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| __NOTOC__ | | __NOTOC__ |
| {{SI}} | | '''For more information about necrotizing fasciitis click [[necrotizing fasciitis|here]] |
| | '''For patient information, click [[Fournier gangrene (patient information)|here]]''' |
| | {{Fournier gangrene}} |
| {{SCC}}; {{AE}} {{YK}}; {{JH}} | | {{SCC}}; {{AE}} {{YK}}; {{JH}} |
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| {{SK}} Idiopathic gangrene of scrotum; Periurethral phlegmon; Streptococcal scrotal gangrene; Genito-perineal gangrene | | {{SK}} Fournier's gangrene; Idiopathic gangrene of scrotum; Periurethral phlegmon; Streptococcal scrotal gangrene; Genito-perineal gangrene; Phagedena |
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| {{Search infobox}} | | {{Search infobox}} |
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| | MeshID = D018934 | | | MeshID = D018934 |
| }} | | }} |
| | ==[[Fournier gangrene overview|Overview]]== |
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| ==Overview== | | ==[[Fournier gangrene historical perspective|Historical Perspective]]== |
| '''Fournier gangrene''' is a type of [[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>
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| ==Historical Perspective== | | ==[[Fournier gangrene classification scheme|Classification]]== |
| *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>
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| *The detailed description of fournier's gangrene was given by Jean Alfred Fournier, who is a French 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>
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| ==Classification== | | ==[[Fournier gangrene pathophysiology|Pathophysiology]]== |
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| ==Pathophysiology== | | ==[[Fournier gangrene causes|Causes]]== |
| *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>
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| :*External trauma (e.g., [[laceration]], [[abrasion]], [[burn]], insect bite)
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| :*Direct spread from a perforated [[viscus]] (particularly [[colon]], [[rectum]], or [[anus]]) or another surgical procedure (e.g., [[vasectomy]], [[hemorrhoidectomy]])
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| :*[[Urogenital|Urogenital organ]]
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| :*[[Perirectal abscess]]
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| :*[[Decubitus ulcer]]
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| *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]],
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| [[subcutaneous fat]], [[nerves]], [[arteries]], and [[veins]].
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| *Superficial skin and deeper muscles are typically spared.
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| *In late stages, lesions develop [[liquefactive necrosis]] at all tissue levels.
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| ===Pathogenesis=== | | ==[[Differentiating Fournier gangrene from other diseases|Differentiating Fournier gangrene from other Diseases]]== |
| *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>
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| :*Host factors: Decrease in host immunity provides favourable environment to initiate the infection
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| :*Bacterial factors: Virulence and synergism between multiple bacteria promotes rapid spread of infection
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| *The aerobic and anaerobic bacteria produce exotoxins and enzymes like collagenase, heparinase, hyaluronidase etc which promote spread of infection.
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| *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.
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| *The cutaneous and subcutaneous vascular necrosis develops leading to local ischemia and further bacterial proliferation.
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| *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.
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| *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.
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| *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>
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| *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>
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| *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>
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| *Sepsis and multiorgan failure is the most common cause of death in Fournier's gangrene.
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| ===Common locations=== | | ==[[Fournier gangrene epidemiology and demographics|Epidemiology and Demographics]]== |
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| ===Microscopic histopathological analysis=== | | ==[[Fournier gangrene risk factors|Risk Factors]]== |
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| ==Causes== | | ==[[Fournier gangrene screening|Screening]]== |
| 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> | |
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| ===Bacteria=== | | ==[[Fournier gangrene natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
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| '''Aerobic organisms'''
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| 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>
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| *Group A streptococcus
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| *[[Escherichia coli]]
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| *[[Klebsiella pneumoniae]]
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| *[[Staphylococcus aureus]]
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| '''Anaerobic organisms'''
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| Most common anaerobic organisms are:
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| *[[Bacteroides fragilis]]
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| ===Other organisms===
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| *Streptococcus
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| *Enterococcus
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| *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>
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| *Clostridium
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| *Pseudomonas
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| *Proteus species
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| *''[[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>
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| *''[[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>
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| ===Idiopathic===
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| 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>
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| ==Differentiating {{PAGENAME}} from Other Diseases==
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| 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>
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| *Scrotal abscess
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| *Herpes simplex
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| *Cellulitis
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| *Strangulated hernia
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| *Streptococcal necrotizing fasciitis
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| *Gonococcal balanitis and edema
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| *Vascular occlusion syndromes
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| *Allergic vasculitis
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| *Pyoderma gangrenosum
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| *Necrolytic migratory erythema
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| *Ecthyma gangrenosum
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| *Warfarin necrosis
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| *Polyarteritis nodosa
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| ==Epidemiology and Demographics==
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| ===Incidence===
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| Only 600 cases of Fournier gangrene were reported in the world literature in the ten years since 1996, with most patients in their 60s or 70s with other concurrent illnesses.<ref>{{cite journal |author=Vaz I |title=Fournier gangrene |journal=Trop Doct |volume=36 |issue=4 |pages=203-4 |year=2006 |id=PMID 17034687}}</ref> However, Fournier's gangrene is not a reportable illness, and the condition is not uncommon, especially among diabetic individuals. A similar infection in women has been occasionally described.<ref>{{cite journal |author=Herzog W |title=[Fournier gangrene--also in females?] |journal=Zentralbl Chir |volume=112 |issue=9 |pages=564-76 |year=1987 |id=PMID 2956804}} </ref>
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| In Turkey it was reported that 46% of patients had [[diabetes mellitus]]<ref name="Yanar2006">{{cite journal |author=Yanar H, Taviloglu K, Ertekin C, Guloglu R, Zorba U, Cabioglu N, Baspinar I |title=Fournier's gangrene: risk factors and strategies for management |journal=World J Surg |volume=30 |issue=9 |pages=1750-4 |year=2006 |id=PMID 16927060}}</ref> whilst other studies have identified approximately a third of patients having either diabetes, alcoholism or malnutrition, and 10% having medical immunosuppression (chemotherapy, steroids, malignancy).<ref>{{cite journal |author=Tahmaz L, Erdemir F, Kibar Y, Cosar A, Yalcýn O |title=Fournier's gangrene: report of thirty-three cases and a review of the literature |journal=Int J Urol |volume=13 |issue=7 |pages=960-7 |year=2006 |id=PMID 16882063}}</ref>
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| ===Age===
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| 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>
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| ===Gender===
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| Men are more commonly affected with fournier's gangrene than women.<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>
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| ==Risk Factors==
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| 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>
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| *Comorbid systemic disorders
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| :*Age>50 yrs
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| :*Male Gender
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| :*Diabetes mellitus
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| :*Alcohol misuse
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| :*Immunosupression
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| :*Chemotherapy
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| :*Chronic corticosteroid use
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| :*HIV
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| :*Leukemia
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| :*Liver disease
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| :*Debilitating illness
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| :*Malignancy
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| :*Cytotoxic drugs
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| 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>
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| ! style="background: #4479BA; width: 400px;" | {{fontcolor|#FFF|Anorectal}}
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| ! style="background: #4479BA; width: 400px;" | {{fontcolor|#FFF|Genitourinary}}
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| ! style="background: #4479BA; width: 400px;" | {{fontcolor|#FFF|Dermatology}}
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| ! style="background: #4479BA; width: 400px;" | {{fontcolor|#FFF|Gynaecological}}
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| |-
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| | style="padding: 5px 5px; background: #F5F5F5;" |
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| *Trauma<br>
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| *Steroid enemas for radiation proctitis<br>
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| *Hemorrhoidectomy<br>
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| *Anal fissures excision<br>
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| *Diverticulitis<br>
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| *Colonic perforations<br>
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| *Ischiorectal, perirectal, or perianal abscesses<br>
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| *Appendicitis<br>
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| *Steroid enemas for radiation proctitis
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| | style="padding: 5px 5px; background: #F5F5F5;" |
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| *Trauma<br>
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| *Cancer invasion to external genitalia<br>
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| *Hemipelvectomy<br>
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| *Epididymitis or orchitis<br>
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| *Penile artificial implant or a foreign body<br>
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| *Hydrocele aspiration<br>
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| *Genital piercing<br>
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| *Intracavernosal cocaine<br>
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| *Urethral catheterization or instrumentation<br>
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| *Penile implantsinsertion<br>Prostatic biopsy<br>
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| *Vasectomy<br>
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| *Urethral strictures with urinary extravasation
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| | style="padding: 5px 5px; background: #F5F5F5;" |
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| *Blunt perineal trauma<br>
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| *Intramuscular injections<br>
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| *Genital piercings<br>
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| *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===
| |
| | |
| ===Complications===
| |
| | |
| ===Prognosis===
| |
|
| |
|
| ==Diagnosis== | | ==Diagnosis== |
| The diagnosis is primarily based on clinical findings.
| | [[Fournier gangrene diagnostic criteria|Diagnostic criteria]] | [[Fournier gangrene history and symptoms|History and Symptoms]] | [[Fournier gangrene physical examination|Physical Examination]] | [[Fournier gangrene laboratory tests|Laboratory Findings]] | [[Fournier gangrene electrocardiogram|Electrocardiogram]] | [[Fournier gangrene x ray|X-Ray Findings]] | [[Fournier gangrene CT|CT-Scan Findings]] | [[Fournier gangrene MRI|MRI Findings]] | [[Fournier gangrene ultrasound or echocardiography|Echocardiography and Ultrasound]] | [[Fournier gangrene other diagnostic studies|Other Diagnostic Studies]] | [[Fournier gangrene other imaging findings|Other Imaging Findings]] |
| ===Diagnostic Criteria===
| |
| '''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)
| |
| | || || || || || || || ||
| |
| |-
| |
| ! rowspan="1" style="border: 1; background: none;"| Serum Potassium (mmol/L)
| |
| | || || || || || || || ||
| |
| |-
| |
| ! rowspan="1" style="border: 1; background: none;"| Serum Creatinine<br>(mg/100/ml*2 for acute renal failure)
| |
| | || || || || || || || ||
| |
| |-
| |
| ! rowspan="1" style="border: 1; background: none;"| Hematocrit
| |
| | || || || || || || || ||
| |
| |-
| |
| ! rowspan="1" style="border: 1; background: none;"| WBC (Total/mm*1000)
| |
| | || || || || || || || ||
| |
| |-
| |
| ! rowspan="1" style="border: 1; background: none;"| Serum Bicarbonate (Venous,mmol/l)
| |
| | || || || || || || || ||
| |
| | |
| |}
| |
| | |
| *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
| |
| | |
| | |
| | |
| '''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===
| |
| ===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 selling in the scrotum
| |
| *Erythema
| |
| *Purulence or wound discharge
| |
| *Pallor
| |
| *Fever>38°C
| |
| *Crepitation
| |
| *Prostration
| |
| *Fluctuance
| |
| *Fetid odour
| |
| | |
| ===Physical examination===
| |
| ====Gallery====
| |
| =====Genitourinary system=====
| |
| | |
| <gallery>
| |
| | |
| Image: Fournier's_gangrene_01.jpeg|Fournier's gangrene. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/disease.jsf?diseaseId=12 With permission from Dermatology Atlas.]''<ref name="www.atlasdermatologico.com.br">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/disease.jsf?diseaseId=157>
| |
| | |
| Image: Fournier's_gangrene_02.jpeg|Fournier's gangrene. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/disease.jsf?diseaseId=12 With permission from Dermatology Atlas.]''<ref name="www.atlasdermatologico.com.br">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/disease.jsf?diseaseId=157>
| |
| | |
| Image: Fournier's_gangrene_03.jpeg|Fournier's gangrene. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/disease.jsf?diseaseId=12 With permission from Dermatology Atlas.]''<ref name="www.atlasdermatologico.com.br">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/disease.jsf?diseaseId=157>
| |
| | |
| Image: Fournier's_gangrene_04.jpeg|Fournier's gangrene. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/disease.jsf?diseaseId=12 With permission from Dermatology Atlas.]''<ref name="www.atlasdermatologico.com.br">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/disease.jsf?diseaseId=157>
| |
| | |
| Image: Fournier's_gangrene_05.jpeg|Fournier's gangrene. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/disease.jsf?diseaseId=12 With permission from Dermatology Atlas.]''<ref name="www.atlasdermatologico.com.br">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/disease.jsf?diseaseId=157>
| |
| | |
| </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:
| |
| :*[[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]]
| |
| [[Image:Founier-gangrene_X-ray.JPG]] | |
| | |
| ====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:
| |
| *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)
| |
| | |
| ===Other Diagnostic Studies===
| |
|
| |
|
| ==Treatment== | | ==Treatment== |
| ===Medical Therapy===
| | [[Fournier gangrene medical therapy|Medical Therapy]] | [[Fournier gangrene surgery|Surgery]] | [[Fournier gangrene primary prevention|Primary Prevention]] | [[Fournier gangrene secondary prevention|Secondary Prevention]] | [[Fournier gangrene cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Fournier gangrene future or investigational therapies|Future or Investigational Therapies]] |
| 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"/>
| |
| ====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]]
| |
| | |
| ===Surgery===
| |
| | |
| ===Prevention===
| |
| | |
| ==External links==
| |
| * {{WhoNamedIt2|synd|2521|Fournier gangrene}} and {{WhoNamedIt|doctor|2209|Jean Alfred Fournier}}
| |
|
| |
|
| ==References== | | ==Case Studies== |
| {{reflist|2}}
| | [[Fournier gangrene case study one|Case #1]] |
| | [[Category:Emergency mdicine]] |
| | [[Category:Disease]] |
|
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|
| | [[Category:Up-To-Date]] |
| | [[Category:Infectious disease]] |
| | [[Category:Surgery]] |
| | [[Category:Orthopedics]] |
| [[Category:Dermatology]] | | [[Category:Dermatology]] |
|
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| {{WH}}
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| {{WS}}
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