Fournier’s gangrene is an acute infection of the external male genitals with necrotizing soft tissues. Initial symptoms include pain, swelling and redness of the genital area, temperature reaction, weakness. Within 2-7 days, clinical manifestations increase, the skin color changes to dark, purulent discharge and wetness appear, pain due to the aggravation of the necrotizing process decreases. The diagnosis is established during examination, ultrasound and radiography, the pathogen is identified using a cultural study. Treatment involves detoxification, antibacterial, anti-shock therapy, surgical intervention.
Fournier’s disease (gangrenous erysipelas of the scrotum, epifascial necrosis, subfascial phlegmon and gangrene of the genitals) is a polymicrobial necrosis of the tissues of the scrotum and penis. The disease was first described in 1764 by the German physician Bauren. In 1883, French venereologist Jean Alfred Fournier summarized observations of five young people suffering from rapidly progressing gangrene of the penis and scrotum. Since then, the disease has been named after him. Pathology has no endemic areas and does not depend on the time of year. A typical portrait of a patient with gangrene of the genitals looks like this: a man over 65-70 years old with severe concomitant pathology and / or abusing alcohol.
The disease is multifactorial. The causes of the extensive infectious process of the genitals can be established in 75-95% of cases. Of the pathogens, streptococci, staphylococci, fusobacteria, spirochetes, other anaerobic and aerobic bacteria are most often identified, in 43% Escherichia coli are isolated. The immune status is important: in persons with concomitant pathology associated with immunosuppression (AIDS, tuberculosis, diabetes mellitus, autoimmune diseases, malignant neoplasms, cirrhosis of the liver, alcoholism, Crohn’s disease, etc.), the risk of Fournier’s gangrene is higher. More often, the infectious agent enters the underlying tissues from the skin, rectal or urogenital area under the following circumstances:
- Genital and perineal injuries. During traumatization (infringement, bite, burn, injury, violation of the integrity of the skin of the scrotum as a result of dermatological diseases, etc.), an entrance gate appears for pathogenic microflora, which, under favorable conditions, begins to actively multiply. The development of pathology after genital piercing is described.
- Urological manipulations and operations. Taking into account the peculiarities of the anatomy of the male urethra (the presence of natural constrictions), the mucous membrane is easily injured during catheterization, bougie, urethrocystoscopy. The addition of a secondary infection leads to inflammatory reactions – edema, infiltration, hyperemia, pain. Functioning urethral catheter, phalloplasty in erectile dysfunction are considered as risk factors for the development of scrotal gangrene, especially in men with immunosuppression of any genesis.
- Urogenital and proctological diseases. Pathology of the genitourinary tract (prostatitis, orchoepididymitis, urethritis, etc.) – foci of chronic infection. The spread of microbes occurs by hematogenic or lymphogenic pathways, which can initiate the development of Fournier’s gangrene. Sources of persistent intestinal infection include paraproctitis, rectal fissure, hemorrhoids, diverticulitis, rectal fistulas and other inflammatory processes.
Intrafacial penetration of polymicrobial infection and its further spread is the main mechanism of development of Fournier’s gangrene. Microorganisms have a symbiotic effect in relation to each other: some produce enzymes that promote thrombosis in blood vessels with a decrease in local blood flow and hypoxia, others produce a number of enzymes that facilitate penetration through tissue barriers and fascia.
The contamination of fascia and interfacial spaces with pathogens entails a lightning-fast progression of inflammation. New areas are involved in the process, including the anterior abdominal wall and the inner surface of the thighs. Favorable conditions for the persistence of microflora ensure the looseness of the epithelial cover, the thinness of the epidermis, a large number of sweat and sebaceous glands and hair follicles. Features of the blood supply to the genitals — an extensive venous network and a meager arterial one — lead to a slowdown in blood flow and increased clotting during inflammation, which exacerbates necrotization.
The prodromal period is characterized by an increase in body temperature, weakness. There are no local manifestations. The duration of the period is variable and ranges from 2 to 7 days. At the stage of infiltration, hyperemia appears (sometimes a red spot stands out against its background), swelling, pain. As the clinical manifestations progress, they become brighter, crepitation during compression of soft tissues due to the accumulation of gases can be determined.
At the stage of abscessing, the patient’s well-being worsens, symptoms of intoxication are added. The severity of common symptoms is individual and depends on the volume of tissues involved. Weakness, loss of appetite, temperature up to 39-40 °With chills, muscle pains, night sweats are present in almost all patients. In a number of observations, ulceration and blisters on the head of the penis and the skin of the scrotum are noted, which are replaced by necrotizing tissues. Purulent discharge with an unpleasant odor may ooze out of them.
Urination occurs in a weakened jet with cuts. In some patients, against the background of pain and swelling, the skin is hyperemic without other external manifestations, and the main process takes place in deeper layers. If there was a penetrating scrotum injury in the anamnesis, the edges of the wound are diluted, pus is released. After a few hours, the skin turns purple, and then black, the pain syndrome decreases due to the death of nerve endings, which can be falsely interpreted as an improvement.
Often, even socialized patients seek help untimely, in a serious condition. Necrosis quickly captures the soft tissues of the perineum, thighs, and anterior abdominal wall. The main formidable complication of Fournier’s gangrene is the addition of sepsis when bacteria enter the bloodstream and intoxication of the body with the products of their vital activity. Long-term complications include the adhesive-scarring process and associated erectile dysfunction, impaired lymph outflow and swelling of the genitals, chronic pain syndrome due to the formation of scar deformity.
Diagnosis is based on examination data, palpation, and medical history. Differential diagnosis is carried out with scrotal phlegmon, paraproctitis, erysipelas, gangrenous balanitis and a complicated form of primary syphiloma. The decision on management tactics is made collectively, the patient is examined by a surgeon, urologist, proctologist, anesthesiologist, therapist. Diagnostic measures include:
- Blood testing. The blood reacts to a purulent catastrophe with hyperleukocytosis exceeding the norm by 3-4 times, neutrophilosis and acceleration of ESR (up to 50-60 mm / h). Positive results of a blood culture study in a patient with Fournier’s gangrene indicate septicopiemia. To detect coagulopathy on the background of sepsis, the coagulation profile (coagulogram) is additionally examined.
- Radiography of soft tissues. X-ray of perineal tissues is performed as a primary instrumental diagnosis, especially when the results of a clinical study are inconclusive. In the pictures, you can see a large amount of gases in the soft tissues, which are detected even before the appearance of pronounced necrotization. MRI of the scrotum organs better visualizes soft tissues, but requires more time for diagnosis, because of this, its use is limited in patients in critical condition.
- Ultrasound of the scrotum and perineum. Ultrasonography of the scrotum is used to determine the fluid or gas, the severity of edema. Testicles and appendages, as a rule, are not changed. Ultrasound scanning allows you to diagnose intratesticular trauma, scrotal cellulite, orchoepididymitis, testicular torsion, inguinal hernia. The disadvantages of ultrasound include the need for pressure on the scrotum, which increases the pain syndrome.
- Biopsy and histology. A biopsy of the affected area is performed for the differential diagnosis of severe cellulite from necrotic infection. The sample is taken from the point of maximum softening, including the skin, superficial and deep fascia. Morphological examination shows fascial necrosis, fibrinoid coagulation of arterioles, polymorphonuclear infiltration, the presence of microorganisms inside the involved tissues.
The patient is hospitalized in the department of purulent surgery or urology. In a serious condition, it is often necessary to place the patient in intensive care. Treatment is based on three aspects: detoxification, antibiotic therapy and emergency surgery. In the future, the patient may need a number of operations, including reconstructive ones.
- Antibiotic therapy. From antibacterial drugs, drugs with maximum anti-anaerobic activity are chosen. Before receiving the results of sowing, amoxicillin, ticarcillin, carbapenems, cephalosporins of the III and IV generation, metronidazole are prescribed. The duration and dosage are determined individually in each case.
- Detoxification therapy. Detoxification involves infusion of crystalloid solutions, albumin, plasmapheresis, hemosorption. Some patients with renal insufficiency may require hemodialysis sessions.
- Surgical intervention. After confirming the diagnosis, all non-viable tissues are excised as radically as possible, the wound is opened and an audit is performed; phlegmons, abscesses and purulent congestion are drained. According to the indications (extensive purulent-necrotic lesion of the anorectal area), a colostomy is removed, with urinary retention, an epicystostomy is performed or a urethral catheter is installed. Penectomy and orchiectomy are performed less often. After stabilization of the condition, a series of reconstructive operations is performed. With extensive skin defects, dermotension is resorted to with the use of tissue expanders.
- Physiotherapy activities. When hyperbaric oxygenation is prescribed as part of the complex therapy of Fournier’s disease, the effect of treatment is higher, and mortality is lower. The effectiveness is due to an increase in arterial blood oxygenation and activation of macrophages in the area of inflammation. HBO enhances the penetration of antibiotics into the affected tissues, reduces edema due to vasoconstriction, stimulates the synthesis of fibroblasts and the formation of granulations.
Prognosis and prevention
Mortality in Fournier’s gangrene remains high and ranges from 47 to 80% according to various sources. The prognosis for life depends on the timeliness of medical care, without treatment, mortality reaches 100%. Prevention includes timely treatment of proctological and urological diseases, correction of immunodeficiency conditions, rejection of piercing and tattooing of the genitals, safe sex, adequate hygiene and a healthy lifestyle. At the first symptoms of trouble, it is important to seek medical help and not self-medicate.