Fournier gangrene

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 years but rarely in women. Other than age, predisposing factors include:

  • diabetes mellitus
  • immunosuppression
  • alcoholism
  • debility
  • 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, Staphylococcus, and Streptococcus.

It begins as a cellulitis that causes an endarteritis and then necrotising infection that spreads through the fascial planes. The organisms often produce gas, thus causing subcutaneous emphysema.

The diagnosis is usually clinical. The role of imaging includes:

  • diagnosis not established
  • determine the extent of disease
  • detect the underlying cause

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 epididymides 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
  • cause of infection may be apparent (e.g. perianal abscess, fistula)

It is considered a urological emergency with a potentially high mortality rate (ranging ~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.

It was first described by French professor of dermatology at the University of Paris, and director of the renowned venereal Hospital of St Louis, Jean Alfred Fournier (1832-1914) 6 in 1883. He 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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Article information

rID: 1355
System: Urogenital
Synonyms or Alternate Spellings:
  • Fournier's gangrene
  • Fournier gangrene
  • Fournier's gangrene (FG)

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