4. Anatomy
The five fascial planes that can be affected are:
Colles’ fascia
Dartos’ fascia
Buck’s fascia
Scarpa’s fascia
Camper’s fascia
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6.
7.
8. 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
9. Etiology and Risk Factors
• Initially described as idiopathic
• Now in more than 75% cases inciting cause is known
• Necrotizing process commonly originates from infection in
anorectum, urogenital tract or skin of genitalia
10. 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
11. 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
- SLE
- Crohn’s diseases
12. Causative Bacteria
• Polymycrobial infection
• Most common aerobe – E. coli
• Most common anaerobes – Bacteroids
• Others – streptococcus, staphylococcus,clostridium and Proteus
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15. Pathology
Pathognomonic findings on pathological evaluation of tissue are:
. Necrosis of superficial and deep fascial planes
. Fibrinoid coagulation of the nutrient arterioles
. Polymorphonuclear cell infiltration
. Presence of micro organisms within the involved tissues
. Air in the perineal tissues
16. 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
17. Clinical Features Contd.
• Obvious gangrene of a portion of the genitalia; purulent discharge
from wounds
• As gangrene develops, pain subsides (nerve necrosis)
22. Ultrasonography
• Can be used to detect fluid or gas in soft tissue
• “Sonographic hallmark” – presence of gas in scrotal tissue
• Excludes other conditions
23. 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, esp. in critically ill patients
25. Medical Treatment
• Restoration of normal organ perfusion
• Reduction of systemic toxicity
• Broad spectrum antibiotics to cover anaerobes as well
• Tetanus prophylaxis
• Irrigation with super oxidized water
• Hyperbaric oxygen therapy
• Antifungal – if required
26. Surgical Treatment
• Repeated aggressive debridement
• Preservation of testes
• Reconstruction after infection is over
• Fecal diversion
• Urinary diversion
• Vacuum assisted closure (VAC)
