This gentleman started with a relatively simple superficial soft tissue infection, which he was essentially incising and draining at home over the past months. Now, however, it has spread deeper into the fascial planes of the scrotum, and is presenting with early Fournier's gangrene. While many patients present looking quite toxic, he is early enough in the disease process that he looks well.
His blood glucose was 415 mg/dl. An IV was established and blood was sent for a CBC, electrolytes, BUN, and creatinine. Cultures of the wound, urine, and blood were collected. He was started on intravenous clindamycin. Control of his hyperglycemia was begun with infusion of normal saline followed by insulin. Urology was consulted emergently in the ED.
An ultrasound done in the ED demonstrated normal testes and epididymis with good blood flow but multiple focal collections of fluid in the scrotum with air in the scrotal wall. The patient was taken to the OR for debridement.
Fournier's gangrene was first described by Baurienne in 1764 as a rapidly progressive soft tissue infection of the male perineum of unknown etiology. Jean-Alfred Fournier (1860–1902), a French venerologist, is credited with identifying the disease. He lectured and wrote about it, which he had seen in previously healthy men. While initially the etiology was unknown and it was thought to be a disease of young men, a cause is now found in the majority of cases, and it can be present at any age in both sexes.
Fournier's gangrene is a necrotizing fasciitis of the perineal and genital region. Usually some inciting event serves as a portal of entry for bacteria into the fascial planes. To best understand this process, one must review some basic anatomy. Colle's fascia is the superficial fascia that covers the perineum. Dartos fascia, which is continuous with Colle's fascia, is the superficial fascia covering the penis and scrotum. As one moves cephalic, the perineal fascia blends into the fasciae of the abdomen (Camper's and Scarpa's fascia). These facial layers in the abdomen continue superiorly to attach to the clavicles. The deeper structures (the testes and epididymis in the scrotum and the corpus cavernosum and corpus spongiosum in the penis) are surrounded by deeper fascia. These deeper layers somewhat protect and limit involvement of the testes, epididymis, and penis. One can see how a localized infection in the scrotum can easily spread along the fascial plains to involve the perineum, abdominal wall, and up the chest to the level of the clavicles.
The local inciting infection may be from several sources. GI sources include perianal, perirectal, and ishiorectal abscesses. GU sources include orchitis, epididymitis, and urethral injury. Local injection, soft tissue injury, or hidradenitis suppurativa may be a dermatologic source. In women, septic abortion, Bartholin gland abscess, or wound infection after hysterectomy or episiotomy may result in Fournier's gangrene.
While rare in infants and children, Fournier's gangrene may result after burns, insect bites, or circumcision. Once bacteria gain entry, there are usually some host factors that result in sufficient immune compromise to permit continued infection. Factors that play a role include diabetes, HIV infection, malnutrition, malignancy, and obesity. By far, the majority of infections are polymicrobial. The most common organisms include Escherichia coli, Bacteroides, Proteus, Staphylococcus, Enterococcus, Streptococcus, Pseudomonas, Klebsiella, and Clostridium species. It is theorized that these bacteria act synergistically, with some producing enzymes to coagulate nutrient vessels while others produce enzymes to digest fascia, both resulting in a favorable environment for bacterial growth.
The physical presentation can be quite varied depending on the inciting etiology. Typically pain is severe and initially is out of proportion to physical exam. The scrotum may be erythematous and tender with induration. With disease progression, the perineum becomes dusky with crepitus. There usually is a feculent odor. As gangrene progresses, pain may actually lessen. Infection can spread cephalad up the abdominal wall or laterally to involve the thighs. Patients are often toxic appearing.
Laboratories and radiographic studies aid in the diagnosis and help exclude other etiologies, but Fournier's gangrene is generally a clinical diagnosis. Plain film may reveal gas. Ultrasound may demonstrate gas in the scrotal wall, the hallmark of Fournier's gangrene. CT scan is more sensitive for demonstrating gas, and is better at identifying the true extent of infection.
Management involves initial attention to patient resuscitation. Broad spectrum antibiotics should be initiated and emergent urologic consultation made in the ED. Patients will need early surgical drainage and debridement of necrotic tissue. Often multiple surgeries will be required for complete treatment with subsequent skin grafting. If urologic consultation is not immediately available, transfer to an appropriate hospital should be arranged.