Abstract

Fournier gangrene is a type of necrotizing fasciitis or gangrene affecting the external genitalia and/or perineum. It commonly occurs in older men, but it

can also occur in women and children. It is more likely to occur in diabetics, alcoholics, or those who are immune compromised.

About 1 per 62,500 males are affected a 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, 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, fever, pallor and generalized weakness. More marked cases are characterized by a foul odor and purulent discharge from the infected tissue. Crepitus has been reported. It begins as a subcutaneous infection. However, soon necrotic patches appear in the overlying skin which later develop into necrosis.

Cause

Most cases of Fournier gangrene are infected by both aerobic and anaerobic bacteria. Resulting mortality increases in individuals lacking access not only to pragmatic resources such as sanitation and medical care, but to psychosocial resources as well.

A 2006 Turkish study reported 46% of those diagnosed with Fourniers had elevated blood sugars. There have been additional findings that seemingly link Fourniers with immunosuppression and alcoholism. One study reported approximately one third of those diagnosed with Fournier had alcoholism with resulting diabetes and malnutrition, while another 10% had been medical immunosuppressed either via chemotherapy, steroids, or malignancy.

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 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 (surgical removal) of necrotic (dead) tissue. In addition to surgery and antibiotics, hyperbaric oxygen therapy (HBOT) may be useful and acts to inhibit the growth of and kill the anaerobic bacteria.

Prognosis

While recent case series (n=9-80) studies have found a mortality rate of 20-40%, a large (n=1641) 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. Out of 1,680 cases identified in the study 39 were women.

Notable cases

The most historically prominent sufferers from this condition may have been Herod the Great, his grandson Herod Agrippa, and possibly the Roman emperor Galerius. Puerto Rican abolitionist and pro-independence leader Segundo Ruiz Belvis died from Fournier gangrene in November 1867.