Penis and scrotum - Fournier’s gangrene

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Penis and scrotum

Infectious disorders

Fournier’s gangrene

Editors: Antonio Cubilla, M.D. and Alcides Chaux, M.D.

Revised: 20 May 2010, last major update May 2010

Definition

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● Serious life-threatening condition characterized by necrotizing fasciitis of genitalia and perineum

Terminology

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● First documented in 1883 by Professor Jean-Alfred Fournier (reference)

Epidemiology

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● Elderly adults (male and female), immunocompromised (particularly diabetes) or those with depressed mental status

Sites

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● Dartos and penile fascia are preferred sites

Etiology

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● 50-60% of infections have GI or GU source of infection

● Usually a polymicrobial infection

● Streptococci and staphylococci most common in children

● Gram-negative bacilli and anaerobic bacteria most common in adults

● Source of infection may be colorectal, urologic or cutaneous

● Infection spreads from skin down fascial plane, causing inflammation, ischemia, and necrosis; low oxygen tension and necrosis promote anaerobes and cause rapid dissemination

● Obliterative endarteritis plays a key role in pathogenesis

Clinical features

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● Patients present with genital induration, pain, erythema, crepitus

● Xrays may show air in perineal tissue

● To diagnose, MUST examine genitals, particularly in elderly or patients with diminished mental status

● Finding nidus of infection is important – may be periurethral or perirectal

● History of perineal trauma is important

● Affects Buck’s fascia and foreskin, sparing glans

● Mortality rate of 7-22%, even with timely and aggressive therapy (J Urol 2009;181:2120)

Risk factors

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● Trauma, burns, anorectal disease, diabetes, leukemia, alcoholic cirrhosis

Prognostic factors

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● Fournier Gangrene Severity Index (FGSI) scores > 9 predicts severity and mortality (J Urol 1995;154:89, J Postgrad Med 2008;54:102)

● FGSI: nine variables are assigned scores of 0-4, which are added together

● Variables are body temperature, heart rate, respiratory rate, serum sodium, serum potassium, serum creatinine, hematocrit, white blood count and serum bicarbonate, see Table

● Cirrhosis, not a FGSI factor, is also a poor prognostic factor (J Microbiol Immunol Infect 2007;40:500)

Case reports

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● 50 year old man with blackened skin on penis and scrotum (The Internet Journal of Emergency Medicine 2009;5(1))

● 65 year old man with third degree burns (J Med Case Reports 2009 May 26;3:7264)

Treatment

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● Aggressive medical treatment (fluids, broad spectrum antibiotics) plus aggressive surgical debridement with aggressive wound care

● Skin grafts are usually not required due to elasticity of genital skin (West J Emerg Med 2009;10:281)

● Hyperbaric oxygen does not appear to be useful

Clinical images

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Necrosis spreading along Lesions on penis and scrotum

fascial planes

Extensive sloughing, ulceration and necrosis of the scrotal skin

Gross images

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Corbus disease

Complete necrosis of glans with Cut surface shows massive necrosis of glans

preservation of foreskin and skin of the shaft and urethra; note the hemorrhage in Buck’s

fascia, consistent with spread via the fascia;

the foreskin is not involved

Micro description (Histopathology)

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● Penile fascia with severe inflammation (neutrophils), bacteria and necrotic tissue

● Thrombosis of small vessels (obliterative endarteritis)

● Deep erectile tissue usually remains unaffected

Micro images

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Bacteria, neutrophils and necrotic tissue

Differential Diagnosis

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● Corbus disease (gangrenous balanitis): similar to Fournier’s gangrene, affects exclusively glans penis, foreskin is usually spared

Additional references

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● eMedicine #1; #2

End of Penis and scrotum > Infectious disorders > Fournier’s gangrene

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