Atypical wounds - Fournier's gangrene
Fournier's gangrene is an aggressive, life-threatening bacterial infection of the genitals and perineum that requires early detection, emergent debridement, antibiotic therapy, and the involvement of a multi-disciplinary medical team for the best patient prognosis.
Fournier’s gangrene (FG) is a life-threatening infection of the perineum and genital area that can spread, like necrotizing fasciitis, to the abdominal wall and the retroperitoneal area, resulting in subcutaneous abscesses and necrosis of the subcutaneous tissue and over-lying skin. The causative microbes are a mix of aerobic and anaerobic bacteria, and a study by Chia has shown that multi-drug resistant organisms, including MRSA, are occurring with greater frequency.[i]
Risk factors for FG include comorbidities affecting microvascular circulation and immune system function, especially diabetes, neutropenia, and alcohol abuse;[ii] penetrating trauma; recent urological surgery; age more than 50 years, and male sex.[iii] Clinical presentation includes scrotal swelling and pain, penile swelling, erythema around the perineal area, dysuria, and skin necrosis, as well as possible systemic signs of multiple organ failure (hypotension, tachycardia, decreased cognition, fever and chills). Imaging may reveal subcutaneous abscesses in the perineal area.
Several prognostic tools that have been developed to help predict healing and mortality include the following:
- Fournier’s Gangrene Severity Index (FGSI) – a score calculated from clinical and laboratory data (heart rate, respiratory rate, temperature, leukocyte count, hematocrit, serum sodium, potassium, creatinine, and bicarbonate. A score >9 is associated with a 75% probability of death; <9, with survival.[iv]
- Uludag score – add age and extension by anatomical regions to the FGSI, with a score ≥9 suggesting the patient is 13.64 times more likely to die.[v]
- Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) – based on blood tests (leukocyte count, hemoglobin, serum sodium, creatinine, glucose, CPR), is also used for diagnostic purposes. A score ≥8 is a strong predictor of FG.
- Combined Urology and Plastics Index (CUPI) – used to predict hospital length of stay (LOS); parameters include age at admission, hematocrit, serum bicarbonate, blood urea nitrogen, serum calcium, alkaline phosphatase, albumin, INR, lactate, and total bilirubin. Scores are 0-15, patients with a score ≤5 had an average LOS of 25 days, those with a score >5 had an average LOS of 71 days.[vi]
A study by Morais found that the Body Surface Area (penis, perineum, scrotum – 1% each, ischiorectal fossa – 2.5%) when combined with FGSI and LRINEC provided a better prognosis for patients with FG.4
Medical management of FG includes early recognition, emergent surgical debridement of all necrotic and infected tissue, fluid resuscitation with crystalloid fluids, empiric antibiotic therapy, Foley catheter placement to monitor resuscitation and minimize perineal contamination, nutrition supplements, supportive care, and pain management with the goal of a clean and granulated wound sufficient for surgical reconstruction if necessary. After debridement, wound management may involve moist dressings with antimicrobial agents (sufficient to manage drainage), negative pressure wound therapy (provided an adequate seal can be obtained), and advanced biological dressings once the wound is clean and granulated. The attached photo shows a FG wound closed with a split-thickness skin graft after meticulous wound care.
In summary, NF is an aggressive bacterial infection of the perineum and genitals which requires emergent and intensive treatment by multiple medical specialists in order to optimize the patient’s prognosis of survival and return to prior level of function.
[i] Chia L, Crum-Cianflone NF. Emergence of multi-drug resistant organisms (MDROs) causing Fournier’s gangrene. Journal of Infection. 2018;76(1):38-43.
[ii] Montrief T, Long B, Koyfman A, Auerback J. Fournier gangrene: A review for emergency clinicians. The Journal of Emergency Medicine. 2019;57(4):488-500.
[iii] Joury A, Mahendra A, Alshehri M, Downing A. Extensive necrotizing fasciitis from Fournier’s gangrene. Urology Case Reports. 2019. Available at https://doi.org/10.1016/j.eucr.2019.100943.
[iv] Morais H, Neves J, Ribeiro HM, et al. Case series of Fournier’s gangrene: Affected body surface area – the underestimated prognostic factor. Annals of Medicine and Surgery. 2017;16:19-22.
[v] Yilmazlar T, Isik O, Ozturk E et al. Fournier’s gangrene: Review of 120 patietns and predictors of mortality. Ulus. Travma Acil Cerrahi Derg. 2014;32(7):333-337.
[vi] Ghodoussipour SB, Gould D, Lifton J, et al. Surviving Fournier’s gangrene: Multivariable analysis and a novel scoring system to predict length of stay. Journal of Plastic, Reconstructive & Aesthetic Surgery. 2018;71(5):712-718.