Fournier's gangrene is a necrotizing fasciitis of the genital region that is usually polymicrobial in nature. It is more common in males ages 30-60 and risk factors include diabetes, alcoholism, malignancy, and immunosuppression. The infection spreads rapidly in fascial planes due to bacterial enzymes and can cause tissue death. Treatment involves aggressive surgical debridement and broad spectrum antibiotics. Complications can include organ failure, shock, and death if not treated promptly.

1. Fournier’s gangrene
By: DR Darayus P.Gazder

2. Fournier’s gangrene
• Definition
• Etiology & risk factors
• Pathogenesis & pathology
• Incidence
• Clinical features
• Differential diagnosis
• Investigations
• Treatment –
- Medical
- Surgical
• Complications

4. Definition
Named after French venereologist
Jean Alfred Fournier (1883).
Fournier gangrene is defined as a
polymicrobial necrotizing fasciitis
of the perineal, perianal, or genital
areas.

5. Risk factors
• Diabetes mellitus
• Alcoholism
• Malignancies
• Cirrhosis Liver
• Chronic steroid use
• HIV infection
• Malnutrition
• Morbid Obesity

6. Etiology & risk factors
• Initially described as idiopathic
• Now in more than 75% cases
inciting cause in known
• Necrotizing process commonly
originates from infection in
anorectum, urogenital tract or skin
of genitalia

7. Etiology
1. Ano-rectal causes –
– infection in the perineal glands
– Manifestation of colorectal injury,
malignancy or diverticulitis
2. Uro-genital causes –
– infection in the bulbourethral glands
– urethral injury
– Iatrogenic injury
– Lower urinary tract infections

8. Etiology (contd.)
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

9. Causative Bacteria
• Polymicrobial infection
• Minimum of four isolates per case
• Most common aerobe – E. coli
• Most common anaerobes – Bacteroids
• Others – Streptococcus, Staphylococcus,
MRSA – Methicillin Resistant Staphylococcus
aureus, Klebsiella Pseudomonas, Proteus &
Clostridium.

10. Mechanism of spread
Entry of bacteria (act through synergism)
Fibrinoid coagulation of nutrient vessels
Decreased locally blood supply to skin
Decreased tissue oxygen tension
Growth of anaerobes & microaerophilic
organisms
Production of enzyme (Collagenase, Lecithinase,
Hyaluronidase )
Digestion of fascial barrier
Rapid spread of infection

11. Pathology
Pathognomonic findings on pathological
evaluation of tissue are :-
• Necrosis of superficial & deep fascial planes
• Fibrinoid coagulation of the nutrient
arterioles
• Polymorphonuclear cell infiltration
• Presence of micro organisms with in the
involved tissues
• Air in the perineal tissue

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)

13. 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)

14. Differential diagnosis
• Balanitis
• Cellulitis
• Epididymitis
• Gas gangrene
• Compicated hernias
• Complicated hydrocele
• Necrotizing fasciitis
• Orchitis
• Testicular torsion

15. Other Problems to be Considered
• Testicular fracture
• Testicular hematoma
• Testicular abscess
• Scrotal abscess
• Vasculitis
• Warfarin gangrenosum
• Polyarteritis nodosum
• Wegener’s granulomatosis

16. Investigations
• (CBC) Complete blood count
• Electrolytes
• BUN / Serum creatinine
• Blood Sugar
• ABG
• Blood and urine culture with sensitivity
• Coagulation profile for DIC

17. Investigations (contd.)
Imaging-
• Conventional radiography
• Ultrasonography
• C.T. Scanning
• MRI

18. Conventional radiography
• Consider where clinical findings
are inconclusive
• Presence of gas in soft tissue

19. Ultrasonography
• Can be used to detect fluid or
gas in soft tissue
• “Sonographic hallmark” –
Presence of gas in scrotal
tissue
• Excludes other conditions
• Testicular blood flow - N
• Limitations – Direct pressure on
involved tissue causes
inconvenience

20. 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
• Create logistic challenges,
especially in critically ill
patients

21. Treatment
• Medical
• Surgical

22. 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
10. Non – conventional
- Unprocessed honey – enzyme action
- dressing with gauge soaked with zinc per oxide

23. Surgical treatment
• Repeated aggressive debridement
• Preservation of testes (subcutaneous
pocket from desiccation)
• Reconstruction after infection is over
• Fecal diversion
• Urinary diversion
• Vacuum assisted closure (VAC)

25. Complications
• ARF
• ARDS
• Septicemia and gram negative shock
• MSOF
• Tetanus
• Death

26. Questions ?

27. Let us revise
• Definition
• Etiology & risk factors
• Pathogenesis & pathology
• Incidence
• Clinical features
• Differential diagnosis
• Investigations
• Treatment –
- Medical
- Surgical
• Complications