Fournier gangrene

Fournier gangrene

1. FOURNIER GANGRENE
Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai
1

2. Moderators:
Professors:
•Prof. Dr. G. Sivasankar, M.S., M.Ch.,
•Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
•Dr. J. Sivabalan, M.S., M.Ch.,
•Dr. R. Bhargavi, M.S., M.Ch.,
•Dr. S. Raju, M.S., M.Ch.,
•Dr. K. Muthurathinam, M.S., M.Ch.,
•Dr. D. Tamilselvan, M.S., M.Ch.,
•Dr. K. Senthilkumar, M.S., M.Ch.
Dept of Urology, GRH and KMC, Chennai. 2

3. •Named after French venereologistJean
Alfred Fournier (1883).
•Fournier gangrene is defined as a
polymicrobial necrotizing fasciitisof the
perineal, perianal, or genitalareas.
3Dept of Urology, GRH and KMC, Chennai.

4. Risk factors
•Diabetes mellitus
•Alcoholism
•Malignancies
•Cirrhosis Liver
•Chronic steroid use
•HIV infection
•Malnutrition
•Morbid Obesity
4Dept of Urology, GRH and KMC, Chennai.

5. •80% have a history of previous
trauma/infection
•over 60% commence in the lower extremities
5Dept of Urology, GRH and KMC, Chennai.

6. Clinical features
•Begins with insidious onset of pruritus and discomfort of external
genitalia
•Prodromal symptoms of fever and lethargy, which may be present
for 2-7 days before gangrene
•The hallmark of Fournier gangrene is out of proportion pain and
tenderness in the genitalia.
•Increasing genital pain and tenderness with progressive erythema
of the overlying skin
•Dusky appearance of the overlying skin; subcutaneous crepitation;
feculent odor
•Obvious gangrene of a portion of the genitalia; purulent discharge
from wounds
•As gangrene develops, pain subsides (Nerve necrosis)
6Dept of Urology, GRH and KMC, Chennai.

7. clinical signs
•Oedemastretching skin
•Erythema
•a woody-hard texture to the subcutaneous
tissues
•inability to distinguish fascialplanes and muscle
groups on palpation
•disproportionate pain in relation to the affected
area,
•skin vesicles
•soft-tissue crepitus
7Dept of Urology, GRH and KMC, Chennai.

8. 8Dept of Urology, GRH and KMC, Chennai.

9. Causes
1. Ano-rectal causes –
•infection in the perinealglands
•Colorectal injury,
•Malignancy or diverticulitis
2. Uro-genital causes –
•Infection in the bulbourethral glands
•Urethral injury
•Iatrogenic injury
•Lower urinary tract infections
9Dept of Urology, GRH and KMC, Chennai.

10. 3. Dermatologic causes –
•Hidradenitissuppurativa
•Ulceration from scrotal pressure
•Trauma to scrotum or perineum
4. Other less common causes –
•Consequence of bone marrowmalignancy
•Systemic lupus erythematosus
•Crohn’sdiseases
10Dept of Urology, GRH and KMC, Chennai.

11. Causative Bacteria
•Polymicrobial infection
•streptococcal species (Group A β-
haemolytic) in combination with
Staphylococcus, Esch erichia coli,
Pseudomonas, Proteus, Clostridia.
•Most common anaerobes –Bacteroids
11Dept of Urology, GRH and KMC, Chennai.

12. •Incidence
•Age –30 –60 years
•Sex –10 times more common in males
•Social habits –More common in male
homosexuals (more pronefor Rectal injury)
12Dept of Urology, GRH and KMC, Chennai.

13. Pathognomonic findings
•Necrosis of superficial & deep fascialplanes
13Dept of Urology, GRH and KMC, Chennai.

14. Polymorphonuclear cell infiltration
14Dept of Urology, GRH and KMC, Chennai.

15. Presence of micro organisms
Fibrinoid coagulation of the nutrient arterioles
15Dept of Urology, GRH and KMC, Chennai.

16. Investigations
•Conventional radiography
•Presence of gas in soft tissue
16Dept of Urology, GRH and KMC, Chennai.

17. Ultrasonography
•Can be used to detect fluid or gas in soft
tissue
•“Sonographichallmark” –Presence of gas in
scrotal
17Dept of Urology, GRH and KMC, Chennai.

18. C.T. Scanning
•Can detect smaller amount of soft tissue gas
•Defines extent more specifically
•Identifies underlying causes eg.
•Small perinealabscess
MRI
•Yields greater soft tissue details
•especially in critically illpatients
18Dept of Urology, GRH and KMC, Chennai.

19. 19Dept of Urology, GRH and KMC, Chennai.

20. Medical Treatment
•1. Restoration of normal organ perfusion
•2. Reduction of systemic toxicity
•3. Broad spectrum antibiotics to cover anaerobes as well
•(cipro+clinda+metro)
•4. Vancomycinfor MRSA
•5. Tetanus prophylaxis
•6. Irrigation with super oxidisedwater
•7. Hyperbaric oxygen therapy
•8. IV immunoglobulinsto neutralize super antigen as
streptotoxin A & B (as adjuvant)
•9. Antifungal –if required
20Dept of Urology, GRH and KMC, Chennai.

21. Surgical treatment
•Repeated aggressive debridement
• Preservation of testes
•Reconstruction after infection is over
•Fecal diversion
•Urinary diversion
•Vacuum assisted closure (VAC)
21Dept of Urology, GRH and KMC, Chennai.

22. Complications
•MODS
•ARDS
•Septicemia
•Tetanus
•Death
22Dept of Urology, GRH and KMC, Chennai.

23. Thank you
23Dept of Urology, GRH and KMC, Chennai.