FOURNIERS GANGRENE

12.1 Summary of recommendations

Full, repeated surgical debridement should commence within 24 h of presentation (LE: 3; GR: B).
Treatment with broad-spectrum antibiotics should be started on presentation, with subsequent
refinement according to culture and clinical response (LE: 3; GR: B).
Adjunctive treatment such as pooled immunoglobulin and hyperbaric oxygen are not
recommended,
except in the context of clinical trials (LE: 3; GR: C).

12.2 Background

Fourniers gangrene is an aggressive and frequently fatal polymicrobial soft tissue infection of the
perineum,
peri-anal region, and external genitalia. It is an anatomical sub-category of necrotising fasciitis with
which it
shares a common aetiology and management pathway. Evidence regarding investigation and
treatment is
predominantly from case series and expert opinion (LE: 3/4).

12.3 Clinical presentation

Fourniers gangrene remains rare but its incidence is increasing with an ageing population and
higher
prevalence of diabetes, and emergence of multi-resistant pathogens. Typically there is painful
swelling of the
scrotum or perineum with severe sepsis. Examination shows small necrotic areas of skin with
surrounding
erythema and oedema. Crepitus on palpation and a foul-smelling exudate occurs with more
advanced
disease. Risk factors include immuno-compromised patients, most commonly diabetes or
malnutrition, or a
recent history of catheterisation, instrumentation or perineal surgery. In up to 40% of cases, the
onset is more
insidious with undiagnosed pain often resulting in delayed treatment. A high index of suspicion and
careful
examination, particularly of obese patients, is required.

12.4 Microbiology

Fourniers gangrene is typically a type 1 necrotising fasciitis that is polymicrobial in origin,

including S.
aureus, Streptococcus sp., Klebsiella sp., E. coli and anaerobs; involvement of Clostridium sp. is
now less
common. These organisms secrete endotoxins causing tissue necrosis and severe cardiovascular
impairment.
Subsequent inflammatory reaction by the host contributes to multi-organ failure and death if
untreated.

12.5 Management

The degree of internal necrosis is usually vastly greater than suggested by external signs, and
consequently,
adequate, repeated surgical debridement is necessary to save the patients life (LE: 3, GR: B).
Disease
specific severity scoring systems do not appear superior to generic critical illness scores and are
therefore
not recommended for routine use (LE: 3; GR: C). Computed tomography or MRI can help define
para-rectal
involvement, suggesting the need for colostomy (LE: 3, GR: C). Consensus from case series
suggests that
surgical debridement should be early (< 24 h) and complete, because delayed and/or inadequate
surgery
results in higher mortality (LE: 3; GR: B). Concurrent parenteral antibiotic treatment should be
given that covers
all causative organisms and can penetrate inflammatory tissue (LE: 3, GR: B). This can then be
refined following
surgical cultures. The benefit of pooled immunoglobulin therapy and hyperbaric oxygen remains
uncertain and
should not be used routinely (LE:3, GR: C). With aggressive early surgical and medical
management, survival
rates are > 70% depending upon patient group and availability of critical care (LE: 3). Following
resolution,

reconstruction using skin grafts is required.

Care pathway