View source for Fournier gangrene

__NOTOC__
{{SI}}
{{SCC}}; {{AE}} {{YK}}; {{JH}}

{{SK}} Idiopathic gangrene of scrotum; Periurethral phlegmon; Streptococcal scrotal gangrene; Genito-perineal gangrene; Phagedena 

{{Search infobox}}

{{Infobox_Disease
 | Name           = Fournier gangrene
 | Image          = 
 | Caption        = 
 | DiseasesDB     = 31119
 | ICD10          = {{ICD10|N|49|8|n|40}} ([[ILDS]] N49.81), {{ICD10|N|76|8|n|70}}
 | ICD9           = {{ICD9|608.83}}
 | ICDO           = 
 | OMIM        {{Search infobox}}   = 
 | MedlinePlus    = <!-- has no entry -->
 | MeshID         = D018934
}}

==Overview==
'''Fournier gangrene''' is a type of synergistic polymicrobial [[necrosis|necrotizing]] [[infection]] ([[gangrene]]) of the [[perineal]], genital or perianal regions usually affecting the male [[genital]]s but can also occur in female and children.<ref name="pmid9523650">{{cite journal| author=Smith GL, Bunker CB, Dinneen MD| title=Fournier's gangrene. | journal=Br J Urol | year= 1998 | volume= 81 | issue= 3 | pages= 347-55 | pmid=9523650 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9523650  }} </ref> It is a fulminant form of [[necrotizing fasciitis]]. It was first described by Baurienne in 1764 and is named after a French [[venereology|venereologist]], Jean-Alfred Fournier following five cases he presented in clinical lectures in 1883.<ref name="pmid9492752">{{cite journal| author=Nathan B| title=Fournier's gangrene: a historical vignette. | journal=Can J Surg | year= 1998 | volume= 41 | issue= 1 | pages= 72 | pmid=9492752 | doi= | pmc=3950066 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9492752  }} </ref><ref name="pmid26445600">{{cite journal| author=Chennamsetty A, Khourdaji I, Burks F, Killinger KA| title=Contemporary diagnosis and management of Fournier's gangrene. | journal=Ther Adv Urol | year= 2015 | volume= 7 | issue= 4 | pages= 203-15 | pmid=26445600 | doi=10.1177/1756287215584740 | pmc=4580094 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26445600  }} </ref>

==Historical Perspective==
*Fournier's gangrene was first described by in 1764 by Baurienne.<ref name="pmid9492752">{{cite journal| author=Nathan B| title=Fournier's gangrene: a historical vignette. | journal=Can J Surg | year= 1998 | volume= 41 | issue= 1 | pages= 72 | pmid=9492752 | doi= | pmc=3950066 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9492752  }} </ref>
*The detailed description of fournier's gangrene was given by Jean Alfred Fournier, who is a French [[venereology|venereologist]] in 1883.<ref name="pmid26445600">{{cite journal| author=Chennamsetty A, Khourdaji I, Burks F, Killinger KA| title=Contemporary diagnosis and management of Fournier's gangrene. | journal=Ther Adv Urol | year= 2015 | volume= 7 | issue= 4 | pages= 203-15 | pmid=26445600 | doi=10.1177/1756287215584740 | pmc=4580094 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26445600  }} </ref>

==Classification==
The ICD 10 classification of Fournier's gangrene include:<ref name=WHO>Classification http://apps.who.int/classifications/icd10/browse/2016/en#/N49.8 (2016) Accessed on October 14, 2016</ref>
*ICD-10: N49.3 
*Code Classification
:*Diseases of the [[genitourinary system]]
::*Diseases of male genital organs (N40-N53)
:::*Inflammatory disorders of male genital organs, NEC (N49)

==Pathophysiology==
*The transmission of [[pathogens]] occurs through the following routes:<ref name="pmid23251819">{{cite journal| author=Mallikarjuna MN, Vijayakumar A, Patil VS, Shivswamy BS| title=Fournier's Gangrene: Current Practices. | journal=ISRN Surg | year= 2012 | volume= 2012 | issue=  | pages= 942437 | pmid=23251819 | doi=10.5402/2012/942437 | pmc=3518952 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23251819  }} </ref>
:*External trauma (e.g., [[laceration]], [[abrasion]], [[burn]], insect bite)
:*Direct spread from a perforated [[viscus]] (particularly [[colon]], [[rectum]], or [[anus]]) or another surgical procedure (e.g., [[vasectomy]], [[hemorrhoidectomy]])
:*[[Urogenital|Urogenital organ]] 
:*[[Perirectal abscess]]
:*[[Decubitus ulcer]]
*Following transmission, the bacteria uses the entry site to invade the [[Fascia|fascial planes]] which causes the wide spread necrosis of [[Fascia|superficial fascia]], [[Fascia|deep fascia]],
[[subcutaneous fat]], [[nerves]], [[arteries]], and [[veins]].
*Superficial skin and deeper muscles are typically spared.
*In late stages, lesions develop [[liquefactive necrosis]] at all tissue levels.

===Pathogenesis===
*The pathogenesis of fournier's gangrene is the result of an imbalance between bacterial and host factors.<ref name="pmid19815967">{{cite journal| author=Morua AG, Lopez JA, Garcia JD, Montelongo RM, Guerra LS| title=Fournier's gangrene: our experience in 5 years, bibliographic review and assessment of the Fournier's gangrene severity index. | journal=Arch Esp Urol | year= 2009 | volume= 62 | issue= 7 | pages= 532-40 | pmid=19815967 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19815967  }} </ref><ref name="pmid23578806">{{cite journal| author=Shyam DC, Rapsang AG| title=Fournier's gangrene. | journal=Surgeon | year= 2013 | volume= 11 | issue= 4 | pages= 222-32 | pmid=23578806 | doi=10.1016/j.surge.2013.02.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23578806  }} </ref><ref name="pmid23251819">{{cite journal| author=Mallikarjuna MN, Vijayakumar A, Patil VS, Shivswamy BS| title=Fournier's Gangrene: Current Practices. | journal=ISRN Surg | year= 2012 | volume= 2012 | issue=  | pages= 942437 | pmid=23251819 | doi=10.5402/2012/942437 | pmc=3518952 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23251819  }} </ref>
:*Host factors: Decrease in host immunity provides favourable environment to initiate the infection
:*Bacterial factors: Virulence and synergism between multiple bacteria promotes rapid spread of infection
*The aerobic and anaerobic bacteria produce exotoxins and enzymes like collagenase, heparinase, hyaluronidase etc which promote spread of infection.
*The aerobic bacteria cause acceleration of coagulation by promoting platelet aggregation and complement fixation and the anaerobic bacteria produce collagenase and heparinase that promote the formation of clots leading to obliterative endarteritis.
*The cutaneous and subcutaneous vascular necrosis develops leading to local ischemia and further bacterial proliferation.
*The infection spreads from superficial (colles fascia) and deep fascial planes of genetalia to the overlying skin sparing the muscles. The infection then spreads from colles fascia to the penis and scrotum via Buck's and Dartos fascia or to the anterior abdominal wall via Scarpa's fascia or vice versa.
*The inferior epigastric and deep circumflex iliac arteries (supply anterior abdominal wall), and external and internal pudendal artery supply the scrotal wall. Except internal pudendal artery, each of these vessels travels with in Camper's fascia and can therefore become thrombosed in the progression of fournier's gangrene.
*The progression of infection to the perineal body, urogenital diaphragm and pubic rami is limited due to perineal fascia.<ref name="pmid24707378">{{cite journal| author=Katib A, Al-Adawi M, Dakkak B, Bakhsh A| title=A three-year review of the management of Fournier's gangrene presented in a single Saudi Arabian institute. | journal=Cent European J Urol | year= 2013 | volume= 66 | issue= 3 | pages= 331-4 | pmid=24707378 | doi=10.5173/ceju.2013.03.art22 | pmc=3974467 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24707378  }} </ref>
*Because of direct supply of blood from aorta, testicular involvement is limited in Fournier's gangrene.<ref name="pmid17323114">{{cite journal| author=Gupta A, Dalela D, Sankhwar SN, Goel MM, Kumar S, Goel A et al.| title=Bilateral testicular gangrene: does it occur in Fournier's gangrene? | journal=Int Urol Nephrol | year= 2007 | volume= 39 | issue= 3 | pages= 913-5 | pmid=17323114 | doi=10.1007/s11255-006-9126-1 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17323114  }} </ref> However involvement of testis suggests retroperitoneal origin or spread of infection.<ref name="pmid12706005">{{cite journal| author=Chawla SN, Gallop C, Mydlo JH| title=Fournier's gangrene: an analysis of repeated surgical debridement. | journal=Eur Urol | year= 2003 | volume= 43 | issue= 5 | pages= 572-5 | pmid=12706005 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12706005  }} </ref>
*Fournier's gangrene of the male genetalia spares testes, urethra and deep penile tissues while the skin sloughs off.<ref name="pmid2383054">{{cite journal| author=Campos JA, Martos JA, Gutiérrez del Pozo R, Carretero P| title=Synchronous caverno-spongious thrombosis and Fournier's gangrene. | journal=Arch Esp Urol | year= 1990 | volume= 43 | issue= 4 | pages= 423-6 | pmid=2383054 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2383054  }} </ref>
*Sepsis and multiorgan failure is the most common cause of death in Fournier's gangrene.

===Common locations===
The common locations of Fournier's gangrene are:<ref name="pmid23578806">{{cite journal| author=Shyam DC, Rapsang AG| title=Fournier's gangrene. | journal=Surgeon | year= 2013 | volume= 11 | issue= 4 | pages= 222-32 | pmid=23578806 | doi=10.1016/j.surge.2013.02.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23578806  }} </ref>
*Perineum
*Scrotum
*Penis

===Gross pathology===
On gross pathology, the characteristic findings of Fournier's gangrene include:
*Subcutaneous emphysema
*Swollen scrotal wall
*Edema
*Erythema
*Bullae
*Skin sloughing

===Microscopic histopathological analysis===
On microscopic histopathological analysis, the characteristic findings of Fournier's gangrene are:
*Early stages
:*[[Vasculitis|Obliterative vasculitis]] with microangiopathic thrombosis
:*Acute inflammation of subcutaneous tissue
:*Superficial hyaline necrosis along with [[edema]] and [[inflammation]] of the dermis and subcutaneous fat
:*Dense [[neutrophil]]-predominant inflammatory infiltrate 
*Late stages
:*Noninflammatory [[Coagulation|intravascular coagulation]] and [[hemorrhage]]
:*[[Myonecrosis]]

<gallery>

Image:FG_1.jpg|Histology of excised skin shows full thickness, featureless, coagulative necrosis with no viable tissue remaining

Image:FG2.jpg|Histology of excised scrotal skin shows zones of neutrophil polymorph infiltration, with embedded foreign material possibly representing hair shafts

Image:FG3.jpg|Histology of excised skin shows bacterial colonies (cocci and bacilli) in the superficial zone

</gallery>

==Causes==
Fournier's gangrene is caused by mixed aerobic and anaerobic organisms which normally exist below the pelvic diaphragm in the perineum and genitalia.<ref name="pmid10848848">{{cite journal| author=Eke N| title=Fournier's gangrene: a review of 1726 cases. | journal=Br J Surg | year= 2000 | volume= 87 | issue= 6 | pages= 718-28 | pmid=10848848 | doi=10.1046/j.1365-2168.2000.01497.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10848848  }} </ref> Fournier's gangrene may be caused by the following organisms:<ref>{{cite journal |author=Thwaini A, Khan A, Malik A, Cherian J, Barua J, Shergill I, Mammen K |title=Fournier's gangrene and its emergency management |journal=Postgrad Med J |volume=82 |issue=970 |pages=516-9 |year=2006 |id=PMID 16891442}}</ref>

===Bacteria===

'''Aerobic organisms'''
Most common aerobic organisms are:<ref name="pmid1736475">{{cite journal| author=Paty R, Smith AD| title=Gangrene and Fournier's gangrene. | journal=Urol Clin North Am | year= 1992 | volume= 19 | issue= 1 | pages= 149-62 | pmid=1736475 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1736475  }} </ref>
*Group A streptococcus
*[[Escherichia coli]] 
*[[Klebsiella pneumoniae]] 
*[[Staphylococcus aureus]]

'''Anaerobic organisms'''
Most common anaerobic organisms are:
*[[Bacteroides fragilis]]

===Other organisms===
*Streptococcus
*Enterococcus
*Coryebacterium<ref name="pmid16927060">{{cite journal| author=Yanar H, Taviloglu K, Ertekin C, Guloglu R, Zorba U, Cabioglu N et al.| title=Fournier's gangrene: risk factors and strategies for management. | journal=World J Surg | year= 2006 | volume= 30 | issue= 9 | pages= 1750-4 | pmid=16927060 | doi=10.1007/s00268-005-0777-3 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16927060  }} </ref>
*Clostridium
*Pseudomonas 
*Proteus species
*''[[Candida]]'' species<ref name="pmid20574621">{{cite journal| author=Jensen P, Zachariae C, Grønhøj Larsen F| title=Necrotizing soft tissue infection of the glans penis due to atypical Candida species complicated with Fournier's gangrene. | journal=Acta Derm Venereol | year= 2010 | volume= 90 | issue= 4 | pages= 431-2 | pmid=20574621 | doi=10.2340/00015555-0847 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20574621  }} </ref>
*''[[Lactobacillus gasseri]]''<ref name="pmid15307582">{{cite journal| author=Tleyjeh IM, Routh J, Qutub MO, Lischer G, Liang KV, Baddour LM| title=Lactobacillus gasseri causing Fournier's gangrene. | journal=Scand J Infect Dis | year= 2004 | volume= 36 | issue= 6-7 | pages= 501-3 | pmid=15307582 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15307582  }} </ref>

===Idiopathic===
Less than quarter of cases of fournier's gangrene are idiopathic.<ref name="pmid9523650">{{cite journal| author=Smith GL, Bunker CB, Dinneen MD| title=Fournier's gangrene. | journal=Br J Urol | year= 1998 | volume= 81 | issue= 3 | pages= 347-55 | pmid=9523650 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9523650  }} </ref><ref name="pmid10584624">{{cite journal| author=Vick R, Carson CC| title=Fournier's disease. | journal=Urol Clin North Am | year= 1999 | volume= 26 | issue= 4 | pages= 841-9 | pmid=10584624 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10584624  }} </ref>

==Differentiating {{PAGENAME}} from Other Diseases==
Fournier's gangrene must be differentiated from other diseases that cause pain, swelling erythema, discharge and raised temperature such as:<ref name=Fournier's>Fournier's gangrene https://radiopaedia.org/articles/fournier-gangrene (2016) Accessed on October 12, 2016 </ref><ref name="pmid23251819">{{cite journal| author=Mallikarjuna MN, Vijayakumar A, Patil VS, Shivswamy BS| title=Fournier's Gangrene: Current Practices. | journal=ISRN Surg | year= 2012 | volume= 2012 | issue=  | pages= 942437 | pmid=23251819 | doi=10.5402/2012/942437 | pmc=3518952 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23251819  }} </ref>
*Scrotal abscess
*Herpes simplex
*Cellulitis
*Strangulated hernia
*Streptococcal necrotizing fasciitis
*Gonococcal balanitis and edema
*Vascular occlusion syndromes
*Allergic vasculitis
*Pyoderma gangrenosum
*Necrolytic migratory erythema
*Ecthyma gangrenosum
*Warfarin necrosis
*Polyarteritis nodosa

==Epidemiology and Demographics==
===Incidence===
Incidence of Fournier's gangrene in the United states:<ref name="pmid27172977">{{cite journal| author=Sorensen MD, Krieger JN| title=Fournier's Gangrene: Epidemiology and Outcomes in the General US Population. | journal=Urol Int | year= 2016 | volume= 97 | issue= 3 | pages= 249-259 | pmid=27172977 | doi=10.1159/000445695 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27172977  }} </ref>
*The overall incidence of Fournier's gangrene annually are 1.6 cases per 100,000 males.The incidence peaked and remained steady after age 50 at 3.3 cases per 100,000 males.
*The incidence of Fournier's gangrene increased 0.2 per 100,000 males for each 1% increase in the regional prevalence of diabetes.
*The incidence rate was highest in the south and the lowest in the west and Midwest US.

<gallery>

Image:Epidemiology.jpg|1000px|Distribution of annual cases per hospital.<ref name="pmid27172977">{{cite journal| author=Sorensen MD, Krieger JN| title=Fournier's Gangrene: Epidemiology and Outcomes in the General US Population. | journal=Urol Int | year= 2016 | volume= 97 | issue= 3 | pages= 249-259 | pmid=27172977 | doi=10.1159/000445695 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27172977  }} </ref>

</gallery>

===Age===
Fournier's gangrene affects individuals of all ages but commonly affects individuals older than 50 years of age.<ref name="pmid23251819">{{cite journal| author=Mallikarjuna MN, Vijayakumar A, Patil VS, Shivswamy BS| title=Fournier's Gangrene: Current Practices. | journal=ISRN Surg | year= 2012 | volume= 2012 | issue=  | pages= 942437 | pmid=23251819 | doi=10.5402/2012/942437 | pmc=3518952 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23251819  }} </ref><ref name="pmid23578806">{{cite journal| author=Shyam DC, Rapsang AG| title=Fournier's gangrene. | journal=Surgeon | year= 2013 | volume= 11 | issue= 4 | pages= 222-32 | pmid=23578806 | doi=10.1016/j.surge.2013.02.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23578806  }} </ref>

===Gender===
Men are more commonly affected with fournier's gangrene than women (male:female ratio is 10:1).<ref name="pmid26445600">{{cite journal| author=Chennamsetty A, Khourdaji I, Burks F, Killinger KA| title=Contemporary diagnosis and management of Fournier's gangrene. | journal=Ther Adv Urol | year= 2015 | volume= 7 | issue= 4 | pages= 203-15 | pmid=26445600 | doi=10.1177/1756287215584740 | pmc=4580094 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26445600  }} </ref><ref name="pmid23578806">{{cite journal| author=Shyam DC, Rapsang AG| title=Fournier's gangrene. | journal=Surgeon | year= 2013 | volume= 11 | issue= 4 | pages= 222-32 | pmid=23578806 | doi=10.1016/j.surge.2013.02.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23578806  }} </ref>

===Mortality===
*Mortality rate decreases with early aggressive treatment.
*The mortality rate of Fournier's gangrene is between 20% to 80%. Higher mortality rates are found in daibetics, alcoholics and those with colorectal sources of infection.<ref name="pmid20062653">{{cite journal| author=Moslemi MK, Sadighi Gilani MA, Moslemi AA, Arabshahi A| title=Fournier gangrene presenting in a patient with undiagnosed rectal adenocarcinoma: a case report. | journal=Cases J | year= 2009 | volume= 2 | issue=  | pages= 9136 | pmid=20062653 | doi=10.1186/1757-1626-2-9136 | pmc=2803933 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20062653  }} </ref>

==Risk Factors==
Common risk factors in the development of fournier's gangrene are:<ref name="pmid2294630">{{cite journal| author=Clayton MD, Fowler JE, Sharifi R, Pearl RK| title=Causes, presentation and survival of fifty-seven patients with necrotizing fasciitis of the male genitalia. | journal=Surg Gynecol Obstet | year= 1990 | volume= 170 | issue= 1 | pages= 49-55 | pmid=2294630 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2294630  }} </ref><ref name="pmid12516849">{{cite journal| author=Morpurgo E, Galandiuk S| title=Fournier's gangrene. | journal=Surg Clin North Am | year= 2002 | volume= 82 | issue= 6 | pages= 1213-24 | pmid=12516849 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12516849  }} </ref><ref name="pmid10584624">{{cite journal| author=Vick R, Carson CC| title=Fournier's disease. | journal=Urol Clin North Am | year= 1999 | volume= 26 | issue= 4 | pages= 841-9 | pmid=10584624 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10584624  }} </ref>
*Comorbid systemic disorders
:*Age>50 yrs
:*Male Gender
:*Diabetes mellitus
:*Alcohol misuse
:*Immunosupression
:*Chemotherapy
:*Chronic corticosteroid use
:*HIV
:*Leukemia
:*Liver disease
:*Debilitating illness
:*Malignancy
:*Cytotoxic drugs
The most common foci of fournier's gangrene include:<ref name="pmid10848848">{{cite journal| author=Eke N| title=Fournier's gangrene: a review of 1726 cases. | journal=Br J Surg | year= 2000 | volume= 87 | issue= 6 | pages= 718-28 | pmid=10848848 | doi=10.1046/j.1365-2168.2000.01497.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10848848  }} </ref><ref name="pmid7950832">{{cite journal| author=Amendola MA, Casillas J, Joseph R, Antun R, Galindez O| title=Fournier's gangrene: CT findings. | journal=Abdom Imaging | year= 1994 | volume= 19 | issue= 5 | pages= 471-4 | pmid=7950832 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7950832  }} </ref>
{| style="border: 0px; font-size: 90%; margin: 3px;" align=center
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! style="background: #4479BA; width: 400px;" | {{fontcolor|#FFF|Anorectal}}
! style="background: #4479BA; width: 400px;" | {{fontcolor|#FFF|Genitourinary}}
! style="background: #4479BA; width: 400px;" | {{fontcolor|#FFF|Dermatology}}
! style="background: #4479BA; width: 400px;" | {{fontcolor|#FFF|Gynaecological}}
|-
| style="padding: 5px 5px; background: #F5F5F5;" | 
*Trauma<br>
*Steroid enemas for radiation proctitis<br>
*Hemorrhoidectomy<br>
*Anal fissures excision<br>
*Diverticulitis<br>
*Colonic perforations<br>
*Ischiorectal, perirectal, or perianal abscesses<br>
*Appendicitis<br>
*Steroid enemas for radiation proctitis
| style="padding: 5px 5px; background: #F5F5F5;" |
*Trauma<br>
*Cancer invasion to external genitalia<br>
*Hemipelvectomy<br>
*Epididymitis or orchitis<br>
*Penile artificial implant or a foreign body<br>
*Hydrocele aspiration<br>
*Genital piercing<br>
*Intracavernosal cocaine<br>
*Urethral catheterization or instrumentation<br>
*Penile implantsinsertion<br>Prostatic biopsy<br>
*Vasectomy<br>
*Urethral strictures with urinary extravasation
| style="padding: 5px 5px; background: #F5F5F5;" | 
*Blunt perineal trauma<br>
*Intramuscular injections<br>
*Genital piercings<br>
*Scrotal furuncle<br>
*Perineal or pelvic surgery/inguinal herniography<br>
| style="padding: 5px 5px; background: #F5F5F5;" | 
*Episiotomy wound<br>
*Infected bartholins gland<br>
*Septic abortion<br>
*Genital mutilation<br>
*Coital injury
|}

'''Neonates and Children'''
*Trauma<ref name="pmid7950832">{{cite journal| author=Amendola MA, Casillas J, Joseph R, Antun R, Galindez O| title=Fournier's gangrene: CT findings. | journal=Abdom Imaging | year= 1994 | volume= 19 | issue= 5 | pages= 471-4 | pmid=7950832 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7950832  }} </ref>
*Burns
*Insect bites
*Circumcision

==Screening==
According to the U.S. Preventive Service Task Force (USPSTF), there is insufficient evidence to recommend routine screening for Fournier's gangrene.

==Natural History, Complications, and Prognosis==
===Natural history===
*If left untreated, the acute inflammatory changes spread quickly, accompanied by high fever and extreme weakness.<ref name="pmid20542593">{{cite journal| author=Morgan MS| title=Diagnosis and management of necrotising fasciitis: a multiparametric approach. | journal=J Hosp Infect | year= 2010 | volume= 75 | issue= 4 | pages= 249-57 | pmid=20542593 | doi=10.1016/j.jhin.2010.01.028 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20542593  }} </ref><ref name="pmid8436051">{{cite journal| author=Ecker KW, Derouet H, Omlor G, Mast GJ| title=[Fournier's gangrene]. | journal=Chirurg | year= 1993 | volume= 64 | issue= 1 | pages= 58-62 | pmid=8436051 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8436051  }} </ref>
*The overlying skin becomes smooth, tense and shiny. Diffuse [[erythema]] without distinct borders is seen.
*First 1 or 2 days, the lesions develop with progressive colour changes from red to purple to blue and then becomes frankly [[gangrene|gangrenous]], first turning black, then greenish yellow.
*If the patient has survived, a line of demarcation between viable and necrotic tissue would become sharply defined from days 7 to 10.
*[[Sloughing]] of necrotic skin would reveal the underlying [[pus]] and extensive [[liquefactive necrosis]] of [[Subcutaneous tissue|subcutaneous tissues]], which will be significantly more extensive than would be suspected with the overlying area of necrotic skin.
*[[Metastatic]] [[abscesses]] and pulmonary distress may develop as well.

===Complications===
Common complications of Fournier's gangrene include:<ref name="pmid19669962">{{cite journal| author=Akcan A, Sözüer E, Akyildiz H, Yilmaz N, Küçük C, Ok E| title=Necessity of preventive colostomy for Fournier's gangrene of the anorectal region. | journal=Ulus Travma Acil Cerrahi Derg | year= 2009 | volume= 15 | issue= 4 | pages= 342-6 | pmid=19669962 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19669962  }} </ref><ref name="pmid16891442">{{cite journal| author=Thwaini A, Khan A, Malik A, Cherian J, Barua J, Shergill I et al.| title=Fournier's gangrene and its emergency management. | journal=Postgrad Med J | year= 2006 | volume= 82 | issue= 970 | pages= 516-9 | pmid=16891442 | doi=10.1136/pgmj.2005.042069 | pmc=2585703 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16891442  }} </ref>

'''Reported complications'''
*Renal failure
*Acute respiratory distress syndrome
*Heart failure
*Cardiac arrhythmias
*Septic metastasis
*Urinary tract infection
*Stroke
*Acute thrombo embolic disease of lower extremities

'''Surgical complications'''
*Wound infection
*Stoma-related complications
*Prolonged ileus (7 days)
*Eventration or evisceration

'''Long term complications'''
*Pain (50% of patients)
*Impaired sexual function (due to penile deviation/torsion, loss of sensitivity of the penile skin or pain during erection)
*Stool incontinence
*Extensive scarring

===Prognosis===
Depending on the underlying comorbidities, the prognosis of Fournier's gangrene varies. Few of the prognostic factors include:
*Severe sepsis
*Affected area calculation/Extension of the necrosis
:*<3% of body surface area rarely die
:*≥5% of body surface area have worse prognosis

==Diagnosis==
The diagnosis of Fournier's gangrene is primarily based on clinical findings. The diagnosis is based on following criteria:<ref name="pmid18087630">{{cite journal| author=Kuo CF, Wang WS, Lee CM, Liu CP, Tseng HK| title=Fournier's gangrene: ten-year experience in a medical center in northern Taiwan. | journal=J Microbiol Immunol Infect | year= 2007 | volume= 40 | issue= 6 | pages= 500-6 | pmid=18087630 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18087630  }} </ref>
*Soft tissue infections with involvement of the scrotum, perineum and perianal areas
*Presence of air infiltrating the subcutaneous tissue (demonstrated by physical examination or radiological findings)
*Surgical findings of gangrenous and necrotic tissue 
*Histologically proven necrotising fasciitis.

===Diagnostic Criteria===
'''The Uludag Fournier's gangrene severity index'''
{| class="wikitable" style="border: 2; background: none;"
! colspan="1" rowspan="2" style="border: 1; background: 1;"| Physiologic Variables
! colspan="4" rowspan="1"| High Abnormal Values
! colspan="1" rowspan="1"| Normal
! colspan="4" rowspan="1"| Low Abnormal Values
|- colspan="1" rowspan="2" style="border: 1; background: 1;"
!  +4  ||  +3  ||  +2  ||  +1  ||  0  ||  +1  ||  +2  ||  +3  ||  + 4
|-
! rowspan="1" style="border: 1; background: none;"| Temperature
| >41 || 39-40.0|| ||38.5-39 || 36-38.4 || 34-35.9 || 32-33.9 || 30-31.9 || <29.9
|-
! rowspan="1" style="border: 1; background: none;"| Heart Rate
| >180 || 140-179 || 110-139 || || 70-109 || || 55-69 || 40-54 || <39
|-
! rowspan="1" style="border: 1; background: none;"| Respiratory Rate
| >50 || 35-49 || ||25-34||12-24||10-11||6-9|| || <5
|-
! rowspan="1" style="border: 1; background: none;"| Serum Sodium (mmol/L)
| >180 ||160-179 ||155-159 ||150-154 ||130-149 ||  ||120-129 ||111-119  ||<110  
|-
! rowspan="1" style="border: 1; background: none;"| Serum Potassium (mmol/L)
|>7 ||6-6.9 ||  || 5.5-5.9 ||3.5-5.4 ||3-3.4  ||2.5-2.9 ||  ||<2.5  
|-
! rowspan="1" style="border: 1; background: none;"| Serum Creatinine<br>(mg/100/ml*2 for acute renal failure)
|>3.5 ||2-3.4 ||1.5-1.9 || ||0.6-1.4 || ||<0.6  ||  || 
|-
! rowspan="1" style="border: 1; background: none;"| Hematocrit
| >60|| ||50-59.9 ||46-49.9  ||30-45.9 || ||20-29.9 ||  ||<20  
|-
! rowspan="1" style="border: 1; background: none;"| WBC (Total/mm*1000)
| >40|| ||20-39.9  ||15-19.9 ||3-14.9 || ||1-2.9 ||  || <1 
|-
! rowspan="1" style="border: 1; background: none;"| Serum Bicarbonate (Venous,mmol/l)
|>52 ||41-51.9 ||  ||32-40.9 ||22-31.9 || ||18-21.9  ||15-17.9  || <15 

|}

*Score >10.5 indicates 96% probability of death<ref name="pmid18563618">{{cite journal| author=Kabay S, Yucel M, Yaylak F, Algin MC, Hacioglu A, Kabay B et al.| title=The clinical features of Fournier's gangrene and the predictivity of the Fournier's Gangrene Severity Index on the outcomes. | journal=Int Urol Nephrol | year= 2008 | volume= 40 | issue= 4 | pages= 997-1004 | pmid=18563618 | doi=10.1007/s11255-008-9401-4 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18563618  }} </ref>
*Score ≤10.5 indicates 96% probability of survival
According to Loar and colleagues, the severity of Fournier's gangrene is:
*Score ≥9 indicates 46% probability of death
*Score <9 indicates 96% probability of survival


'''Laboratory risk indicator for necrotizing fasciitis (LRINEC) scoring system'''
*LRINEC is a diagnostic scoring system used to distinguish necrotizing fasciitis from other soft tissue infections.<ref name="pmid15241098">{{cite journal| author=Wong CH, Khin LW, Heng KS, Tan KC, Low CO| title=The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections. | journal=Crit Care Med | year= 2004 | volume= 32 | issue= 7 | pages= 1535-41 | pmid=15241098 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15241098  }} </ref><ref name="pmid23251819">{{cite journal| author=Mallikarjuna MN, Vijayakumar A, Patil VS, Shivswamy BS| title=Fournier's Gangrene: Current Practices. | journal=ISRN Surg | year= 2012 | volume= 2012 | issue=  | pages= 942437 | pmid=23251819 | doi=10.5402/2012/942437 | pmc=3518952 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23251819  }} </ref>
*It was first established by Wong et al in 2004.
*Risk assessment of necrotizing faciitis using LRINEC score:
:*Low risk: ≤5
:*Intermediate risk: 6-7 
:*High risk: ≥8

{| class="wikitable" style="text-align: center

|-

! Variable

! Score

|-

| [[C reactive protein]] (mg/dL) 
<150 <br>
>150

|
0 <br>
4

|-

| Total [[white blood cell]] count (/mm3)
<15 <br>
15-25 <br>
>25

| <br>
0 <br>
1 <br>
2

|-

| [[Hemoglobin]] (g/dL)
<13.5 <br>
11-13.5 <br>
<11

| <br>
0 <br>
1 <br>
2 <br>

|-

| [[Sodium]] (mmol/L)
≥135 <br>
<135

| <br>
0 <br>
2

|-

| [[Creatinine]] (μmol/L)
<141 <br>
>141

| <br>
0 <br>
2

|-

| [[Glucose]] (mmol/L)
<10 <br>
>10

| <br>
0 <br>
1

|-

|}

===History===
A detailed and thorough history from the patient is necessary. Specific areas of focus when obtaining a history from the patient include:
*Trauma
*Alcohol misuse
*Immunosupression
*Chemotherapy
*Chronic corticosteroid use
*HIV
*Leukemia
*Liver disease
*Debilitating illness
*Malignancy
*Cytotoxic drugs
*Abdominal disease
*Surgery
*Epididymitis or orchitis

===Symptoms===
The symptoms of Fournier's gangrene include:<ref name="pmid23251819">{{cite journal| author=Mallikarjuna MN, Vijayakumar A, Patil VS, Shivswamy BS| title=Fournier's Gangrene: Current Practices. | journal=ISRN Surg | year= 2012 | volume= 2012 | issue=  | pages= 942437 | pmid=23251819 | doi=10.5402/2012/942437 | pmc=3518952 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23251819  }} </ref><ref name="pmid15302463">{{cite journal| author=Yeniyol CO, Suelozgen T, Arslan M, Ayder AR| title=Fournier's gangrene: experience with 25 patients and use of Fournier's gangrene severity index score. | journal=Urology | year= 2004 | volume= 64 | issue= 2 | pages= 218-22 | pmid=15302463 | doi=10.1016/j.urology.2004.03.049 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15302463  }} </ref>
*Pain and swelling in the scrotum
*Erythema
*Discoloration of involved skin
*Purulence or wound discharge
*Pallor
*Fever>38°C
*Crepitation
*Prostration
*Fluctuance
*Fetid odour

===Physical examination===
The physical examination of Fournier's gangrene include:

'''Appearance of the Patient'''

The patients with Fournier's gangrene are usually ill appearing.

'''Vitals'''

*Fever (is often absent)
*Tachycardia
*Low blood pressure
*Tachypnea

'''Skin'''

*Jaundice
*Evidence of trauma, surgery, insect or human bites, or injection sites

'''Local examination'''

Local examination of patient under local anesthesia includes palpation of genetalia and perineum, and digital rectal examination.
*Induration
*Warmth
*Tenderness beyond margins of erythema
*Swelling
*Erythema with ill defined margins
*Blistering/bullae
*Skin discoloration
*Foul discharge (greyish or brown discharge)
*Fluctuance
*Crepitus
*Skin sloughing or necrosis
*Absence of lymphangitis or lymphadenopathy (lymphangitis is rarely seen in necrotizing fasciitis)
*Sensory and motor deficits (e.g. localized anesthesia)

====Images====

'''Genitourinary system'''

<gallery>

Image:Fourniers_gangrene_1.jpg|Brownish-black discolouration of the penis with erythema of the scrotum.<ref name="pmid20606995">{{cite journal| author=Talwar A, Puri N, Singh M| title=Fournier's Gangrene of the Penis: A Rare Entity. | journal=J Cutan Aesthet Surg | year= 2010 | volume= 3 | issue= 1 | pages= 41-4 | pmid=20606995 | doi=10.4103/0974-2077.63394 | pmc=2890137 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20606995  }} </ref>

Image:Fourniers_gangrene_2.jpg|Discolouration of the penis with vesicles filled with hemorrhagic fluid.<ref name="pmid20606995">{{cite journal| author=Talwar A, Puri N, Singh M| title=Fournier's Gangrene of the Penis: A Rare Entity. | journal=J Cutan Aesthet Surg | year= 2010 | volume= 3 | issue= 1 | pages= 41-4 | pmid=20606995 | doi=10.4103/0974-2077.63394 | pmc=2890137 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20606995  }} </ref>

Image: Fournier's_gangrene_01.jpeg|Fournier's gangrene. <ref name=FG>Fourniers gangrene http://www.atlasdermatologico.com.br/disease.jsf?diseaseId=157 Accessed on October 14,2016 </ref>

Image: Fournier's_gangrene_02.jpeg|Fournier's gangrene. <ref name=FG>Fourniers gangrene http://www.atlasdermatologico.com.br/disease.jsf?diseaseId=157 Accessed on October 14,2016 </ref>

Image: Fournier's_gangrene_03.jpeg|Fournier's gangrene. <ref name=FG>Fourniers gangrene http://www.atlasdermatologico.com.br/disease.jsf?diseaseId=157 Accessed on October 14,2016 </ref>

Image: Fournier's_gangrene_04.jpeg|Fournier's gangrene. <ref name=FG>Fourniers gangrene http://www.atlasdermatologico.com.br/disease.jsf?diseaseId=157 Accessed on October 14,2016 </ref>

Image: Fournier's_gangrene_05.jpeg|Fournier's gangrene. <ref name=FG>Fourniers gangrene http://www.atlasdermatologico.com.br/disease.jsf?diseaseId=157 Accessed on October 14,2016 </ref>

</gallery>

===Laboratory Findings===
Laboratory findings consistent with the diagnosis of Fournier's gangrene include:
*CBC with differential count
*Culture of open wound or abscess
*Disseminated intravascular coagulation panel
:*Coagulation studies(PT, aPTT, thrombin time etc)
:*Fibrinogen/fibrin degradation product levels
*Blood culture
*Urine culture
*Arterial blood gas analysis
*Electrolyte panel
*Blood urea nitrogen (BUN)
*Creatinine
*Blood glucose levels

===Imaging Findings===
The diagnosis of Fournier's gangrene is based on clinical findings.The role of imaging includes:<ref name=Fournier's>Fournier's gangrene https://radiopaedia.org/articles/fournier-gangrene (2016) Accessed on October 12, 2016 </ref>
*Diagnosis not established
*Determine the extent of disease
*Detect underlying cause
====Radiography====
*On X-ray, Fournier's gangrene is characterized by:<ref name=Fournier's>Fournier's gangrene https://radiopaedia.org/articles/fournier-gangrene (2016) Accessed on October 12, 2016 </ref>
:*[[Subcutaneous]] gas or [[soft tissue]] swelling (specific x-ray finding) seen extending from scrotum and perineum to the inguinal regions, anterior abdominal wall, and thighs. 
:*Increase in the soft tissue thickness and opacity.
*Plain x-ray is a poor screening study for Fournier's gangrene because:
:*Subcutaneous [[emphysema]] is an insensitive finding and is present in a minority of patients
:*In the early stages the findings are similar to [[cellulitis]]

====Ultrasound====
On ultrasound, Fournier's gangrene is characterized by:<ref name="pmid23251819">{{cite journal| author=Mallikarjuna MN, Vijayakumar A, Patil VS, Shivswamy BS| title=Fournier's Gangrene: Current Practices. | journal=ISRN Surg | year= 2012 | volume= 2012 | issue=  | pages= 942437 | pmid=23251819 | doi=10.5402/2012/942437 | pmc=3518952 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23251819  }} </ref><ref name="pmid9423625">{{cite journal| author=Rajan DK, Scharer KA| title=Radiology of Fournier's gangrene. | journal=AJR Am J Roentgenol | year= 1998 | volume= 170 | issue= 1 | pages= 163-8 | pmid=9423625 | doi=10.2214/ajr.170.1.9423625 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9423625  }} </ref>
*Thickened scrotal wall
*Echogenic gas foci in scrotum pathognomonic-Seen as dirty shadowing
*Testes and epididymi spared (due to their separate blood supply)
*Reactive unilateral or bilateral hydroceles are present
*Differentiate Fournier gangrene from inguinoscrotal incarcerated hernia (In inguinoscrotal incarcerated hernia gas is observed in the obstructed bowel lumen, away from the scrotal wall)

====Computed tomography====
The CT of Fournier's gangrene is characterized by:<ref name=Fournier's>Fournier's gangrene https://radiopaedia.org/articles/fournier-gangrene (2016) Accessed on October 12, 2016 </ref>
*Soft tissue stranding and fascial thickening
*Soft tissue gas
*The extent of disease can be assessed prior to surgery
*A cause of infection may be apparent(e.g.perineal abscess, fistula)

====MRI====
On MRI, Fournier's gangrene is characterized by:<ref name="pmid11372608">{{cite journal| author=Kickuth R, Adams S, Kirchner J, Pastor J, Simon S, Liermann D| title=Magnetic resonance imaging in the diagnosis of Fournier's gangrene. | journal=Eur Radiol | year= 2001 | volume= 11 | issue= 5 | pages= 787-90 | pmid=11372608 | doi=10.1007/s003300000599 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11372608  }} </ref>
*Edema and inflammation of skin and subcutaneous planes of the scrotum and perineal planes
*Subcutaneous emphysema

===Gallery of Imaging Findings===
<gallery>
Image:Founier-gangrene_X-ray.JPG|200px|X ray of Fournier's gangrene <ref name=Fournier's>Fournier's gangrene https://radiopaedia.org/articles/fournier-gangrene (2016) Accessed on October 12, 2016 </ref>

Image:Fournier-gangrene-usg.jpg|200px|Ultrasound of Fournier's gangrene <ref name=Fournier's>Fournier's gangrene https://radiopaedia.org/articles/fournier-gangrene (2016) Accessed on October 12, 2016 </ref>

Image:Fournier-gangrene_CT.jpg|200px|CT of Fournier's gangrene <ref name=Fournier's>Fournier's gangrene https://radiopaedia.org/articles/fournier-gangrene (2016) Accessed on October 12, 2016 </ref>

Image:Fournier-gangrene-spontaneous-perforation-of-rectal-cancer.jpg|200px|CT of Fournier's gangrene with spontaneous perforation of rectal cancer <ref name=Fournier's>Fournier's gangrene https://radiopaedia.org/articles/fournier-gangrene (2016) Accessed on October 12, 2016 </ref>
</gallery>

==Treatment==
===Medical Therapy===
Fournier gangrene is a urological emergency requiring intravenous antibiotics and debridement (surgical removal) of necrotic (dead) tissue. Despite such measures, the mortality rate overall is 40%, but 78% if [[sepsis]] is already present at the time of initial hospital admission.<ref name="Yanar2006"/>The spread of gangrene is rapid at the rate of 2–3 cm/h, hence early diagnosis and emergency surgical treatment is of very importance.<ref name="pmid1736475">{{cite journal| author=Paty R, Smith AD| title=Gangrene and Fournier's gangrene. | journal=Urol Clin North Am | year= 1992 | volume= 19 | issue= 1 | pages= 149-62 | pmid=1736475 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1736475  }} </ref>
====Antimicrobial Therapy====
* Fournier gangrene<ref>{{cite book | last = Gilbert | first = David | title = The Sanford guide to antimicrobial therapy | publisher = Antimicrobial Therapy | location = Sperryville, Va | year = 2015 | isbn = 978-1930808843 }}</ref>
:* '''If caused by streptococcus species or clostridia''' 
::* Preferred regimen: [[Penicillin G]] 
:* '''Polymicrobial''' 

::* Preferred regimen: [[Doripenem]] {{or}} [[imipenem]] {{or}} [[meropenem]]
:* '''MRSA (methicillin resistant staphylococcus aureus) suspected''' 

::* Preferred regimen: [[vancomycin]] {{or}} [[daptomycin]]

===Nutritional Support===
*The metabolic demands of Fournier's gangrene patients are similar to those of other major [[trauma]] or [[burns]].<ref name="pmid25593960">{{cite journal| author=Misiakos EP, Bagias G, Patapis P, Sotiropoulos D, Kanavidis P, Machairas A| title=Current concepts in the management of necrotizing fasciitis. | journal=Front Surg | year= 2014 | volume= 1 | issue=  | pages= 36 | pmid=25593960 | doi=10.3389/fsurg.2014.00036 | pmc=4286984 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25593960  }} </ref>
*Nutritional support to replace lost [[proteins]] and fluids from large wounds and/or the result of [[shock]] is required from the first day of patients hospital admission.

===Hyperbaric oxygen===
*Delivery of 100% oxygen (hyperbaric) at two or three times the atmospheric pressure for 30 to 90 minutes with three to four treatments daily.<ref name="pmid16509286">{{cite journal| author=Escobar SJ, Slade JB, Hunt TK, Cianci P| title=Adjuvant hyperbaric oxygen therapy (HBO2)for treatment of necrotizing fasciitis reduces mortality and amputation rate. | journal=Undersea Hyperb Med | year= 2005 | volume= 32 | issue= 6 | pages= 437-43 | pmid=16509286 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16509286  }} </ref>
*Hyperbaric oxygen inhibits [[infection]] and [[exotoxin]] release.<ref name="pmid11199291">{{cite journal| author=Korhonen K| title=Hyperbaric oxygen therapy in acute necrotizing infections with a special reference to the effects on tissue gas tensions. | journal=Ann Chir Gynaecol Suppl | year= 2000 | volume=  | issue= 214 | pages= 7-36 | pmid=11199291 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11199291  }} </ref>
*It enhances efficacy of [[antibiotics]] by increasing local oxygen tension in tissue and augment [[oxidative burst]] and killing ability of [[leukocytes]].<ref>Hyperbaric oxygen therapy. http://onlinelibrary.wiley.com/doi/10.1080/110241500750008583/abstract (2016) Accessed on September 12, 2016</ref>
*These effects results in reduced need for surgical [[debridement]] and improved [[morbidity]] and [[mortality]] in patients with necrotizing fasciitis.
Contraindications to hyperbaric oxygen are:<ref name="pmid1924583">{{cite journal| author=Kindwall EP, Gottlieb LJ, Larson DL| title=Hyperbaric oxygen therapy in plastic surgery: a review article. | journal=Plast Reconstr Surg | year= 1991 | volume= 88 | issue= 5 | pages= 898-908 | pmid=1924583 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1924583  }} </ref><ref name="pmid10458334">{{cite journal| author=Capelli-Schellpfeffer M, Gerber GS| title=The use of hyperbaric oxygen in urology. | journal=J Urol | year= 1999 | volume= 162 | issue= 3 Pt 1 | pages= 647-54 | pmid=10458334 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10458334  }} </ref>
*Pneumothorax
*Cisplastin ((which decreases the production of superoxide dismutase which is protective against damaging effects of high partial O2 pressure)
*Doxorubicin therapy
Side effects of hyperbaric oxygen are:
*Barotrauma of the middle ear
*Seizures
*Loss of respiratory drive in hypercapnic patients (therefore, frequent periods of breathing in room air are interposed when patients are on HBOT)
*Vasoconstriction

===IV γ-globulin===
*Use of [[intravenous]] [[immune globulin]] is not FDA approved.
*If used, this treatment is restricted to critically ill patients with either [[staphylococcal]] or [[streptococcal]] [[infections]].<ref name="pmid16686841">{{cite journal| author=Darabi K, Abdel-Wahab O, Dzik WH| title=Current usage of intravenous immune globulin and the rationale behind it: the Massachusetts General Hospital data and a review of the literature. | journal=Transfusion | year= 2006 | volume= 46 | issue= 5 | pages= 741-53 | pmid=16686841 | doi=10.1111/j.1537-2995.2006.00792.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16686841  }} </ref>

===Surgery===
'''Radical surgical debridement'''

Surgery is the mainstay of treatment for Fournier's gangrene.<ref name="pmid25593960">{{cite journal| author=Misiakos EP, Bagias G, Patapis P, Sotiropoulos D, Kanavidis P, Machairas A| title=Current concepts in the management of necrotizing fasciitis. | journal=Front Surg | year= 2014 | volume= 1 | issue=  | pages= 36 | pmid=25593960 | doi=10.3389/fsurg.2014.00036 | pmc=4286984 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25593960  }} </ref>
*Indications include:<ref name="pmid25593960">{{cite journal| author=Misiakos EP, Bagias G, Patapis P, Sotiropoulos D, Kanavidis P, Machairas A| title=Current concepts in the management of necrotizing fasciitis. | journal=Front Surg | year= 2014 | volume= 1 | issue=  | pages= 36 | pmid=25593960 | doi=10.3389/fsurg.2014.00036 | pmc=4286984 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25593960  }} </ref>
:*Patients displaying intense pain and skin color change such as [[edema]] and/or [[ecchymoses]]
:*Signs of [[ischemia|skin ischemia]] with [[blister|blisters]] and bullae
:*[[Altered mental status]], [[hypotension]], elevated [[band cell|band forms]] in the differential [[WBC]] count and [[metabolic acidosis]].
* Immediate surgical referral remains the only method of reducing [[mortality]] and [[morbidity]] in Fournier's gangrene patients.<ref name="pmid22196774">{{cite journal| author=Roje Z, Roje Z, Matić D, Librenjak D, Dokuzović S, Varvodić J| title=Necrotizing fasciitis: literature review of contemporary strategies for diagnosing and management with three case reports: torso, abdominal wall, upper and lower limbs. | journal=World J Emerg Surg | year= 2011 | volume= 6 | issue= 1 | pages= 46 | pmid=22196774 | doi=10.1186/1749-7922-6-46 | pmc=3310784 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22196774  }} </ref><ref name="pmid16830885">{{cite journal| author=Mok MY, Wong SY, Chan TM, Tang WM, Wong WS, Lau CS| title=Necrotizing fasciitis in rheumatic diseases. | journal=Lupus | year= 2006 | volume= 15 | issue= 6 | pages= 380-3 | pmid=16830885 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16830885  }} </ref>
*As the patient's are cardiovascularly unstable, immediate [[resuscitation]] with [[intravenous fluids]], [[colloids]] and [[inotropes|inotropic agents]] are usually necessary.<ref name="pmid11097546">{{cite journal| author=Baxter F, McChesney J| title=Severe group A streptococcal infection and streptococcal toxic shock syndrome. | journal=Can J Anaesth | year= 2000 | volume= 47 | issue= 11 | pages= 1129-40 | pmid=11097546 | doi=10.1007/BF03027968 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11097546  }} </ref>
*Effects of [[analgesia]] can be measured by documenting pain score regularly.
*Stop the [[NSAID|NSAID's]] on admission of patients.

'''Procedure'''
*Radical debridement of areas of overt subcutaneous necrosis should be done in operation theater in the lithotomy position (allows access to all perineal structures).
*Deep fascia and muscle are rarely involved. Hence debridement is usually not required.
*Separation of the skin and subcutaneous tissue with a haemostat has been recommended to define the limits of excision. Debridement is stopped where these tissues do not separate easily.

'''Fecal and urinary diversion'''
*Urinary or fecal diversion are required to treat an underlying condition or prevent wound contamination.<ref name="pmid1736475">{{cite journal| author=Paty R, Smith AD| title=Gangrene and Fournier's gangrene. | journal=Urol Clin North Am | year= 1992 | volume= 19 | issue= 1 | pages= 149-62 | pmid=1736475 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1736475  }} </ref>
*When there is gross urinary extravasation or periurethral inflammation, suprapubic cystostomy is required (urinary catheter is used in milder cases).
*Colostomy is required when there is gross sphincter infection or colonic or rectal perforation.
*Testes are temporarily implanted into subcutaneous tissue pouch (medial thigh or lower abdomen) until healing or reconstruction is complete. 
*Orchidectomy is performed if there is any pre-existing epididymo-orchitis or scrotal abscess.

'''Plastic reconstruction'''
*The split thickness skin graft is commonly used technique for reconstructive surgery. For large defects, rotational or free myocutaneous flaps and omental flaps are used to cover larger defects.<ref name="pmid1736475">{{cite journal| author=Paty R, Smith AD| title=Gangrene and Fournier's gangrene. | journal=Urol Clin North Am | year= 1992 | volume= 19 | issue= 1 | pages= 149-62 | pmid=1736475 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1736475  }} </ref>

'''Wound management'''
*The wound is monitored closely after surgery.
*Multiple surgical debridement are required with an average of 3.5 procedures per patient.<ref name="pmid12706005">{{cite journal| author=Chawla SN, Gallop C, Mydlo JH| title=Fournier's gangrene: an analysis of repeated surgical debridement. | journal=Eur Urol | year= 2003 | volume= 43 | issue= 5 | pages= 572-5 | pmid=12706005 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12706005  }} </ref>
*Sodium hypochlorite or hydrogen peroxide are used post-operatively for topical application.<ref name="pmid8650874">{{cite journal| author=Hejase MJ, Simonin JE, Bihrle R, Coogan CL| title=Genital Fournier's gangrene: experience with 38 patients. | journal=Urology | year= 1996 | volume= 47 | issue= 5 | pages= 734-9 | pmid=8650874 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8650874  }} </ref>
*Lyophilized collagenase (an enzyme that digests and debrides necrotic tissues) is used for enzymatic debridement twice daily until definite reconstruction can be performed.<ref name="pmid9803004">{{cite journal| author=Aşci R, Sarikaya S, Büyükalpelli R, Yilmaz AF, Yildiz S| title=Fournier's gangrene: risk assessment and enzymatic debridement with lyophilized collagenase application. | journal=Eur Urol | year= 1998 | volume= 34 | issue= 5 | pages= 411-8 | pmid=9803004 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9803004  }} </ref>

'''Vacuum-assisted closure device'''
*Vacuum assisted closure device is used for faster and  effective wound closure.<ref name="pmid18470279">{{cite journal| author=Silberstein J, Grabowski J, Parsons JK| title=Use of a Vacuum-Assisted Device for Fournier's Gangrene: A New Paradigm. | journal=Rev Urol | year= 2008 | volume= 10 | issue= 1 | pages= 76-80 | pmid=18470279 | doi= | pmc=2312348 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18470279  }} </ref><ref name="pmid25593960">{{cite journal| author=Misiakos EP, Bagias G, Patapis P, Sotiropoulos D, Kanavidis P, Machairas A| title=Current concepts in the management of necrotizing fasciitis. | journal=Front Surg | year= 2014 | volume= 1 | issue=  | pages= 36 | pmid=25593960 | doi=10.3389/fsurg.2014.00036 | pmc=4286984 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25593960  }} </ref>
*Helps wound healing by absorbing excess [[exudates]], reducing localized [[edema]], and finally drawing wound edges together.

===Prevention===
'''Primary prevention'''

Effective measures for the primary prevention of Fournier's gangrene include:
*Prevention of trauma/breaks in skin integrity that act as portal of entry
*Treatment of [[cellulitis]] to prevent extension into the [[subcutaneous tissue]]
*Wounds should be cleaned and monitored for signs of infection
*Do not delay first aid of wounds like [[blister|blisters]], scrapes, or any break in the skin
*Patients with underlying co-morbidities should watch carefully for any signs of infection


'''Secondary prevention'''

Secondary prevention strategies following Fournier's gangrene include:
*Early diagnosis and prompt treatment with either [[antibiotics]] or surgery.  
*This strategy prevents or slows the progression and complications of the disease.

==External links==
* {{WhoNamedIt2|synd|2521|Fournier gangrene}} and {{WhoNamedIt|doctor|2209|Jean Alfred Fournier}}

==References==
{{reflist|2}}

[[Category:Dermatology]]

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