For patients with Fournier’s gangrene, a prompt clinical diagnosis followed by aggressive debridement of infected soft tissues is critical to saving lives and preventing severe morbidity.
Most commonly a polymicrobial bacterial infection, Fournier’s originates in the perineal, genital or perianal region. This rare form of necrotizing fasciitis can spread as quickly as three centimeters an hour along fascial planes that run from the genitalia up to the clavicles, causing devastating microvascular thrombosis and tissue ischemia.
Exotoxins released in the bloodstream also are damaging to vital organs. Mortality rate is high, ranging from 20 to 40 percent, and patients commonly require prolonged intensive care.
If patients can survive the infection, however, as reconstructive surgeons we can restore a very good quality of life. Achieving such a positive outcome requires immediate treatment with intravenous fluids and antibiotics and, ideally, debridement by a genitourinary surgeon within 12 hours of presentation. A second procedure usually is performed within 24 to 48 hours.
It is important for all physicians to be aware that Fournier’s can strike both males and females of all ages. Patients also should understand that they will face a fairly lengthy recovery with several follow-up surgeries, including reconstruction once their infection clears.
Nearly all cases of Fournier’s present in the emergency room. Unfortunately, many patients have waited days to report symptoms such as pain, redness, swelling, fever, difficulty urinating and a foul smell in the genital region.
Patients with conditions that affect microcirculation or immune system function are at higher risk. Included are diabetes, obesity, peripheral vascular disease, cancer, renal or liver failure, and a history of smoking or alcohol abuse.
The point of entry for bacteria can be as small as an ingrown hair; in many cases, the cause is idiopathic. Other possible causes are urethral strictures that obstruct and become infected or, in women, gynecological surgery or traumatic childbirth.
Fournier’s is a clinical diagnosis that does not require imaging tests, though if performed they will show air in the soft tissues. Specialists have developed a severity index rating system and at times must partner with general surgeons in the operating room. Patients then require close monitoring in the ICU.
Fortunately, treatment has improved vastly for a disease first described in modern medicine in 1764, when a French boy was gored by an ox in the scrotum. Fournier’s was later named for Dr. Jean Alfred Fournier, a syphilis expert in France who detailed its risk factors in 1883.
Today, we use negative pressure wound therapy to promote healing and, if necessary, divert urine or stool from damaged areas with a suprapubic catheter or colostomy.
About five days after a final debridement, most wound beds are healthy enough to begin reconstructive procedures that can restore function and cosmesis, most often through split-thickness skin grafts harvested from the anterior or lateral thigh.
Our hope is that raising awareness of Fournier’s – and the critical medical emergency that it is – will deliver more patients to our operating rooms faster.
Dr. DeLong and Dr. Virasoro are reconstructive genitourinary surgeons with Urology of Virginia and faculty in the Department of Urology at Eastern Virginia Medical School. urologyofva.net
