Fournier's gangrene often begins when bacteria enter the genitalia, perineum, or colorectal area through a wound and cause an infection that deprives the infected tissue of oxygen, thus leading to necrosis. The skin, as well as the superficial and deep fibrous membranes that separate the muscles and guard nerves and vessels around the genital region, are typically destroyed. If an existing condition such as an immune system deficiency is present, the spread of the infection is greatly assisted and may reach the buttocks, abdominal wall, back, pelvis, retroperitoneum, and beyond.
The most common symptoms of Fournier's gangrene is the graying or blackening of the skin and a foul odor coming from the infection site. Although extremely rare, it is important that Fournier's gangrene, if suspected, is treated immediately to avoid excessive debridement, multiple organ failure, amputation, or death (particularly if the infection reaches the blood).
Fournier's Gangrene Causes
Fournier gangrene results from a bacterial infection in the genital area. Most cases are sparked by a combination of aerobic (requiring air) and anaerobic (living without oxygen) bacteria. Anaerobic microorganisms particularly flourish in oxygen-poor environments and generate enzymes that cause the infection to spread. E.coli (an aerobic microorganism often found within the digestive tract), bacteroides (anaerobic), streptococcus (anaerobic), enterococcus (aerobic), staphylococcus facultative anaerobes that grow by aerobic respiration), pseudomonas (anaerobic), klebsiella pneumoniae (aerobic), and proteus (aerobic) are the most common bacteria that lead to infection associated with Fournier's gangrene. These organisms tend to make the blood clot, thus depriving tissue of necessary oxygen.
Fournier's Gangrene Risks
Men
Men are 10 times more likely than women to develop Fournier's gangrene. Often the testicles, urethra (tube that allows urine to exit the body), and the chamber inside the penis that fills with blood to produce an erection are not usually affected. Rather, the superficial and deep layers of fibrous tissue, as well as the skin, are typically destroyed.
The following are risk factors associated with men and this condition:
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Vasectomy (male sterilization procedure that requires the vas deferens tubes to be clipped and tied off)
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Penile prosthesis
- Hydrocele aspiration (draining a fluid-filled sack in the scrotum)
- Zipper injury to the foreskin
- Circumcision
Women
Though women rarely develop Fournier's gangrene, destruction usually occurs in the fibrous tissue that makes up the vaginal wall, buttocks, abdominal wall, back, pelvis, and retroperitoneum.
The following risk factors are associated with Fournier's gangrene in women:
- A pus-producing bacterial infection (abscess) in the vaginal area
- Episiotomy (a surgical cut made in the perineum and vagina to keep the skin from tearing during child birth)
- A septic abortion (an abortion that leads to infection in the lining of the uterus and fever)
- Hysterectomy (surgery to remove the uterus)
- An infected Bartholin's gland, the two oval glands positioned on each side of the vaginal opening that secrete the fluid that lubricates the vagina.
Other associated conditions and/or events that involve both men and women include:
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Perineal abscess (when pus collects in the area between the scrotum and the anus in men or between the vulva and anus in women)
- Perineal trauma
- Injury occurred during sexual intercourse
- Genital mutilation
- Genital piercing
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Injury during catheterization
- Excessive drug or alcohol use
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Morbid obesity
- Steroid use
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Diabetes
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Leukemia
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Immune system deficiencies (e.g. HIV or Crohn's disease)
Fournier's Gangrene Symptoms
Typically, Fournier's gangrene presents with:
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Intense pain in the genital region, followed by waning pain as the nerve tissue become necrotic
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Increased sensitivity in the genital region
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Fever
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Fatigue
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Redness and inflammation
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Edema
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Fluid drainage
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Soft tissue gas
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Graying or blackening skin, a sign of tissue death
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Septic shock
- Rapid heart rate
- Low blood pressure
- A foul odor coming from the infection site
- Pus seeping form the site of injury
- Blisters
Diagnosing Fournier's Gangrene
Since Fournier's gangrene is extremely aggressive, diagnosis should made through clinical examination rather than waiting for diagnostic tests and procedures, which can lead to delayed treatment. Clinical examination should include palpation of the urogenital and perineal areas; noting any sensitivity to touch, localized tenderness, visible wounds, excess pus or soft-tissue decay.
When diagnostic tests are called for, they may include one or more of the following:
- Imaging studies (including radiography, CT, ultrasound, and MRI) to produce images of the internal body so that the presence and extent of the disease can be determined.
- Chemistry panel to examine electrolyte and glucose levels
- Arterial blood gas (ABG) to assess the pH of the blood
- Blood tests to look for signs of infection and inflammation, and to count the red blood cells
Should a diagnosis not be made after these tests, a tissue sample may be taken and examined under a microscope to look for and determine the type of bacterial infection.
Fournier's Gangrene Treatment
Treatment for Fournier's gangrene starts with antibiotics, followed by debridement of the dying skin. These may also be paired with hyperbaric oxygen therapy. Depending on the aggressiveness of the gangrene, amputation may be required.
References:
Liang S., Chen H., Lin S., et al. (2008). Fournier's gangrene in female patients. J Soc Colon Rectal Surgeon
Thwaini A., Khan A., & Mammen K. (2008). Fournier's gangrene and its emergency management. Postgraduate Medical Journal
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