[Fournier's gangrene].
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Fournier's gangrene is a necrotizing fasciitis of the genital and scrotal region due to infectious process. The gangrene is rare. Most cases are diagnosed in elderly patients with immunodeficiency, especially in diabetics or alcoholics. Currently a primary infection focus can be revealed in about 95% cases. The nidus is usually located in the genitourinary tract, lower gastrointestinal tract or skin. Fournier's gangrene is a mixed infection caused by both aerobic and anaerobic bacterial flora. The development and progression of the gangrene is often fulminating and can rapidly cause multiple organ failure and death. Early surgical debridement of necrotic tissues and antibiotics are fundamental in the treatment of Fournier's gangrene. Despite of advanced management mortality is still high and averages 20-30%.Keywords:
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Fournier gangrene
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Abstract Background Although there is much consensus, certain controversies exist regarding the management of Fournier's gangrene. Method Publications in English on Fournier's gangrene from January 1950 to September 1999 were obtained through the Medline database and relevant reference lists in publications. It was possible to identify 1726 cases for study. Data extracted for review included country of reported cases, number of patients in each report and relevant clinical features. Results Fournier's gangrene occurs worldwide. However, its definition has generated considerable controversy as efforts are made to refine the original description in the light of increasingly understood aetiological factors. Attempts to classify the disease into primary and secondary forms have not been successful. The basic pathological process, necrotizing fasciitis, has been identified in the perineum of women and children, although the disease afflicts the male more often than the female. Most reported cases have occurred in the USA and Canada. The major sources of sepsis are the local skin, colon, anus and rectum, and the lower urinary tract. Colonic, anal and rectal sources carry the worst prognosis. Diabetes mellitus is important in aetiological terms. Rare causes include vasectomy and circumcision. Investigations are essential to define the cause of an episode but not for the diagnosis of the disease. Early aggressive treatment of Fournier's gangrene and underlying conditions is essential. Hyperbaric oxygen and honey are treatment modalities yet to be universally adopted. Risk of death, 16 per cent overall in this series, is related to the patient's condition at presentation. Conclusion Controversies over the definition of Fournier's gangrene persist but these do not affect the treatment options. The diagnosis is made on clinical grounds. The occurrence of the disease in women is under-reported and may go unrecognized by some clinicians. Some treatment options, such as hyperbaric oxygenation and radical excision, remain controversial.
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Much has been written in the medical literature of all countries engaged in the World War bearing on various phases of acute bacterial gangrene produced by anaerobic organisms. But almost no attention has been given to another group of cases characterized by a rapidly developing gangrenous process from which only the hemolytic streptococcus can be recovered with regularity. These two groups differ from one another quite widely in several important respects, both clinically and pathologically. The latter is a clear cut clinical entity which can readily be recognized and whose clinical course and bacteriologic findings can be fairly well predicted. On questioning other medical men in China, I have learned that the disease is fairly common and has a rather wide distribution in that part of the Orient; but little has been written on the subject. A review of the general medical literature indicates that the condition is relatively rare
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Fournier gangrene is a rapidly progressive necrotizing fasciitis involving the genitalia. It can be treated with antibiotics and immediate debridement along with treatment of the predisposing condition. We evaluated the prognostic factors, clinical characteristics and treatment of patients of the Fournier gangrene.The subjects were 40 male patients diagnosed with Fournier gangrene who visited Wonkwang University Hospital, Iksan, Korea between January 1991 and December 2000. Their medical records were reviewed with respect to demographics, medical history, symptoms and signs, physical examination, laboratory data, bacteriology, extent of disease, clinical course, and therapy. The extent of disease was quantified for each patient using a modification of the diagram used to assess the extent of burns.The average age was 55.3 years (range 29.6-92.8). Of the 40 patients, 11 died (36%) and 29 survived (64%). Anorectal infections were the underlying local disease most commonly associated with high mortality (75%). Although the most common associated illness was diabetes, it was not related to the prognosis (death rate: 20.0%). In contrast, the death rate was highest in chronic renal failure, reaching 50%. The mortality rate increased with the duration of symptoms before hospitalization. Patients with <6% surface area involvement were more likely to survive. On admission, serum blood urea nitrogen (s-BUN) and serum creatinine were significantly higher in the patients who died.Survival is associated significantly with anorectal infection, chronic renal failure, the duration of symptoms before hospitalization, the extent of gangrene, and s-BUN and creatinine level on admission.
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In Brief This paper presents 4 consecutive cases using negative-pressure dressings (VAC) to bolster skin grafts in male genital reconstruction. In this series reconstruction followed 1 case of tumor ablation and 3 cases of debridement of abscesses or Fornier's gangrene. The VAC was applied circumferentially to the penis to secure skin grafts either directly to the penile shaft or to facilitate skin grafting to the scrotum. Graft areas ranged from 75 to 250 cm. All cases resulted in successful genital wound coverage; minor complications are described. Three practical points are brought forth. First, the VAC facilitates skin grafting to the complex contour of male genitalia. Second, the VAC can be applied circumferentially to the penis without the need for perfusion monitoring or fears of avascular necrosis. Third, with the use of the VAC, bolster use can likely be discontinued as early as 72 hours with good graft adherence and survival. Negative pressure dressings with the VAC device were successfully used in a circumferential configuration for skin grafting of the penile shaft and scrotum.
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We treated 30 patients with Fournier's gangrene during a 15-year period. Data were collected on demographics, medical history, admission signs and symptoms, physical examination, admission laboratory studies and bacteriology. The timing and degree of surgical débridement as well as antibiotic therapy were also reviewed. The extent of disease was calculated from body surface area nomograms. Data were stratified according to the outcomes of death (13 patients) or survival (17). Patients who survived were significantly younger (53 years old, range 23 to 90) than those who died (71 years old, range 53 to 83, p = 0.004). Admission laboratory parameters that were statistically related to outcome included hematocrit, blood urea nitrogen, calcium, albumin, alkaline phosphatase and cholesterol levels. White blood count, platelets, potassium, bicarbonate, blood urea nitrogen, total protein, albumin and lactic dehydrogenase levels 1 week following hospitalization were also associated with outcome. The greater mean extent of body surface area involved among patients who died was not statistically different from that of those who lived (7.16 and 4.32%, respectively, p = 0.1). The number of surgical débridements did not seem to influence outcome. To assess better the physiological profile of the patients in both outcome categories, the acute physiology and chronic health evaluation II severity score was modified to create a Fournier's gangrene severity index. The mean Fournier's gangrene severity index for survivors was 6.9 +/- 0.9 compared to 13.5 +/- 1.5 for nonsurvivors. Regression analysis demonstrated a strong correlation between Fournier's gangrene severity index and death rate (correlation coefficient = 0.934, p = 0.005). Using a Fournier's gangrene severity index threshold value of 9, there was a 75% probability of death with a score greater than 9, while a score of 9 or less was associated with a 78% probability of survival (p = 0.008). In conclusion, Fournier's gangrene is an infectious disease affecting an ever aging population of patients. Deviation from homeostasis is the most important parameter predictive of outcome and not the extent of disease or performance of surgical débridement. The Fournier's gangrene severity index is an objective and simple method to quantify the extent of metabolic aberration that may be used to predict outcome. We recommend the use of the Fournier's gangrene severity index when evaluating therapeutic options and reporting results.
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Surgical infections are almost always polymicrobial, yet the critical importance of bacterial mixtures in these infections has received relatively little attention. The convincing data on the prevalence of mixed infections in surgery are reviewed. Both clinical and experimental evidence indicate that true synergy between certain aerobes and anaerobes may exist. Of the possible mechanisms of synergy, the most important seems to be the ability of anaerobes, their metabolic products, or their capsules to inhibit phagocytosis of aerobes by leukocytes. Other mechanisms of importance in special microbial combinations include provision of essential nutrients such as vitamin K, succinate, and various growth factors by one microbe to the other; alteration of local environment, including reduction of the oxygen tension and lowering of redox potential; and the provision of substances toxic to the host that permit species of bacteria to flourish concurrently. Further study of these interactions will shed light on the causes and correction of treatment failure.
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No AccessJournal of UrologyClinical Urology: Review Article1 Sep 1999THE USE OF HYPERBARIC OXYGEN IN UROLOGY M. CAPELLI-SCHELLPFEFFER and GLENN S. GERBER M. CAPELLI-SCHELLPFEFFERM. CAPELLI-SCHELLPFEFFER and GLENN S. GERBERGLENN S. GERBER View All Author Informationhttps://doi.org/10.1097/00005392-199909010-00002AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract Purpose: We review the use of hyperbaric oxygen therapy in urology, and present the mechanisms of hyperoxia action in whole body hyperbaric chamber treatments, patient outcomes and patient selection criteria. Materials and Methods: The literature on hyperbaric oxygen use in urology was reviewed. Results: Hyperbaric oxygen is a treatment alternative for patients with an underlying ischemic process unresponsive to conventional therapy. Specific factors which may influence patient selection of hyperbaric oxygen include cancer and absolute contraindications of active viral disease, intercurrent pneumothorax and treatment with doxorubicin or cisplatin. This technique is particularly useful in the treatment of intractable hemorrhagic cystitis secondary to pelvic radiation therapy. Further investigation of the efficacy of hyperbaric oxygen is warranted for patients with necrotizing fasciitis (Fournier's gangrene), posttraumatic ischemic injury and/or impaired wound healing. Conclusions: Hyperbaric oxygen is a therapeutic alternative which complements the surgical and medical options for select patients. References 1 : Hyperbaric oxygen therapy: a committee report. Bethesda, Maryland: Undersea and Hyperbaric Medicine Society1992. Google Scholar 2 : The effect of oxygen on man at pressures from 1 to 4 atmospheres. Amer. J. Physiol.1935; 110: 565. Google Scholar 3 : Hyperbaric oxygen therapy. Intens. Care Med.1989; 4: 55. 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Google Scholar From the Department of Surgery, Sections of Plastic and Reconstructive Surgery, and Urology, University of Chicago, Chicago, Illinois(Gerber) Financial interest and/or other relationship with Richard Wolf, Inc. and Pfizer.© 1999 by American Urological Association, Inc.FiguresReferencesRelatedDetailsCited byKALAYOĞLU-BEŞIŞIK S, ABDUL-RAHMAN İ, ERER B, YENEREL M, OĞUZ F, TUNÇ M and SARGIN D (2018) Outcome After Hyperbaric Oxygen Treatment for Cyclophosphamide-Induced Refractory Hemorrhagic CystitisJournal of Urology, VOL. 170, NO. 3, (922-922), Online publication date: 1-Sep-2003.KORKMAZ A, OTER S, DEVECI S, OZGURTAS T, TOPAL T, SADIR S and BILGIC H (2018) Involvement of Nitric Oxide and Hyperbaric Oxygen in the Pathogenesis of Cyclophosphamide Induced Hemorrhagic Cystitis in RatsJournal of Urology, VOL. 170, NO. 6, (2498-2502), Online publication date: 1-Dec-2003.KORKMAZ A, OTER S, DEVECİ S, GOKSOY C and BİLGİC H (2018) PREVENTION OF FURTHER CYCLOPHOSPHAMIDE INDUCED HEMORRHAGIC CYSTITIS BY HYPERBARIC OXYGEN AND MESNA IN GUINEA PIGSJournal of Urology, VOL. 166, NO. 3, (1119-1123), Online publication date: 1-Sep-2001. Volume 162Issue 3 Part 1September 1999Page: 647-654 Advertisement Copyright & Permissions© 1999 by American Urological Association, Inc.MetricsAuthor Information M. CAPELLI-SCHELLPFEFFER More articles by this author GLENN S. GERBER More articles by this author Expand All Advertisement PDF downloadLoading ...
Gas gangrene
Fournier gangrene
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Gangrene
Fulminant
Debridement (dental)
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We describe a 19-year-old Japanese man with severe extensive necrotizing fasciitis that started as Fournier's gangrene to involve the external genitalia, thigh and lower abdomen. High creatine phosphokinase, transient immunosuppression (reduced serum IgG level and negative tuberculin skin test reaction) and disseminated intravascular coagulation occurred during the necrotizing fasciitis.
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Fournier gangrene
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