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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> | *The progression of infection to the perineal body, urogenital diaphragm and pubic rami is limited due to perineal fascia.<ref name="pmid24707378">{{cite journal| author=Katib A, Al-Adawi M, Dakkak B, Bakhsh A| title=A three-year review of the management of Fournier's gangrene presented in a single Saudi Arabian institute. | journal=Cent European J Urol | year= 2013 | volume= 66 | issue= 3 | pages= 331-4 | pmid=24707378 | doi=10.5173/ceju.2013.03.art22 | pmc=3974467 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24707378 }} </ref> | ||
*Because of direct supply of blood from aorta, testicular involvement is limited in Fournier's gangrene.<ref name="pmid17323114">{{cite journal| author=Gupta A, Dalela D, Sankhwar SN, Goel MM, Kumar S, Goel A et al.| title=Bilateral testicular gangrene: does it occur in Fournier's gangrene? | journal=Int Urol Nephrol | year= 2007 | volume= 39 | issue= 3 | pages= 913-5 | pmid=17323114 | doi=10.1007/s11255-006-9126-1 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17323114 }} </ref> However involvement of testis suggests retroperitoneal origin or spread of infection.<ref name="pmid12706005">{{cite journal| author=Chawla SN, Gallop C, Mydlo JH| title=Fournier's gangrene: an analysis of repeated surgical debridement. | journal=Eur Urol | year= 2003 | volume= 43 | issue= 5 | pages= 572-5 | pmid=12706005 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12706005 }} </ref> | *Because of direct supply of blood from aorta, testicular involvement is limited in Fournier's gangrene.<ref name="pmid17323114">{{cite journal| author=Gupta A, Dalela D, Sankhwar SN, Goel MM, Kumar S, Goel A et al.| title=Bilateral testicular gangrene: does it occur in Fournier's gangrene? | journal=Int Urol Nephrol | year= 2007 | volume= 39 | issue= 3 | pages= 913-5 | pmid=17323114 | doi=10.1007/s11255-006-9126-1 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17323114 }} </ref> However involvement of testis suggests retroperitoneal origin or spread of infection.<ref name="pmid12706005">{{cite journal| author=Chawla SN, Gallop C, Mydlo JH| title=Fournier's gangrene: an analysis of repeated surgical debridement. | journal=Eur Urol | year= 2003 | volume= 43 | issue= 5 | pages= 572-5 | pmid=12706005 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12706005 }} </ref> | ||
*Fournier's gangrene of the male ganatalia spares testes, urethra and deep penile tissues.<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> | |||
===Common locations=== | ===Common locations=== | ||
Revision as of 19:12, 11 October 2016
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Steven C. Campbell, M.D., Ph.D.; Associate Editor(s)-in-Chief: Yamuna Kondapally, M.B.B.S[1]; Jesus Rosario Hernandez, M.D. [2]
Synonyms and keywords: Idiopathic gangrene of scrotum; Periurethral phlegmon; Streptococcal scrotal gangrene; Genito-perineal gangrene
| Fournier gangrene | |
| ICD-10 | N49.8 (ILDS N49.81), N76.8 |
|---|---|
| ICD-9 | 608.83 |
| DiseasesDB | 31119 |
| MeSH | D018934 |
Overview
Fournier gangrene is a type of necrotizing infection (gangrene) of the perineal, genital or perianal regions usually affecting the male genitals but can also occur in female and children.[1] It is a fulminant form of necrotizing fasciitis. It was first described by Baurienne in 1764 and is named after a French venereologist, Jean-Alfred Fournier following five cases he presented in clinical lectures in 1883.[2][3]
Historical Perspective
- Fournier's gangrene was first described by in 1764 by Baurienne.[2]
- The detailed description of fournier's gangrene was given by Jean Alfred Fournier, who is a French venereologist in 1883.[3]
Classification
Pathophysiology
- The transmission of pathogens occurs through the following routes:[4]
- External trauma (e.g., laceration, abrasion, burn, insect bite)
- Direct spread from a perforated viscus (particularly colon, rectum, or anus) or another surgical procedure (e.g., vasectomy, hemorrhoidectomy)
- Urogenital organ
- Perirectal abscess
- Decubitus ulcer
- Following transmission, the bacteria uses the entry site to invade the fascial planes which causes the wide spread necrosis of superficial fascia, deep fascia,
subcutaneous fat, nerves, arteries, and veins.
- Superficial skin and deeper muscles are typically spared.
- In late stages, lesions develop liquefactive necrosis at all tissue levels.
Pathogenesis
- The pathogenesis of fournier's gangrene is the result of an imbalance between bacterial and host factors.[5][6][4]
- Host factors: Decrease in host immunity provides favourable environment to initiate the infection
- Bacterial factors: Virulence and synergism between multiple bacteria promotes rapid spread of infection
- The aerobic and anaerobic bacteria produce exotoxins and enzymes like collagenase, heparinase, hyaluronidase etc which promote spread of infection.
- The aerobic bacteria cause acceleration of coagulation by promoting platelet aggregation and complement fixation and the anaerobic bacteria produce collagenase and heparinase that promote the formation of clots leading to obliterative endarteritis.
- The cutaneous and subcutaneous vascular necrosis develops leading to local ischemia and further bacterial proliferation.
- The infection spreads from superficial (colles fascia) and deep fascial planes of genetalia to the overlying skin sparing the muscles. The infection then spreads from colles fascia to the penis and scrotum via Buck's and Dartos fascia or to the anterior abdominal wall via Scarpa's fascia or vice versa.
- The inferior epigastric and deep circumflex iliac arteries (supply anterior abdominal wall), and external and internal pudendal artery supply the scrotal wall. Except internal pudendal artery, each of these vessels travels with in Camper's fascia and can therefore become thrombosed in the progression of fournier's gangrene.
- The progression of infection to the perineal body, urogenital diaphragm and pubic rami is limited due to perineal fascia.[7]
- Because of direct supply of blood from aorta, testicular involvement is limited in Fournier's gangrene.[8] However involvement of testis suggests retroperitoneal origin or spread of infection.[9]
- Fournier's gangrene of the male ganatalia spares testes, urethra and deep penile tissues.[10]
Common locations
Microscopic histopathological analysis
Causes
Fournier's gangrene is caused by mixed aerobic and anaerobic organisms which normally exist below the pelvic diaphragm in the perineum and genitalia.[11] Fournier's gangrene may be caused by the following organisms:[12]
Bacteria
Aerobic organisms Most common aerobic organisms are:[13]
- Group A streptococcus
- Escherichia coli
- Klebsiella pneumoniae
- Staphylococcus aureus
Anaerobic organisms Most common anaerobic organisms are:
Other organisms
- Streptococcus
- Enterococcus
- Coryebacterium[14]
- Clostridium
- Pseudomonas
- Proteus species
- Candida species[15]
- Lactobacillus gasseri[16]
Idiopathic
Less than quarter of cases of fournier's gangrene are idiopathic.[1][17]
Differentiating Fournier gangrene from Other Diseases
Epidemiology and Demographics
Incidence
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.[18] 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.[19]
In Turkey it was reported that 46% of patients had diabetes mellitus[20] whilst other studies have identified approximately a third of patients having either diabetes, alcoholism or malnutrition, and 10% having medical immunosuppression (chemotherapy, steroids, malignancy).[21]
Age
Fournier's gangrene affects individuals of all ages but commonly affects individuals older than 50 years of age.[4]
Gender
Men are more commonly affected with fournier's gangrene than women.[3]
Risk Factors
Common risk factors in the development of fournier's gangrene are:[22][23][17]
- Comorbid systemic disorders
- Age>50 yrs
- Male Gender
- Diabetes mellitus
- Alcohol misuse
- Immunosupression
- Chemotherapy
- Chronic corticosteroid use
- HIV
- Leukemia
- Liver disease
- Debilitating illness
- Malignancy
- Cytotoxic drugs
The most common foci of fournier's gangrene include:[11][24]
| Anorectal | Genitourinary | Dermatology | Gynaecological |
|---|---|---|---|
|
|
|
|
Neonates and Children
- Trauma[24]
- Burns
- Insect bites
- Circumcision
Screening
Natural History, Complications, and Prognosis
Natural history
Complications
Prognosis
Diagnosis
Diagnostic Criteria
History
Symptoms
Physical examination
Gallery
Genitourinary system
Laboratory Findings
Imaging Findings
Other Diagnostic Studies
Treatment
Medical Therapy
Fournier gangrene is a urological emergency requiring intravenous antibiotics and debridement (surgical removal) of necrotic (dead) tissue. Despite such measures, the mortality rate overall is 40%, but 78% if sepsis is already present at the time of initial hospital admission.[20]
Antimicrobial Therapy
- Fournier gangrene[25]
- If caused by streptococcus species or clostridia
- Preferred regimen: Penicillin G
- Polymicrobial
-
- MRSA (methicillin resistant staphylococcus aureus) suspected
- Preferred regimen: vancomycin OR daptomycin
Surgery
Prevention
External links
References
- ↑ 1.0 1.1 Smith GL, Bunker CB, Dinneen MD (1998). "Fournier's gangrene". Br J Urol. 81 (3): 347–55. PMID 9523650.
- ↑ 2.0 2.1 Nathan B (1998). "Fournier's gangrene: a historical vignette". Can J Surg. 41 (1): 72. PMC 3950066. PMID 9492752.
- ↑ 3.0 3.1 3.2 Chennamsetty A, Khourdaji I, Burks F, Killinger KA (2015). "Contemporary diagnosis and management of Fournier's gangrene". Ther Adv Urol. 7 (4): 203–15. doi:10.1177/1756287215584740. PMC 4580094. PMID 26445600.
- ↑ 4.0 4.1 4.2 Mallikarjuna MN, Vijayakumar A, Patil VS, Shivswamy BS (2012). "Fournier's Gangrene: Current Practices". ISRN Surg. 2012: 942437. doi:10.5402/2012/942437. PMC 3518952. PMID 23251819.
- ↑ Morua AG, Lopez JA, Garcia JD, Montelongo RM, Guerra LS (2009). "Fournier's gangrene: our experience in 5 years, bibliographic review and assessment of the Fournier's gangrene severity index". Arch Esp Urol. 62 (7): 532–40. PMID 19815967.
- ↑ Shyam DC, Rapsang AG (2013). "Fournier's gangrene". Surgeon. 11 (4): 222–32. doi:10.1016/j.surge.2013.02.001. PMID 23578806.
- ↑ Katib A, Al-Adawi M, Dakkak B, Bakhsh A (2013). "A three-year review of the management of Fournier's gangrene presented in a single Saudi Arabian institute". Cent European J Urol. 66 (3): 331–4. doi:10.5173/ceju.2013.03.art22. PMC 3974467. PMID 24707378.
- ↑ Gupta A, Dalela D, Sankhwar SN, Goel MM, Kumar S, Goel A; et al. (2007). "Bilateral testicular gangrene: does it occur in Fournier's gangrene?". Int Urol Nephrol. 39 (3): 913–5. doi:10.1007/s11255-006-9126-1. PMID 17323114.
- ↑ Chawla SN, Gallop C, Mydlo JH (2003). "Fournier's gangrene: an analysis of repeated surgical debridement". Eur Urol. 43 (5): 572–5. PMID 12706005.
- ↑ Campos JA, Martos JA, Gutiérrez del Pozo R, Carretero P (1990). "Synchronous caverno-spongious thrombosis and Fournier's gangrene". Arch Esp Urol. 43 (4): 423–6. PMID 2383054.
- ↑ 11.0 11.1 Eke N (2000). "Fournier's gangrene: a review of 1726 cases". Br J Surg. 87 (6): 718–28. doi:10.1046/j.1365-2168.2000.01497.x. PMID 10848848.
- ↑ Thwaini A, Khan A, Malik A, Cherian J, Barua J, Shergill I, Mammen K (2006). "Fournier's gangrene and its emergency management". Postgrad Med J. 82 (970): 516–9. PMID 16891442.
- ↑ Paty R, Smith AD (1992). "Gangrene and Fournier's gangrene". Urol Clin North Am. 19 (1): 149–62. PMID 1736475.
- ↑ Yanar H, Taviloglu K, Ertekin C, Guloglu R, Zorba U, Cabioglu N; et al. (2006). "Fournier's gangrene: risk factors and strategies for management". World J Surg. 30 (9): 1750–4. doi:10.1007/s00268-005-0777-3. PMID 16927060.
- ↑ Jensen P, Zachariae C, Grønhøj Larsen F (2010). "Necrotizing soft tissue infection of the glans penis due to atypical Candida species complicated with Fournier's gangrene". Acta Derm Venereol. 90 (4): 431–2. doi:10.2340/00015555-0847. PMID 20574621.
- ↑ Tleyjeh IM, Routh J, Qutub MO, Lischer G, Liang KV, Baddour LM (2004). "Lactobacillus gasseri causing Fournier's gangrene". Scand J Infect Dis. 36 (6–7): 501–3. PMID 15307582.
- ↑ 17.0 17.1 Vick R, Carson CC (1999). "Fournier's disease". Urol Clin North Am. 26 (4): 841–9. PMID 10584624.
- ↑ Vaz I (2006). "Fournier gangrene". Trop Doct. 36 (4): 203–4. PMID 17034687.
- ↑ Herzog W (1987). "[Fournier gangrene--also in females?]". Zentralbl Chir. 112 (9): 564–76. PMID 2956804.
- ↑ 20.0 20.1 Yanar H, Taviloglu K, Ertekin C, Guloglu R, Zorba U, Cabioglu N, Baspinar I (2006). "Fournier's gangrene: risk factors and strategies for management". World J Surg. 30 (9): 1750–4. PMID 16927060.
- ↑ Tahmaz L, Erdemir F, Kibar Y, Cosar A, Yalcýn O (2006). "Fournier's gangrene: report of thirty-three cases and a review of the literature". Int J Urol. 13 (7): 960–7. PMID 16882063.
- ↑ Clayton MD, Fowler JE, Sharifi R, Pearl RK (1990). "Causes, presentation and survival of fifty-seven patients with necrotizing fasciitis of the male genitalia". Surg Gynecol Obstet. 170 (1): 49–55. PMID 2294630.
- ↑ Morpurgo E, Galandiuk S (2002). "Fournier's gangrene". Surg Clin North Am. 82 (6): 1213–24. PMID 12516849.
- ↑ 24.0 24.1 Amendola MA, Casillas J, Joseph R, Antun R, Galindez O (1994). "Fournier's gangrene: CT findings". Abdom Imaging. 19 (5): 471–4. PMID 7950832.
- ↑ Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.