A 65-year-old man was referred to our department with clinical signs of septic shock and necrotizing soft tissue infection of the scrotal, perianal and right inguinal region. Initial presentation was a typical Fournier’s gangrene. Because of the life-threatening condition, the initial treatment was extensive removal of necrotic tissue. Antibiotic therapy was administered and several debridements of the wound were done afterwards. Three weeks after the initial treatment, wide wound defects of the perianal, scrotal and inguinal regions were closed secondarily and the patient was discharged from the hospital. Fournier’s gangrene is a surgical emergency. Although rare, it remains a life-threatening disease. Rapid and accurate diagnosis remains the key component in achieving successful outcome. Early aggressive surgical intervention together with fluid, hemodynamic and nutritional support and broad-spectrum antibiotics is the essential management to reduce mortality.Šezdesetpetogodišnji muškarac je primljen u našu ustanovu s kliničkom slikom septičkog šoka i nekroze u skrotalnom, perianalnom i desnostranom ingvinalnom području. Postavljena je dijagnoza Fournierove gangrene. Zbog lošeg općeg stanja bolesnik je odmah kirurški zbrinut, učinjena je opsežna nekrektomja. Antibiotska terapija je ordinirana, a nakon prve operacije je učinjeno nekoliko debridmana rane. Sedamnaest dana nakon operacije su postavljeni sekundarni šavi, a 23. dana bolesnik je otpušten na kućnu njegu. Fournierova gangrena je hitno kirurško stanje te, iako je rijetka, predstavlja tešku i za život opasnu bolest. Brza i točna dijagnostika uz agresivnu kiruršku terapiju i opetovane debridmane te antibiotici širokog spektra i dalje su ključ uspješnog liječenja

Goran Benko

Goran Štimac

Igor Grubišić

Jordan Dimanovski

Josip Katušić

Šoip Šoipi

English

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Acta Clin Croat,  Vol. 48,  No. 3,  2009 453Acta Clin Croat 2010; 49:453-457 Case ReportMAnAgeMent of fouRnieR’s gAngRene: CAse RepoRt And liteRAtuRe ReviewJosip Katušić1, goran Štimac1, goran Benko2, igor grubišić1, Šoip Šoipi1 and Jordan dimanovski1 1university department of urology, sestre milosrdnice university Hospital, Zagreb; 2department of urology, varaždin general Hospital, varaždin, CroatiasuMMARY – A 65-year-old man was referred to our department with clinical signs of septic shock and necrotizing soft tissue infection of the scrotal, perianal and right inguinal region. initial presentation was a typical fournier’s gangrene. Because of the life-threatening condition, the initial treatment was extensive removal of necrotic tissue. Antibiotic therapy was administered and several debridements of the wound were done afterwards. Three weeks after the initial treatment, wide wo-und defects of the perianal, scrotal and inguinal regions were closed secondarily and the patient was discharged from the hospital. fournier’s gangrene is a surgical emergency. Although rare, it remains a life-threatening disease. Rapid and accurate diagnosis remains the key component in achieving su-ccessful outcome. early aggressive surgical intervention together with fluid, hemodynamic and nu-tritional support and broad-spectrum antibiotics is the essential management to reduce mortality.Key words: Fournier gangrene – diagnosis; Fournier gangrene – surgery; Fournier gangrene – therapy; Debridement; Emergencies; Acute disease; Case reportCorrespondence to: Josip Katušić, MD, 1university department of urology, sestre milosrdnice university Hospital, vinogradska c. 29, HR-10000, Zagreb, Croatiae-mail: josip.katusic@zg.t-com.hrReceived April 6, 2010, accepted november 11, 2010Introductionfournier’s gangrene is a necrotising fasciitis in-volving the genital, perianal or perineal regions. The infective process leads to thrombosis of subcutaneous blood vessels, resulting in gangrene of the overlying skin. early recognition of this condition with prompt surgical treatment and early antibiotics make the cor-nerstone in its management. Jean Alfred fournier, a parisian dermatologist and venereologist was the first to describe this condition in a specific region of the body, i.e. scrotum in 18831. The infection may spread along subcutaneous planes and result in tissue necro-sis. infections are usually polymicrobial. The organ-isms most commonly isolated from wound cultures include Bacteroides, coliforms, Streptococcus, Staphy-lococcus, and Peptostreptococcus. Anorectal infections, genitourinary infections, and cutaneous injuries are the most common sources of infection in necrotizing genital gangrene. Among gastrointestinal causes (30% to 50%), ischiorectal, perianal, and intrasphincteric abscesses account for approximately 70%2. necrotiz-ing gangrene has also been reported to be secondary to minor anorectal procedures such as rectal mucosal biopsy, anal dilation, and hemorrhoidectomy as well as appendicitis, colorectal malignancy, and diverticu-litis. genitourinary foci comprise the second major source of initial infection (20% to 40%); underlying urethral stricture and periurethral infection are most common. urologic conditions also associated include urethral trauma and instrumentation, indwelling ure-thral catheters, urethral calculi, epididymitis, prostate biopsy and massage, and bladder cancer extension2. Cutaneous injuries and infection account for 20% of cases. Malnutrition, Aids, malignancy, renal failure, and immunosuppressive chemotherapy are other risk factors2. As tissue necrosis progresses, normal flora in-J. Katušić et al. Management of fournier’s gangrene: Case report and literature review454 Acta Clin Croat,  Vol. 49,   No. 4,  2010vades in a perifascial fashion and colonizes previously sterile sites. with continued bacterial overgrowth and bacterial synergy, oxygen tension decreases and local ischemia develops, allowing for proliferation of anaerobic organisms. detailed bacteriologic stud-ies have revealed the infections to be polymicrobial. The organisms most commonly isolated from wound cultures include Bacteroides, coliforms, Streptococcus, Staphylococcus, and Peptostreptococcus; anaerobes are less reliably isolated but invariably present (table 1)2,3. Anorectal infections are typically caused by monobac-terial anaerobes, clostridial and nonclostridial gas-formers, and aerobic-anaerobic combinations. urinary pathogens usually include streptococci, staphylococci, and gram-negative rods, while cutaneous infections involve skin flora such as staphylococci2,3. infections originating in the anorectal region first penetrate sphincteric musculature. Then, the infection spreads along the perianal region and may extend along Col-les’ fascia. while lateral spread is prevented by attach-ments of Colles’ fascia, anterior and superior exten-sion along dartos and scarpa’s fasciae is unhindered2. Alternatively, anorectal infection may spread through the urogenital diaphragm to the perivesical space, then to the scrotum via the spermatic fascia. Most cases of necrotizing gangrene, regardless of location, begin insidiously. patients initially complain of scro-tal discomfort and associated malaise. As the infec-tion worsens, fever and chills develop with genital skin changes. scrotal swelling is usually present with erythema and increased pain. However, the skin can appear relatively normal, which may account for the delay in presentation after the onset of symptoms, usually averaging 5 days. in addition, the pain may subside as pressure necrosis and infection of cutane-ous nerves take place. signs and symptoms frequently found at presentation include pain (100%), swelling (80% to 100%), fever (60% to 80%), and crepitus (60% to 70%)2. systemic manifestations, such as overt shock and altered mental status, do not often correlate with physical findings and must be recognized early.Case ReportA 65-year-old man was transferred to our hospi-tal with clinical signs of septic shock and necrotiz-ing soft tissue infection of the scrotal and perianal regions and right inguinal region. one year before, inoperable colorectal carcinoma with the possible pulmonary metastases was diagnosed and definitive anus praeter sigmoideus was formed. At the time of admission, the patient was septic with temperature of 38 ºC. The patient denied dysuria frequency or ure-thral discharge and had suffered no local trauma to the scrotum recently. He had well-demarcated necro-sis of the scrotum, perianal and right inguinal region (fig. 1). fournier’s gangrene was suspected based on these findings. progression of rectal carcinoma was confirmed with digitorectal examination. due to life-threatening status, the patient was transferred im-mediately to the operating room to remove necrotic tissue. The area was cleaned with antiseptic solution and urinary catheter was placed. Blood and wound cultures were taken. The involved nonviable soft tis-Table 1. Fournier’s gangrene – causative bacteriagram-negative bacteria gram-positive bacteria Anaerobic bacteria fungiFusobacteriumSalmonellaEscherichia coliEnterobacterProteusKlebsiellaSerratiaPseudomonasShigellaNeisseriaPasteurellaStreptococcus(not group A)StaphylococcusCorynebacteriumStreptococcus group ABacterioides ClostridiumPeptococcusCandidaHistoplasmaCryptococcusActa Clin Croat,  Vol. 49,  No. 4,  2010 455J. Katušić et al. Management of fournier’s gangrene: Case report and literature reviewsue areas were debrided and necrotic tissue was ex-cised. Hydrogen peroxide and iodine-povidone solu-tions were used for local wound care. The wound was left open, covered by gauzes impregnated with normal saline. After initial prompt fluid resuscitation, anti-biotic therapy with gentamicin, metronidazole and cefuroxime was started. The patient had penicillin al-lergy in his history. on the next day, the patient had second debridement, became afebrile and remained so until discharge (fig. 2). After two days, blood culture was positive and Escherichia coli, susceptible to the an-tibiotic therapy administered, was found. seventeen days of the first operation, wide wound defects of the perianal, scrotal and inguinal regions were closed sec-ondarily. small wounds healed by second intention. during this procedure, right orchiectomy was per-formed because of necrosis (fig. 3). in wound culture, Pseudomonas aeruginosa susceptible to ceftazidime was found. The patient did well after the surgery and no further wound debridement was required. After 23 days, the patient was discharged from the hospital. two months after the surgery, genital and inguinal region completely healed (fig. 4).Fig. 1. Initial presentation of the patient with Fournier’s gangrene. Before surgery, considerable edema and scrotal ne-crosis with gas are seen.Fig. 2. Perineal and inguinal areas after repetitive extensive debridements of the liquefied necrosis and necrotic fascial tis-sues. The patient is prepared for reconstructive surgery with exposed testicles.Fig. 3. Postoperative view of reconstructed anogenital and inguinal region. Right testicle was removed.Fig. 4. Healed genital and inguinal region two months after surgery.J. Katušić et al. Management of fournier’s gangrene: Case report and literature review456 Acta Clin Croat,  Vol. 49,   No. 4,  2010Discussionfournier’s gangrene is described as a fulminant in-fection of the perineum and abdominal wall, and the scrotum and penis in men. Analysis of the predispos-ing and accompanying conditions suggests that most cases occur as a result of the one of three mechanisms: trauma to the area, providing access of organisms to the subcutaneous tissues; extension from urinary tract infection, probably most commonly a periure-thral gland infection, with dissection along the fascial planes involving the penis and scrotum; and extension of infection from the perianal area or, less commonly, the retroperitoneal space along fascial planes to the penis and scrotum4. other predisposing conditions include diabetes mellitus, chronic alcoholism, malig-nancy and immunosuppression, prior prolonged hos-pitalization, and prior surgical intervention5 (table 2). Colorectal causes of fournier’s gangrene include carcinoma of the sigmoid colon and rectum, colonic anastomotic dehiscence, appendicitis, perforated sig-moid diverticulitis and rectal perforation by foreign body6. Colorectal lesions are the most common foci of sepsis7. The precise etiology of fournier’s gangrene re-mains unclear8. The disease commonly begins locally with discomfort, itching and swelling of the scrotum and perineum. At presentation, edema and crepitus may be noted with systemic symptoms of fever, leuko-cytosis, anemia and electrolyte abnormalities. Before entering the operating room, all patients undergo ag-gressive fluid resuscitation, broad-spectrum antimi-crobial therapy and hemodynamic support if needed. early diagnosis and urgent debridement are necessary to control the associated septic process and improve the chances for survival9. The most widely used agents for local wound care are hydrogen peroxide and io-dine-povidone solutions. Hydrogen peroxide solution generates nascent oxygen, which helps destroy an-aerobic organisms7,9. it is necessary to determine the extent of disease and to identify any underlying col-orectal or urogenital pathology. The testes are rarely affected owing to the abdominal source of their blood supply. if they are involved, intra-abdominal pathol-ogy should be suspected10. The patient should undergo orchiectomy when severe infection in the peritesticu-lar tissues is observed intraoperatively, even though the testicular tissues were not found to be involved histologically. Because most patients require more than one debridement, primary closure of skin defects is impossible during the initial surgery; furthermore, patients have various sizes of skin defects following multiple debridements. Although most authors sug-gest that defects should be closed by secondary heal-ing, the number of institutions that prioritize recon-structive surgery is not small8. The disease still has a high mortality rate for delayed patients. The causes of death include severe sepsis, coagulopathy, acute renal failure and multiple organ failure7. Hyperbaric oxygen therapy could be an optional therapy; it may optimize neutrophil function and inhibit anaerobic growth and should be used as an adjuvant to surgery7. The patient from this case report was treated success-Table 2. Fournier’s gangrene – predisposing conditionsgenitourinary gastrointestinal obstetric/gynecologicpathologicinfection trauma urethral stricture periurethral abscess epididymitis paraphimosis soft tissue injuries post-coitalAnorectal abscess ischiorectal abscess perianal fistula Hemorrhoids  perforated rectal carcinoma Rectal perforation by foreign body  perforated sigmoid diverticulitispost-coital vulvar abscess  Bartholin's gland abscess septic abortionprocedural postoperative tuRp traumatic catheterizationAnoscopy/sigmoidoscopy Colonoscopy postoperative Anastomotic dehiscenceHysterectomy  Cervical/pudendal nerve block  postoperative episiotomy  pelvic exenterationActa Clin Croat,  Vol. 49,  No. 4,  2010 457J. Katušić et al. Management of fournier’s gangrene: Case report and literature reviewfully in accordance with current therapeutic concepts, hemodynamic stabilization, broad-spectrum antimi-crobial chemotherapy, and efficient surgical excision to remove all devitalized tissue. Conclusionfournier’s gangrene is a surgical emergency. Al-though rare, it remains a life-threatening disease. Many patients may present with only minor skin le-sions in the early stages of the disease. Rapid and accu-rate diagnosis remains the key component in achiev-ing a successful outcome. early aggressive surgical intervention together with fluid, hemodynamic and nutritional support, and broad-spectrum antibiotics is the essential management to reduce mortality.References1. efeM se. The features and aetiology of fournier’s gangrene. postgrad Med J 1994;70:568-71.2. Meng Mv, McAninCH Jw. necrotizing gangrene of the genitalia and perineum. infect urol 1999;12:132-40.  3. CHAMpion se. A case of fournier’s gangrene. urol nurs 2007;27:296-9.  4. Kiliç A, AKsoY Y, Kiliç l. fournier’s gangrene: etiolo-gy, treatment and complications. Ann plast surg 2001;47:523-7.  5. tleYJeH Mi, RoutH J, QutuB oM, lisCHeR g, liAng vK, BAddouR Ml. Lactobacillus gasseri causing fournier’s gangrene. scand J infect dis 2004;36:501-3.  6. leHnHARdt M, steinstRAesseR l, dRueCKe d, MueHlBeRgeR t, steinAu uH, HoMAnn HH. fournier’s gangrene after Milligan-Morgan hemorrhoidec-tomy requiring subsequent abdominoperineal resection of the rectum: report of a case. dis Colon Rectum 2004;47:1731-2.  7. AtAKAn iM, KAplAn M, KAYA e, AKtoZ t, inCi o. A life threatening infection – fournier’s gangrene. int urol nephrol 2002;34:387-92.  8. CoRMAn JM, MoodY JA, ARonson wJ. fournier’s gangrene in a modern surgical setting: improved survival with aggressive management. BJu int 1999;84:85-8.  9. YAnAR H, tAviloglu K, eRteKin C, guloglu R, ZoRBA u, CABioglu n, BAspinAR i. fournier’s gangrene: risk factors and strategies for management. world J surg 2006;30:1750-4.10. AHo t, CAnAl A, neAl de. fournier’s gangrene. nat Clin pract urol 2006;3:54-7.sažetakliJeČenJe fouRnieRove gAngRene: pRiKAZ sluČAJA i pRegled liteRAtuReJ. Katušić, G. Štimac, G. Benko, I. Grubišić, Š. Šoipi i J. DimanovskiŠezdesetpetogodišnji muškarac je primljen u našu ustanovu s kliničkom slikom septičkog šoka i nekroze u skrotalnom, perianalnom i desnostranom ingvinalnom području. postavljena je dijagnoza fournierove gangrene. Zbog lošeg općeg stanja bolesnik je odmah kirurški zbrinut, učinjena je opsežna nekrektomja. Antibiotska terapija je ordinirana, a nakon prve operacije je učinjeno nekoliko debridmana rane. sedamnaest dana nakon operacije su postavljeni sekundarni šavi, a 23. dana bolesnik je otpušten na kućnu njegu. fournierova gangrena je hitno kirurško stanje te, iako je rijetka, predstavlja tešku i za život opasnu bolest. Brza i točna dijagnostika uz agresivnu kiruršku terapiju i opetovane debridmane te antibi-otici širokog spektra i dalje su ključ uspješnog liječenja. Ključne riječi: Fournierova gangrena – dijagnostika; Fournierova gangrena – kirurgija; Fournierova gangrena – terapija; Debrideman; Hitni slučajevi; Akutna bolest; Prikaz slučaja

Liječenje Fournierove gangrene : prikaz slučaja i pregled literature

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