Abstract: Fournier's gangrene is a life-threatening necrotizing synergistic fasciitis of the perineum, abdominal wall, and genitalia [Surg Clin North Am 2002;82:1213; Urol Clin North Am 1991;26:841]. We describe a case of a 66-year-old man whose atypical presentation posed a diagnostic and clinical challenge of such a urological emergency. Clinicians need to have a high index of suspicion for this disease in individuals with predisposing or associated conditions, given the risk for widespread extension and impact on patients' outcome.
Division of Infectious Diseases, Naval Medical Center Portsmouth, VA.
The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government.
Currently with the Division of Infectious Diseases, Naval Medical Center San Diego.
Address correspondence and reprint requests to Helen M Chun, MD, Division of Infectious Diseases, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134. E-mail: firstname.lastname@example.org.
A 66-year-old African American male with a history of diabetes mellitus and peripheral vascular disease was admitted in December 2004 to a hospital emergency department with fever, chills, dysuria, and fluctuating blood sugars. He denied any penile discharge, unprotected intercourse, or costovertebral tenderness. He reported falling without loss of consciousness before arrival to the emergency department. Physical examination was unremarkable; there was no prostate tenderness. Values for standard laboratory tests revealed the following: white blood cell count 41 × 1000/mm3, 70% neutrophils, 19% bands; urinalysis, 30 white blood cells per high-power field, negative nitrite, 2+ leukocyte esterase, moderate bacteria; sodium 133 mmol/L, potassium 3.3 mmol/L, bicarbonate 15 mmol/L, creatinine 1.1 mg/dL, lactate 2.9 mmol/L (range 0.5-2.2). No abnormalities were seen on chest radiograph and renal ultrasound.
The patient was treated for a presumptive urinary infection with a fluoroquinolone. One day after discharge, the patient re-presented after awaking from sleep with a painful penis and scrotum and a weak interrupted urinary stream. Findings on physical examination revealed a nontoxic man with stable vital signs and a tender nonfluctuant suprapubic mass with scrotal, penile, and perineal edema. Laboratory analysis revealed white blood cell count 70.2 × 1000/mm3, 86% neutrophils, 7% bands; sodium 132 mmol/L, potassium 4.0 mmol/L, bicarbonate 18 mmol/L, creatinine 0.7 mg/dL, lactate 0.7 mmol/L. Blood and urine cultures were negative. Computed tomography examination of the abdomen and pelvis demonstrated air in the subcutaneous tissue overlying the pelvis and perineum, along the fascial planes, extending halfway to the umbilicus (Fig. 1). These findings were suggestive of Fournier's gangrene.
The patient was immediately taken to surgery for debridement of the perineum and corpora spongiosum. The patient was treated with intravenous imipenem and clindamycin. Wound Gram stain and culture revealed budding yeast that cultured out as Candida albicans; pathological tissue examination from the perineum revealed necrotic involvement of the skin and subcutaneous fat and fascia. Special stains for bacteria, acid-fast bacilli, and fungi were negative. The patient was taken to the operating room daily for repeated examination and debridement ultimately requiring a penectomy 21 days after initial debridement. Perineal wound vacuum cultures from 6 days after penectomy demonstrated Candida glabrata sensitive to voriconazole and caspofungin. The patient underwent a diverting colostomy because of continued wound contamination with fecal flora and urinary diversion with suprapubic catheter. The patient continues to recover with twice-weekly wound vacuum changes.
Fournier's gangrene is a life-threatening necrotizing synergistic fasciitis of the perineum, abdominal wall, and genitalia,1,2 affecting both sexes, but more predominant in men, who often have scrotal and penile involvement, whereas women can have vulvar involvement. Predisposing or associated conditions include a history of trauma to the region or extension of infection from the colon, rectum, or lower genitourinary tract or cutaneous region of the genitalia, perineum, or anus.3 Postsurgical Fournier's after circumcision or herniorrhaphy has been reported.4 Associated comorbidities include diabetes mellitus, alcohol use, or immunocompromise.1,5,6
The infection commonly begins as cellulitis adjacent to the portal of entry with painful swelling and induration of the penis, scrotum, or perineum. Eschar, necrosis, crepitus, patchy areas of hypoesthesia, and foul odor may also be seen.3 Patients may have fever, malaise, nonspecific abdominal pain, or signs of sepsis7 or may lack any specific symptoms from the perineal area.8 Swelling and crepitus progress rapidly to gangrene with potential for rapid spread via fascial planes with abdominal wall involvement.1,9
Patients are not typically bacteremic. Wound cultures are typically polymicrobial and have demonstrated a variety of aerobic and anaerobic organisms including Staphylococcus, Streptococus, Enterococcus, Bacteroides spp, Pseudomonas aeruginosa, clostridia, and Enterobacteriaceae. Only 3 cases of Fournier's gangrene caused by Candida spp have been reported.10-12
The mechanism of acute gangrene appears to be caused by organisms reaching the subcutaneous tissues, leading to an obliterative endarteritis of the vasculature supplying the scrotal skin.2 Inflammation, edema, and infection in an enclosed space lead to tissue hypoxia allowing the growth of facultative and obligatory anaerobes.13 Crepitus, which can be appreciated clinically, results from gas formation and accumulation in subcutaneous tissues via anaerobic metabolism by these organisms.2,14 Infections originating in the genitalia can spread along Dartos fascia of the scrotum and penis to Colles fascia of the perineum and Scarpa's fascia of the anterior abdominal wall because of continuous fascial planes.1 There rarely is involvement of deep fascial planes and musculature. However, invasion through the anal sphincter can allow for spread along the rectum into the presacral space, retrovesical space, and pelvirectal tissue with subsequent involvement of the retroperitoneum.1
Computed tomography and magnetic resonance imaging can demonstrate subcutaneous and fascial edema and tissue gas15-17; however, imaging should not delay surgical therapy. Frozen section examination of biopsy specimens demonstrating an intact epidermis, dermal necrosis, vascular thrombosis, neutrophilic infiltration, and subcutaneous tissue necrosis has been helpful for early diagnosis.7,18
The mainstay of treatment includes immediate wide surgical debridement with excision of all necrotic and devitalized skin and subcutaneous tissue,2 copious irrigation, and the use of broad-spectrum antibiotics based on Gram stain, culture, and sensitivities, when available. Empiric therapy with ampicillin or ampicillin and sulbactam in combination with either clindamycin or metronidazole can be used, unless the patient was hospitalized or had antibiotic use recently, necessitating broader gram-negative coverage with piperacillin-tazobactam or ticarcillin-clavulanic acid in place of ampicillin or by addition of a fluorinated quinolone or an aminoglycoside.19 Surgical re-exploration is often needed.1,20
Orchiectomy is typically not required because of lack of testicular involvement. Testicular blood supply is different from that to the penis and scrotum.21 Testicular preservation can be accomplished by subcutaneous placement in the thigh.2
If a colonic source is suspected, a diverting colostomy may be required. In addition, urinary diversion by suprapubic catheter for urethral stricture, urinary extravasation, and decreased further risk of bacterial seeding of the wound may be required/performed.13
In addition to antibiotics and supportive care, adequate nutrition and strict control of diabetes and metabolites are crucial to proper wound healing. The use of hyperbaric oxygen therapy in the treatment of Fournier's gangrene remains controversial.2
Despite significant improvements in critical care, the mortality from Fournier's gangrene still remains quite high (11%-45%).14,22,23 This can be reduced with prompt diagnosis using a high index of suspicion, aggressive surgical intervention, and broad-spectrum antibiotics.
The author thanks Mark R. Wallace for editing and Waine MacAllister for manuscript preparation.
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