Fournier gangrene is a type of

necrotizing fasciitis Necrotizing fasciitis (NF), also known as flesh-eating disease, is an infection that kills the body's soft tissue. It is a serious disease that begins and spreads quickly. Symptoms include red or purple or black skin, swelling, severe pain, fever ...

gangrene Gangrene is a type of tissue death caused by a lack of blood supply. Symptoms may include a change in skin color to red or black, numbness, swelling, pain, skin breakdown, and coolness. The feet and hands are most commonly affected. If the ga ...

affecting the external genitalia or

perineum The perineum (: perineums or perinea) in placentalia, placental mammals is the space between the anus and the genitals. The human perineum is between the anus and scrotum in the male or between the anus and vulva in the female. The perineum is ...

. It commonly occurs in older men, but it can also occur both in women and children and in people with diabetes or alcoholism or those who are immunocompromised.

Epidemiology and history

About one per 62,500 males are affected per year. Males are affected about 40 times more often than females. It was first described by Baurienne in 1764 and is named after a French venereologist,

Jean Alfred Fournier Jean Alfred Fournier (; 21 May 1832 – 23 December 1914) was a French dermatologist who specialized in the study of venereal disease. Biography As a young man Fournier served as an intern at the Hôpital du Midi as an understudy to Philippe ...

, following five cases he presented in clinical lectures in 1883.

Signs and symptoms

Initial symptoms of Fournier gangrene include swelling or sudden pain in the

scrotum In most terrestrial mammals, the scrotum (: scrotums or scrota; possibly from Latin ''scortum'', meaning "hide" or "skin") or scrotal sac is a part of the external male genitalia located at the base of the penis. It consists of a sac of skin ...

, fever, pallor, and generalized weakness. It is characterized by pain that extends beyond the border of the demarcated

erythema Erythema (, ) is redness of the skin or mucous membranes, caused by hyperemia (increased blood flow) in superficial capillaries. It occurs with any skin injury, infection, or inflammation. Examples of erythema not associated with pathology inc ...

. Most cases present mildly, but can progress in hours. Subcutaneous air is often one of the specific clinical signs, but is not seen in >50% of presenting clinical cases. More marked cases are characterized by a foul odor and necrotic infected tissue.

Crepitus Crepitus is "a grating sound or sensation produced by friction between bone and cartilage or the fractured parts of a bone". Various types of crepitus that can be heard in joint pathologies are: *Bone crepitus: This can be heard when two frag ...

has been reported. It begins as a subcutaneous infection. However, necrotic patches soon appear in the overlying skin, which later develop into necrosis.

Cause

Most cases of Fournier gangrene are infected with both

aerobic Aerobic means "requiring air," in which "air" usually means oxygen. Aerobic may also refer to * Aerobic exercise, prolonged exercise of moderate intensity * Aerobics, a form of aerobic exercise * Aerobic respiration, the aerobic process of cellu ...

and

anaerobic Anaerobic means "living, active, occurring, or existing in the absence of free oxygen", as opposed to aerobic which means "living, active, or occurring only in the presence of oxygen." Anaerobic may also refer to: *Adhesive#Anaerobic, Anaerobic ad ...

bacteria such as ''

Clostridium perfringens ''Clostridium perfringens'' (formerly known as ''C. welchii'', or ''Bacillus welchii'') is a Gram-positive, bacillus (rod-shaped), anaerobic, spore-forming pathogenic bacterium of the genus '' Clostridium''. ''C. perfringens'' is ever-present ...

''. It can also result from infections caused by

group A streptococcus Lancefield grouping is a system of classification that classifies catalase-negative Gram-positive cocci based on the carbohydrate composition of bacterial antigens found on their cell walls. The system, created by Rebecca Lancefield, was histori ...

(GAS), as well as other pathogens such as ''

Staphylococcus aureus ''Staphylococcus aureus'' is a Gram-positive spherically shaped bacterium, a member of the Bacillota, and is a usual member of the microbiota of the body, frequently found in the upper respiratory tract and on the skin. It is often posi ...

'' and ''

Vibrio vulnificus ''Vibrio vulnificus'' is a species of Gram-negative, motile, curved rod-shaped (vibrio), pathogenic bacteria of the genus ''Vibrio''. Present in marine environments such as estuaries, brackish ponds, or coastal areas, ''V. vulnificus'' is related ...

''. Lack of access to

sanitation Sanitation refers to public health conditions related to clean drinking water and treatment and disposal of human excreta and sewage. Preventing human contact with feces is part of sanitation, as is hand washing with soap. Sanitation systems ...

medical care Health care, or healthcare, is the improvement or maintenance of health via the prevention, diagnosis, treatment, amelioration or cure of disease, illness, injury, and other physical and mental impairments in people. Health care is deliver ...

, and

psychosocial The psychosocial approach looks at individuals in the context of the combined influence that psychological factors and the surrounding social environment have on their physical and mental wellness and their ability to function. This approach is ...

resources has been linked to increased mortality. A 2006 Turkish study reported that blood sugar levels were elevated in 46 percent of patients diagnosed with Fourniers. Another study reported that about one third of patients were

alcoholic Alcoholism is the continued drinking of alcohol despite it causing problems. Some definitions require evidence of dependence and withdrawal. Problematic use of alcohol has been mentioned in the earliest historical records. The World Hea ...

diabetic Diabetes mellitus, commonly known as diabetes, is a group of common endocrine diseases characterized by sustained high blood sugar levels. Diabetes is due to either the pancreas not producing enough of the hormone insulin, or the cells of th ...

, and

malnourished Malnutrition occurs when an organism gets too few or too many nutrients, resulting in health problems. Specifically, it is a deficiency, excess, or imbalance of energy, protein and other nutrients which adversely affects the body's tissues a ...

, while another ten percent had been

immunosuppressed Immunosuppression is a reduction of the activation or efficacy of the immune system. Some portions of the immune system itself have immunosuppressive effects on other parts of the immune system, and immunosuppression may occur as an adverse react ...

through

chemotherapy Chemotherapy (often abbreviated chemo, sometimes CTX and CTx) is the type of cancer treatment that uses one or more anti-cancer drugs (list of chemotherapeutic agents, chemotherapeutic agents or alkylating agents) in a standard chemotherapy re ...

steroid A steroid is an organic compound with four fused compound, fused rings (designated A, B, C, and D) arranged in a specific molecular configuration. Steroids have two principal biological functions: as important components of cell membranes t ...

s, or

malignancy Malignancy () is the tendency of a medical condition to become progressively worse; the term is most familiar as a characterization of cancer. A ''malignant'' tumor contrasts with a non-cancerous ''benign'' tumor in that a malignancy is not ...

. Fournier gangrene is a rare

side effect In medicine, a side effect is an effect of the use of a medicinal drug or other treatment, usually adverse but sometimes beneficial, that is unintended. Herbal and traditional medicines also have side effects. A drug or procedure usually use ...

SGLT2 inhibitor SGLT2 inhibitors (also called gliflozins or flozins) are a class of medications that inhibit sodium-glucose transport proteins in the nephron (the functional units of the kidney), unlike SGLT1, SGLT1 inhibitors that perform a similar function in ...

s (

canagliflozin Canagliflozin, sold under the brand name Invokana among others, is a medication used to treat type 2 diabetes. It is used together with exercise and diet. It is not recommended in type 1 diabetes. It is taken by mouth. Common side effects in ...

dapagliflozin Dapagliflozin, sold under the brand names Farxiga (US) and Forxiga (EU) among others, is a medication used to treat type2 diabetes. It is also used to treat adults with heart failure and chronic kidney disease. It reversibly inhibits sodium- ...

, and

empagliflozin Empagliflozin, sold under the brand name Jardiance ( ), among others, is an antidiabetic medication used to improve glucose control in people with type2 diabetes and/or for patients with established heart failure with reduced ejection fract ...

), which increase the excretion of glucose in the urine.

Diagnosis

Fournier gangrene is usually diagnosed clinically, but laboratory tests and imaging studies are used to confirm diagnosis, determine severity, and predict outcomes. X-rays and ultrasounds may show the presence of gas below the surface of the skin. A

CT scan A computed tomography scan (CT scan), formerly called computed axial tomography scan (CAT scan), is a medical imaging technique used to obtain detailed internal images of the body. The personnel that perform CT scans are called radiographers or ...

can be useful in determining the site of origin and extent of spread.

Treatment

Fournier gangrene is a urological emergency requiring intravenous antibiotics and

debridement Debridement is the medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue. Removal may be surgical, mechanical, chemical, autolytic (self-digestion), or by maggot therapy. In ...

(surgical removal) of dead tissue. Formation of a colostomy may be required to divert bowel motions away from the area. In addition to surgery and antibiotics,

hyperbaric oxygen therapy Hyperbaric medicine is medical treatment in which an increase in barometric pressure of typically air or oxygen is used. The immediate effects include reducing the size of gas emboli and raising the partial pressures of the gases present. Initial ...

may be useful and acts to inhibit the growth of and kill the anaerobic bacteria. Multiple wound debridement may be required in cases with extensive tissue involvement. Simple reconstructive procedures following wound debridement yield satisfactory outcomes in majority of the cases.

Prognosis

While recent case series (''n'' = 980) studies have found a mortality rate of 20–40%, a large (''n'' = 1,641) 2009 study reported a mortality rate of 7.5%.

Epidemiology

A 2009 epidemiological study found the incidence of Fournier gangrene to be 1.6 cases per 100,000 males, in the United States. Males 50 to 79 years old had the highest rate at 3.3 per 100,000. Of 1,680 cases identified in the study, 39 were women.

References

External links

* and {{Bacterial cutaneous infections Bacterium-related cutaneous conditions Gangrene Urological conditions