,
Pseudomonas, Proteus, Clostridia.
• Most common anaerobes – Bacteroids
11
Dept of Urology, GRH and KMC, Chennai.

12. • Incidence
• Age – 30 – 60 years
• Sex – 10 times more common in males
• Social habits – More common in male
homosexuals (more prone for Rectal injury)
12
Dept of Urology, GRH and KMC, Chennai.

13. Pathognomonic findings
• Necrosis of superficial & deep fascial planes
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Dept of Urology, GRH and KMC, Chennai.

14. Polymorphonuclear cell infiltration
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Dept of Urology, GRH and KMC, Chennai.

15. Presence of micro organisms
Fibrinoid coagulation of the nutrient arterioles
15
Dept of Urology, GRH and KMC, Chennai.

16. Investigations
• Conventional radiography
• Presence of gas in soft tissue
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Dept of Urology, GRH and KMC, Chennai.

17. Ultrasonography
• Can be used to detect fluid or gas in soft
tissue
• “Sonographic hallmark” – Presence of gas in
scrotal
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Dept of Urology, GRH and KMC, Chennai.

18. C.T. Scanning
• Can detect smaller amount of soft tissue gas
• Defines extent more specifically
• Identifies underlying causes eg.
• Small perineal abscess
MRI
• Yields greater soft tissue details
• especially in critically ill patients
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Dept of Urology, GRH and KMC, Chennai.

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Dept of Urology, GRH and KMC, Chennai.

20. Medical Treatment
• 1. Restoration of normal organ perfusion
• 2. Reduction of systemic toxicity
• 3. Broad spectrum antibiotics to cover anaerobes as well
• (cipro+clinda+metro)
• 4. Vancomycin for MRSA
• 5. Tetanus prophylaxis
• 6. Irrigation with super oxidised water
• 7. Hyperbaric oxygen therapy
• 8. IV immunoglobulins to neutralize super antigen as
streptotoxin A & B (as adjuvant)
• 9. Antifungal – if required
20
Dept of Urology, GRH and KMC, Chennai.

21. Surgical treatment
• Repeated aggressive debridement
• Preservation of testes
• Reconstruction after infection is over
• Fecal diversion
• Urinary diversion
• Vacuum assisted closure (VAC)
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Dept of Urology, GRH and KMC, Chennai.

22. Complications
• MODS
• ARDS
• Septicemia
• Tetanus
• Death
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Dept of Urology, GRH and KMC, Chennai.

23. Thank you
23
Dept of Urology, GRH and KMC, Chennai.