Fourniers Gangrene
 Jean Alfred Fournier - Parisian dermatologist and venereologist ( 1883)
 polymicrobial necrotizing fasciitis of the perineal, perianal, or genital areas
Anatomy
 superficial perineal fascia (Colles' fascia) is attached
o laterally to the pubic rami and fascia lata of the thighs
o posteriorly to the urogenital diaphragm and perineal membrane.
 anterior extensions of Colles' fascia include the tunica dartos of the penis and
scrotum and Scarpa's fascia of the anterior abdominal wall.
 Infections originating in the ano-rectal region first penetrate the sphincteric
musculature. Then, the infection spreads along the perianal region and may extend
along Colles' fascia. While lateral spread is prevented by attachments of Colles'
fascia, anterior and superior extension along dartos and Scarpa's fasciae is
unhindered. Alternatively, anorectal infection may spread through the urogenital
diaphragm to the perivesical space, then to the scrotum via the spermatic fascia.
 Buck's fascia of the penis, deep to the tunica dartos, is bound by adherence to the
tunica albuginea distally at the coronal sulcus of the glans and proximally at the
crus and suspensory ligament of the penis
 Urethral infections are initially limited by Buck's fascia, surrounding the corpora
spongiosum and cavernosa. Once Buck's fascia is traversed, the infection spreads
along the overlying tunica dartos and the contiguous layers of Scarpa and Colles.
 In general, necrotizing gangrene of urethral origin does not spread to the anal
triangle, because Colles' fascia is attached to the perineal membrane posteriorly;
however, if Colles' fascia or the urogenital diaphragm is violated, the infection can
involve the ischiorectal and perivesical spaces.
 Testicular involvement is rare, as the testicular arteries originate directly from the
aorta and thus have a blood supply separate from the affected region.
Classification
 Type 1 – polymicrobial
 Type 2 – monomicrobial
 Type 3 – Clostridial
Fournier gangrene severity index score-has been shown to aid in prognosis.
 A score from 0 to 4 is assigned to each of the following parameters (Yeniyol,
2004): temperature; heart rate; respiratory rate; serum sodium, potassium,
bicarbonate, and creatinine levels; hematocrit; and white blood cell count.
 Mortality is associated with a total score >9.
Pathophysiology
 Localized infection adjacent to a portal of entry is the inciting event in the
development of Fournier gangrene.
 Infection often occurs secondary to perianal, perirectal, and ischiorectal abscesses;
anal fissures; colonic perforations; urethral strictures with urinary extravasation;
chronic urinary tract infections; epididymitis; orchitis; or hidradenitis
 in women genital gangrene typically arises from vulval or Bartholin's abscess and
spreads to involve the vulva or perineum. It may also complicate episiotomy,
hysterectomy, septic abortion, and cervical or pudendal nerve blocks.
 source of infection may be either urogenital (45%), anorectal (33%) or
cutaneous (21%) - Clayton, Surg Gynaecol Obstet 1990
 Wound cultures from patients with Fournier gangrene reveal that it is a
polymicrobial infection with an average of 4 isolates per case:
o Escherichia coli is the predominant aerobe, and Bacteroides is the
predominant anaerobe.
o Other common microflora include Proteus, Staphylococcus,
Enterococcus, aerobic and anaerobic Streptococcus, Pseudomonas,
Klebsiella, and Clostridium.
 Ultimately, an obliterative endarteritis develops, and the ensuing cutaneous and
subcutaneous vascular necrosis leads to localized ischemia and further bacterial
proliferation
Risk factors
1. Diabetes mellitus (present in up to 60% of cases)
2. Alcoholism
3. Extremes of age
4. Malignancy
5. Chronic steroid use
6. Malnutrition
7. HIV infection
Epidemiology
 M>F 10:1
 Most reported cases occur in patients aged 30-60 years.
 only 56 pediatric cases reported, with 66% of those in infants younger than 3
months.
 Lower incidence in females may be caused by better drainage of the perineal
region through vaginal secretions.
 reported mortality rate for Fournier gangrene varies widely from 4-75%.
Clinical
 Classic triad: severe pain + swelling + fever (systemic sepsis)
 Pain out of proportion to the physical findings is the most consistent feature
 Bullae; Crepitus (50 to 62%)
 Gangrene
 "Dirty dishwater fluid"
 finger sweep test - : the area of suspected involvement is infiltrated with local
anesthesia. A 2-cm incision is made in the skin down to the deep fascia. A gentle,
probing manoeuvre with the index finger is performed at the level of the deep
fascia. If the tissues dissect with minimal resistance, the finger test is positive. In
addition, lack of bleeding is considered as an ominous sign of a necrotizing
process. On many occasions, a "murky dishwater fluid" can also be noted in the
wound.
Investigations
US – differentiate from testicular vs scrotal pathology
CT - soft-tissue and fascial thickening, fat stranding, and soft-tissue gas collections.
frozen section - confirm the early diagnosis of necrotizing gangrene.
Differentials
1. Other infections: scrotal cellulitis or balanoposthitis. More serious conditions that
mimic Fournier's gangrene include scrotal abscesses or incarcerated hernia.
2. Vasculitis include IgE-positive hypersensitivity vasculitis, poly-arteritis nodosa,
and pyoderma gangrenosum
Complications
 Early complications include sepsis, respiratory and renal failure, and coagulopathy
 Delayed complications include fistulae, infertility, and urethral strictures
Treatment
1. Resuscitation
2. after blood cultures are taken, commence on antibiotics
3. prompt debridement with patient in a lithotomy position
4. Supportive
 ICU
 Nutrition
 Wound care
 Hyperbaric
 ?honey (case reports)
5. reconstruction
Debridement
 Aggressive initial debridement
 Leave no undermining - Skin edges should slope down to wound bed.
 multiple return to theatre often required
 Diversion, either fecal or urinary, is occasionally required. Controversy exists
regarding the need for colostomy. While some advocate diverting colostomy in
most cases of perineal necrotizing gangrene, others believe this to be unnecessary,
even with significant gangrene of perirectal tissues. Generally, colostomy is
indicated if the sphincter is grossly infected, rectal or colonic perforation has
occurred, incontinence is present, or if the rectal wound is large
 indications for supra- pubic catheterizations include stricture disease and urinary
extravasation or phlegmon
 Orchiectomy is performed when conditions such as scrotal abscesses or severe
epididymo-orchitis affect testicular viability. Coverage of the testes is important to
prevent dessication. Initially, moist dressings and gauze impregnated with
petroleum jelly provide sufficient protection. Delayed closure of the scrotum is
often an option because of the redundant nature of scrotal skin. If this is not
possible, the testes can be placed in temporary subcutaneous pouches of the medial
thighs or lower abdominal wall for later scrotal reconstruction
Scrotal reconstruction
 Reconstruction of the scrotum is important for functional, cosmetic, and
psychological reasons.
 Protection of the exposed testicles is necessary for both hormonal production by
the Leydig cells and spermatogenesis
 Transposition of the testicles and spermatic cord to a subcutaneous pocket in the
upper thigh has been extensively used. Permanent placement in the thigh has been
reported, but concerns over temperature regulation and reports of pain and
adverse psychological effects generally support relocating the testicles
anatomically at some point in the reconstruction.
 BJPS Jul 2003 – with the use of thick flaps or buried testis, spermatogenesis was
not altered in the early stage (up to three months), but was substantially abnormal
in the late stage (after two years).
Management
 Testes initially buried
 SSG
o Good results
o testes are covered with meshed, split-thickness skin grafts, creating a
neoscrotum, and the penile shaft is covered with unmeshed split-thickness skin
graft
o technically difficult to apply skin grafts to the testes and cords. The graft take
is usually not satisfactory as the scrotal defect, may be contaminated with
bacteria, and the testes may be devoid of the graftable tunica vaginalis.
Furthermore, the results are less acceptable cosmetically and leave the patient
aware of the lack of protection and increased vulnerability
 Local flaps
o Medial thigh flaps used traditionally
 superomedial thigh fasciocutaneous flap is limited in its transverse
dimension so that bilateral flaps are required to reconstruct the whole
scrotum which results in scarring of both thighs. The medial thigh
fasciocutaneous flap is usually associated with a rotation dog-ear which
requires a later revision
 The surviving tissue is edematous and friable, and sufficient time must be
allowed for the tissue to recover before flaps from this area can be safely
transferred
 in many thigh flaps, some require more than one stage to complete
o Anterolateral thigh flap
 can be transferred at any time after the infection is controlled: typically,
neither the pedicle nor the skin is involved in Fournier's gangrene.
o Gracilis muscle + SSG
o Rectus abdominus muscle
 free myocutaneous flaps and omental flaps
Anterolateral thigh flap (PRS Feb 2002)
 flap reaches the scrotal area without difficulty.
 It can be wrapped around the testes, which are maintained in their anatomic
position.
 In the initial postoperative period, the flap appears to be slightly bulky, but after
several months the edema resolves. If needed, the flap can be safely thinned after it
is raised. In partial scrotal reconstruction, there may be some color mismatch and
slightly different hair density between the flap and native skin.
 may also be transferred as a sensate flap because it is innervated by the lateral
femoral cutaneous nerve.
Method
 anterosuperior iliac spine and the superolateral aspect of the patella were
identified, and a line was drawn between these two points.
 midpoint of this line was identified and a 3-cm-radius circle was outlined. A
Doppler probe was used to identify perforators in this area (peforators - inferior
lateral)
 The desired size of the flap was then marked, with the upper third of the flap
centered over the perforators. For ischial ulcer reconstruction, the flap was
extended more distally so that a larger random portion was carried with the flap to
increase reach.
 The medial incision of the flap was made first down to the fascia over the rectus
femoris. Subfascial dissection proceeded laterally toward the intermuscular space
between the rectus femoris and vastus lateralis muscles. Septocutaneous
perforators were then identified, and dissection followed to the main descending
branch of the lateral circumflex femoris artery. The remainder of the flap was then
incised, and the vascular pedicle was dissected to the origin of the descending
branch distally to proximally. When no septocutaneous perforators were present,
musculocutaneous perforators were identified and followed through the vastus
lateralis muscle to the main trunk. In these cases, a small cuff of muscle was taken
with the perforators.
 The dissection is much more tedious in cases of musculocutaneous perforators
only. It should be noted that the origin of the lateral circumflex vessels is beneath
the rectus femoris muscle. Transposition of the flap medially to the perineal or
ischial area with the vascular pedicle laid over the rectus femoris muscle will
shorten the arc of rotation by 2 cm. For this reason, the flap is passed under the
rectus femoris muscle and brought to the perineal or ischial defects through a
subcutaneous tunnel in the medial thigh.
 Care is taken not to injure the saphenous vein when making this tunnel.