THE DIAGNOSIS AND MANAGEMENT OF FOURNIER'S GANGRENE.pptx

This PowerPoint is aimed at helping Registrars in urology understand the concept of Fournier's gangrene and also help the medical students build a foundation for understanding the basic principles of Fournier's gangrene. Strictly for education purposes

1. FOURNIER'S GANGRENE Dr. Chipili B . Bsc.HB, MBChB, FZCMS (Urology)

2. Definition Fournier’s gangrene is a synergistic polymicrobial necrotizing fasciitis of the perineum and external genitalia It’s a type I necrotizing fasciitis caused by mixed bacterial flora which include gram positive, gram negative and anaerobic bacteria Escherichia coli , Bacteroides spp ., S. pyogenes , and S. aureus are common etiologic pathogens

3. Risk factors Predisposing factors HIV/AIDS Diabetes Malnutrition Chronic alcoholism Advanced age Immunosuppressants Malignancy Liver cirrhosis Chronic steroid use

4. Risk factors Precipitating factors Urogenital trauma Insect bite Urine extravasation Perianal or scrotal abscess Hair follicle infections UTIs Surgical site infections Scrotal pressure sores Recent urethral or perineal surgery

5. Pathophysiology Inoculation of the primary bacteria into the subcutaneous soft tissues of the perineum and external genitalia leads to obliterative end arteritis This results into reduced oxygen tension and local tissue hypoxia which promotes the proliferation of anaerobic bacteria The proliferation of anaerobes synergistically promotes the growth and spread of the primary and other associated organisms resulting into further spread of infection along the fascial planes The hallmark of Fournier's gangrene a rapid progression from signs and symptoms of cellulitis to clinically visible ischemia and eventually foul-smelling necrotic lesion

6. Anatomy of fascial planes affected by FG

7. Clinical presentation Genital/perineal pain (out of proportion to visible extent of infection) Genital/perineal swelling Necrotic skin patch Fetid odor Septicemia

8. Diagnosis of Fournier’s gangrene Diagnosis is clinical Investigations should not delay the management as spread is very rapid The initial and important investigations involve; FBC,DC,ESR KFTs Blood culture Pus swab for m/c/s Imaging with plain radiographs, U/S scan and/or CT scan may demonstrate gas bubbles within the tissues

9. Management of Fournier’s gangrene Fournier’s gangrene is a urological emergency which requires prompt action Management starts with resuscitation ABCs Secure IV access Adequate analgesia Administration of empiric IV broad-spectrum antibiotics which are adjusted after culture results Urine diversion by urethral catheterization or suprapubic cystostomy Extensive surgical debridement to margins of healthy bleeding tissues

10. Management of Fournier’s gangrene A second look debridement may be necessary after 24 to 48 hours This allows meticulous debridement in a more stable patient The use of hyperbaric oxygen remains controversial Further management includes continued chemical debridement with hydrogen peroxide to daily wound care Once all the infection has cleared wound closure is planned Wound closure ranges from secondary suturing to skin grafting and musculocutaneous flaps depending on the extent of the defect Small defects especially in the scrotum undergoes self closure

11. References Lous R. Kavoussi , Andrew C. Novick, Alan W. Partin, Craig A. Peters, CAMPBELL-WALSH Urology , 12 th Edition, Chapter 59, Elsevier Saunders, USA. European Association of Urology, 2024 updated guidelines, limited edition.