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| __NOTOC__ | | __NOTOC__ |
| '''For more information about necrotizing fasciitis click [[necrotizing fasciitis|here]] | | '''For more information about necrotizing fasciitis click [[necrotizing fasciitis|here]] |
| {{SI}} | | '''For patient information, click [[Fournier gangrene (patient information)|here]]''' |
| | {{Fournier gangrene}} |
| {{SCC}}; {{AE}} {{YK}}; {{JH}} | | {{SCC}}; {{AE}} {{YK}}; {{JH}} |
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| | MeshID = D018934 | | | MeshID = D018934 |
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| | ==[[Fournier gangrene overview|Overview]]== |
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| ==Overview== | | ==[[Fournier gangrene historical perspective|Historical Perspective]]== |
| '''Fournier gangrene''' is a type of [[Synergy|synergistic]] polymicrobial [[necrosis|necrotizing]] [[infection]] ([[gangrene]]) of the [[perineal]], [[genital]] or perianal regions usually affecting the male [[genital]]s but can also occur in females 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 gangrene was first described 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 gangrene was given by Jean Alfred Fournier, 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>
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| ==Classification== | | ==[[Fournier gangrene pathophysiology|Pathophysiology]]== |
| The ICD 10 classification of Fournier gangrene include:<ref name=WHO>Classification http://apps.who.int/classifications/icd10/browse/2016/en#/N49.8 (2016) Accessed on October 14, 2016</ref>
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| *ICD-10: N49.3
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| *Code Classification
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| :*Diseases of the [[genitourinary system]]
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| ::*Diseases of male [[genital]] organs (N40-N53)
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| :::*Inflammatory disorders of male [[genital]] organs, NEC (N49)
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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]], [[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.
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| ===Pathogenesis=== | | ==[[Differentiating Fournier gangrene from other diseases|Differentiating Fournier gangrene from other Diseases]]== |
| The pathogenesis of Fournier gangrene is the result of an imbalance between host and bacterial 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> A decrease in host [[immunity]] provides a favorable environment to initiate the [[infection]], while [[Virulence|virulence]] and [[synergy|synergism]] between multiple bacteria promotes rapid spread of [[infection]].
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| The [[aerobic]] and [[anaerobic]] bacteria produce [[exotoxins]] and [[enzymes]], such as [[collagenase]], [[Heparin lyase|heparinase]], and [[hyaluronidase]], which promote the spread of [[infection]]. The [[aerobic]] bacteria accelerate [[coagulation]] by promoting [[platelet aggregation]] and [[complement fixation]]. The [[anaerobic]] bacteria produce [[collagenase]] and [[Heparin lyase|heparinase]] that promote the formation of clots leading to [[Obliterating endarteritis]]. The development of [[cutaneous]] and [[subcutaneous]] [[necrosis|vascular necrosis]] leads to local [[ischemia]] and further bacterial proliferation.
| | ==[[Fournier gangrene epidemiology and demographics|Epidemiology and Demographics]]== |
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| The [[infection]] spreads from superficial ([[Fascia of Colles|colles fascia]]) and deep fascial planes of [[genitalia]] to the overlying skin sparing the muscles. The [[infection]] then spreads from [[Fascia of Colles|colles fascia]] to the [[penis]] and [[scrotum]] via [[buck's fascia|Buck's]] and [[Dartos]] fascia or to the anterior abdominal wall via [[Fascia of Scarpa|Scarpa's fascia]] or vice versa. The [[inferior epigastric artery|inferior epigastric]] and deep [[iliac artery|circumflex iliac]] arteries supply the anterior abdominal wall, and the [[deep external pudendal artery|deep external pudendal]] and [[internal pudendal artery|internal pudendal]] arteries supply the scrotal wall. Except for the [[internal pudendal artery]], each of these vessels travels within [[Fascia of Camper|Camper's fascia]] and can therefore become [[thrombosis|thrombosed]] in the progression of Fournier gangrene.
| | ==[[Fournier gangrene risk factors|Risk Factors]]== |
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| The progression of [[infection]] to the [[perineal body]], [[urogenital diaphragm]] and [[ramus|pubic rami]] is limited due to [[Fascia of perineum|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 the direct supply of blood from the [[aorta]], [[testes|testicular]] involvement is limited in Fournier 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 gangrene of the male genetalia spares [[testes]], [[urethra]] and deep [[penis|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>
| | ==[[Fournier gangrene screening|Screening]]== |
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| [[Sepsis]] and multiorgan failure is the most common cause of death in Fournier gangrene.
| | ==[[Fournier gangrene natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
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| ===Common locations===
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| The common locations of Fournier 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>
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| *[[Perineum]]
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| *[[Scrotum]]
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| *[[Penis]]
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| ===Gross pathology===
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| On gross pathology, the characteristic findings of Fournier gangrene include:
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| *[[Subcutaneous]] [[emphysema]]
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| *Swollen scrotal wall
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| *[[Edema]]
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| *[[Erythema]]
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| *Bullae
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| *Skin sloughing
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| ===Microscopic histopathological analysis===
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| On microscopic histopathological analysis, the characteristic findings of Fournier gangrene are:
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| *Early stages
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| :*[[vasculitis|Obliterative vasculitis]] with [[Microvascular disease|microangiopathic thrombosis]]
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| :*Acute [[inflammation]] of [[subcutaneous|subcutaneous tissue]]
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| :*Superficial hyaline [[necrosis]] along with [[edema]] and [[inflammation]] of the [[dermis]] and [[subcutaneous fat]]
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| :*Dense [[neutrophil]]-predominant inflammatory infiltrate
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| *Late stages
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| :*Noninflammatory [[Coagulation|intravascular coagulation]] and [[hemorrhage]]
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| :*[[Myonecrosis]]
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| <gallery>
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| Image:FG_1.jpg|Histology of excised skin shows full thickness, featureless, [[coagulative necrosis]] with no viable tissue remaining
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| Image:FG2.jpg|Histology of excised scrotal skin shows zones of [[neutrophil]] polymorph infiltration, with embedded foreign material possibly representing hair shafts
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| Image:FG3.jpg|Histology of excised skin shows bacterial colonies ([[cocci]] and [[bacilli]]) in the superficial zone
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| </gallery>
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| ==Causes==
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| Fournier 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 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===
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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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| *[[Streptococcus|''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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| *[[Corynebacterium]]<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|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|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 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 gangrene must be differentiated from other diseases that cause [[pain]], [[swelling]], [[erythema]], [[discharge]] and raised temperature ([[fever]]) 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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| *[[abscess|Scrotal abscess]]
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| *[[Herpes simplex]]
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| *[[Cellulitis]]
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| *[[Strangulated hernia]]
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| *[[necrotizing fasciitis|Streptococcal necrotizing fasciitis]]
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| *[[Balanitis|Gonococcal balanitis]] and [[edema]]
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| *Vascular occlusion syndromes
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| *[[Vasculitis|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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| [[Incidence]] of Fournier 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>
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| *The overall [[incidence]] of Fournier gangrene annually is 1.6 cases per 100,000 males. The [[incidence]] peaked and remained steady after age 50 at 3.3 cases per 100,000 males.
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| *The [[incidence]] of Fournier gangrene increased 0.2 per 100,000 males for each 1% increase in the regional prevalence of [[diabetes]].
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| *The [[incidence rate]] was highest in the southern U.S. and lowest in the western and mid-western U.S.
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| <gallery>
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| 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>
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| </gallery>
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| ===Age===
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| Fournier gangrene affects individuals of all ages but more 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>
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| ===Gender===
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| Men are more commonly affected with Fournier gangrene than women, with a male:female ratio of 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>
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| ===Mortality===
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| *Mortality rate decreases with early aggressive treatment.
| |
| *The mortality rate of Fournier gangrene is between 20% to 80%. Higher mortality rates are found in [[diabetes|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 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 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
| |
| |+
| |
| ! 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>
| |
| *[[Enemas|Steroid enemas]] for [[colitis|radiation proctitis]]<br>
| |
| *[[Hemorrhoidectomy]]<br>
| |
| *[[Anal fissure|Anal fissures excision]]<br>
| |
| *[[Diverticulitis]]<br>
| |
| *[[Colon|Colonic perforations]]<br>
| |
| *[[Ischiorectal fossa|Ischiorectal]], [[perirectal]], or [[perianal abscesses]]<br>
| |
| *[[Appendicitis]]<br>
| |
| *[[Enemas|Steroid enemas]] for [[Colitis|radiation proctitis]]
| |
| | style="padding: 5px 5px; background: #F5F5F5;" |
| |
| *Trauma<br>
| |
| *[[Cancer]] invasion to external genitalia<br>
| |
| *[[Hemipelvectomy]]<br>
| |
| *[[Epididymitis]] or [[orchitis]]<br>
| |
| *[[Penile implant|Penile artificial implant]] or a foreign body<br>
| |
| *[[Hydrocele]] aspiration<br>
| |
| *Genital piercing<br>
| |
| *[[Cavernous sinus|Intracavernosal]] cocaine<br>
| |
| *[[Urethral catheterization]] or instrumentation<br>
| |
| *[[Penile prosthesis|Penile implants]] insertion<br>[[Biopsy|Prostatic biopsy]]<br>
| |
| *[[Vasectomy]]<br>
| |
| *Urethral strictures with urinary extravasation
| |
| | style="padding: 5px 5px; background: #F5F5F5;" |
| |
| *Blunt [[perineal]] trauma<br>
| |
| *[[Intramuscular injection|Intramuscular injections]]<br>
| |
| *Genital piercings<br>
| |
| *[[Furuncle|Scrotal furuncle]]<br>
| |
| *Perineal or pelvic surgery/inguinal [[herniorrhaphy]]<br>
| |
| | style="padding: 5px 5px; background: #F5F5F5;" |
| |
| *[[Episiotomy]] wound<br>
| |
| *Infected [[bartholin's gland]]<br>
| |
| *[[Abortion|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 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 and diffuse [[erythema]] without distinct borders are seen.
| |
| | |
| During the first 1 or 2 days, the lesions develop with progressive color changes from red to purple to blue and then become [[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 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>
| |
| | |
| '''Systemic complications'''
| |
| *[[Renal failure]]
| |
| *[[Acute respiratory distress syndrome]]
| |
| *[[Heart failure]]
| |
| *[[Cardiac arrhythmias]]
| |
| *Septic metastasis
| |
| *[[Urinary tract infection]]
| |
| *[[Stroke]]
| |
| *Acute [[thromboembolic]] 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 [[Scar|scarring]]
| |
| | |
| ===Prognosis===
| |
| Depending on the underlying comorbidities, the prognosis of Fournier gangrene varies. Some of the prognostic factors include:
| |
| *Severe [[sepsis]]
| |
| *If the affected area calculation/extension of the [[necrosis]] is:
| |
| :*<3% of the body surface area, death is rare
| |
| :*≥5% of the body surface area, the prognosis is worse
| |
|
| |
|
| ==Diagnosis== | | ==Diagnosis== |
| The diagnosis of Fournier 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>
| | [[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]] |
| *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 [[gangrene|gangrenous]] and [[necrosis|necrotic tissue]]
| |
| *Histologically proven [[necrotizing fasciitis]].
| |
| | |
| ===Diagnostic Criteria===
| |
| '''The Uludag Fournier 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 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.
| |
| | |
| {| class="wikitable" style="border: 2; background: none;"
| |
| ! colspan="1" rowspan="2" style="border: 1; background: 1;"| Variable
| |
| ! colspan="5" rowspan="1"| Score
| |
| |- colspan="1" rowspan="2" style="border: 1; background: 1;"
| |
| ! 0 || +1 || +2 || +3 || +4
| |
| |-
| |
| ! rowspan="1" style="border: 1; background: none;"| [[C reactive protein|C-reactive protein]] (mg/dL)
| |
| | <150 || || || || >150
| |
| |-
| |
| ! rowspan="1" style="border: 1; background: none;"| Total [[white blood cell|White Blood Cell]] Count (/mm3)
| |
| | <15 || 15-25 || >25 || ||
| |
| |-
| |
| ! rowspan="1" style="border: 1; background: none;"| [[Hemoglobin]] (g/dL)
| |
| | <13.5 || 11-13.5 || <11 || ||
| |
| |-
| |
| ! rowspan="1" style="border: 1; background: none;"| [[Sodium]] (mmol/L)
| |
| | ≥135 || || <135 || ||
| |
| |-
| |
| ! rowspan="1" style="border: 1; background: none;"| [[Creatinine]] (μmol/L)
| |
| | <141 || || >141 || ||
| |
| |-
| |
| ! rowspan="1" style="border: 1; background: none;"| [[Glucose]] (mmol/L)
| |
| | <10 || >10 || || ||
| |
| |}
| |
| | |
| *Score of ≤5 indicates low risk
| |
| *Score of 6-7 indicates intermediate risk
| |
| *Score of ≥8 indicates high risk
| |
| | |
| ===History===
| |
| A detailed and thorough history from the patient is necessary. Specific areas of focus when obtaining a history from the patient include:<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>
| |
| *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 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
| |
| *[[Purulent|Purulence]] or wound discharge
| |
| *Pallor
| |
| *Fever>38°C
| |
| *[[Crepitus|Crepitation]]
| |
| *[[Prostration]]
| |
| *Fluctuance
| |
| *Fetid odour
| |
| | |
| ===Physical examination===
| |
| The physical examination of Fournier gangrene include:
| |
| | |
| '''Appearance of the Patient'''
| |
| | |
| The patients with Fournier 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 [[genitalia]] and [[perineum]], and [[digital rectal examination]].
| |
| *[[Induration]]
| |
| *Warmth
| |
| *Tenderness beyond margins of [[erythema]]
| |
| *[[Swelling]]
| |
| *Erythema with ill defined margins
| |
| *[[Blister|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 Fournier gangrene)
| |
| *Sensory and motor deficits (e.g. [[Anesthesia|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 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 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 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 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 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 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]]
| |
| *[[ABG|Arterial blood gas analysis]]
| |
| *Electrolyte panel
| |
| *[[Blood urea nitrogen]] ([[BUN]])
| |
| *[[Creatinine]]
| |
| *[[Blood sugar|Blood glucose levels]]
| |
| | |
| ===Imaging Findings===
| |
| The diagnosis of Fournier 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 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 region|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 gangrene because:
| |
| :*[[Emphysema|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 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 [[Epididymis|epididymi]] spared (due to their separate blood supply)
| |
| *Reactive unilateral or bilateral [[Hydrocele|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 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 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
| |
| *[[Emphysema|Subcutaneous emphysema]]
| |
| | |
| ===Gallery of Imaging Findings===
| |
| <gallery>
| |
| Image:Founier-gangrene_X-ray.JPG|200px|X ray of Fournier 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 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 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 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== | | ==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="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>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 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]]
| |
| *[[Cisplatin]] ((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 [[hypercapnia|hypercapnic]] patients (therefore, frequent periods of breathing in room air are interposed when patients are on [[hyperbaric oxygen|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 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>
| | ==Case Studies== |
| *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>
| | [[Fournier gangrene case study one|Case #1]] |
| :*Patients displaying intense pain and skin color change such as [[edema]] and/or [[ecchymoses]]
| | [[Category:Emergency mdicine]] |
| :*Signs of [[ischemia|skin ischemia]] with [[blister|blisters]] and bullae
| | [[Category:Disease]] |
| :*[[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 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 [[necrosis|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 hemostat 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 [[abscess|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>
| |
| *[[Collagenase|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 [[exudate|exudates]], reducing localized [[edema]], and finally drawing wound edges together.
| |
| | |
| ===Prevention===
| |
| '''Primary prevention'''
| |
| | |
| Effective measures for the primary prevention of Fournier 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
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| *Patients with underlying co-morbidities should watch carefully for any signs of infection
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| '''Secondary prevention'''
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| Secondary prevention strategies following Fournier gangrene include:
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| *Early diagnosis and prompt treatment with either [[antibiotics]] or surgery.
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| *This strategy prevents or slows the progression and complications of the disease.
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| ==External links==
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| * {{WhoNamedIt2|synd|2521|Fournier gangrene}} and {{WhoNamedIt|doctor|2209|Jean Alfred Fournier}}
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| ==References==
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| {{reflist|2}}
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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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