Fournier gangrene is a necrotising fasciitis of the perineum. It is a true urological emergency due to the high mortality rate but fortunately, the condition is rare.
Fournier gangrene is typically seen in diabetic men aged 50-70 but rarely in women. Other than age, predisposing factors include:
- diabetes mellitus
- perineal/scrotal pain, swelling, redness
- crepitus from soft tissue gas (up to 65%)
- systemically unwell
- fever and leukocytosis
The source of infection can usually be identified, most commonly anorectal (such as from a perianal fistula or abscess) and less commonly genitourinary or perineal trauma. Sometimes the cause is not found.
The infection is usually polymicrobial. The most common organisms cultured are E.coli, Klebsiella, Proteus, Staph., and Strep.
The diagnosis is usually clinical. The role of imaging includes:
- diagnosis not established
- determine the extent of disease
- detect the underlying cause
May show radiolucent soft-tissue gas may be seen in the region overlying the scrotum or perineum. Subcutaneous emphysema may extend from the scrotum and perineum to the inguinal regions, anterior abdominal wall, and thighs.
- thickened scrotal wall
- echogenic gas foci in the scrotum are pathognomonic: seen as dirty shadowing
- testes and epididymi spared (due to their separate blood supply)
- soft tissue stranding, fascial thickening
- soft tissue gas
- the extent of disease can be assessed prior to surgery
- a cause of infection may be apparent (e.g. perianal abscess, fistula)
Treatment and prognosis
It is considered a urological emergency with a potentially high mortality rate (ranging around 15-50% 3),
Management options include:
- immediate radical surgical debridement of necrotic tissue
- intravenous antibiotics
- hyperbaric oxygen therapy has been used
- testes replaced into remaining scrotum or covered by skin graft (once infection settled)
Often carries a poor prognosis with up to 33% mortality.
History and etymology
It was first described by French venereologist Jean Alfred Fournier (1832-1914) in 1883 who noted a fulminating gangrenous infection of male genitalia in young healthy males without an obvious cause.
The differential in the setting of acute scrotal pain includes:
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- 2. Uppot RN, Levy HM, Patel PH. Case 54: Fournier gangrene. Radiology. 2003;226 (1): 115-7. doi:10.1148/radiol.2261010714 - Pubmed citation
- 3. Levenson RB, Singh AK, Novelline RA. Fournier gangrene: role of imaging. (2008) Radiographics : a review publication of the Radiological Society of North America, Inc. 28 (2): 519-28. doi:10.1148/rg.282075048 - Pubmed
- 4. Erika Kube, Stanislaw P Stawicki, David P Bahner. Ultrasound in the diagnosis of Fournier's gangrene. (2012) International Journal of Critical Illness and Injury Science. 2 (2): 104. doi:10.4103/2229-5151.97276 - Pubmed
- 5. Marco Di Serafino, Chiara Gullotto, Chiara Gregorini, Claudia Nocentini. A clinical case of Fournier’s gangrene: imaging ultrasound. (2014) Journal of Ultrasound. 17 (4): 303. doi:10.1007/s40477-014-0106-5 - Pubmed