Fournier’s Gangrene: A Urologic Emergency

You Don’t Want to Miss!Angela Lou Reu, B.A., M.S., PA-C

Emergency Care Consultants

Chief Complaint: Flu-like Symptoms

HPI: The patient is a 43 y/o male with h/o DM, HTN, HLD, and obesity who presents to the ED with flu-like symptoms. He c/o feeling feverish with chills, diaphoresis, nausea and generalized body aches x 4-5 days. He reports decreased appetite and has not been taking his home meds for the past few days d/t not feeling well. Sugars have been “high”. No temp taken at home. He denies headache, neck pain or stiffness, cough or URI symptoms, sore throat, runny nose, sinus congestion, earache, chest pain, SOB, abdominal pain, vomiting, diarrhea, constipation, urinary symptoms, rashes, recent illness or ill contacts and has no other complaints or concerns at this time.

History cont.

PMH: DM, HTN, HLD, obesity

PSH: None

Home Meds: ASA, Metformin, Lantus, Lipitor, Losartan

Allergies: NKDA

SH: Lives at home with wife. Former smoker. Daily drinker (reports 4 beers daily).

FH: Noncontributory

ROS – pertinent positives and negatives

General: feverish with chills, diaphoresis, decreased appetite

HEENT: no headache, sore throat, runny nose, sinus congestion, earache

CV: no chest pain

Pulm: no cough, sputum, or SOB

GI: nausea without vomiting, no diarrhea or constipation

GU: denies urinary complaints

MS: myalgias, denies neck pain/stiffness

Skin: denies rash

Physical Exam

Vitals: T 102.2 HR 114 BP 104/87 RR 22 Sats 98% on RA

General: lethargic, appears ill, diaphoretic, uncomfortable, mild distress

HEENT: NC/AT, PERRLA, conjunctiva clear, sclera white, EOMI, EACs clear, TMs noninjected with good light reflex, dry mucous membranes, no oropharyngeal edema, erythema, or exudate, uvula midline

Neck: soft, supple, no LAD, no meningeal signs

CV: regular rhythm, tachycardic, no m/r/g

Physical Exam cont.

Pulm: Tachypneic, Lungs CTAB, no wheezing or rales

Abdomen: obese, soft, nondistended, nontender, normal bowel sounds

MS: Extremities warm, well perfused, no cyanosis, clubbing, edema, SILT, MAE

Neuro: lethargic, oriented x 3, CN II-XII grossly intact

Skin: good color, warm to touch, diaphoresis noted

Differential Diagnosis

F/C, diaphoresis, decreased appetite, nausea, myalgias

Influenza or viral illness

Otitis media/externa

Sinusitis

Bacterial or viral pharyngitis

Pneumonia

Gastroenteritis

UTI/pyelonephritis

* Wait! After family leaves the room, the nurse tells you that the patient has something he wants to show you. *

The rest of the story…

Upon reassessment, the patient tells you that he has a “problem” in his groin area.

You pull back the blanket, and to your surprise...

GU Exam

Erythematous, edematous scrotum with warmth and exquisite tenderness on palpation. Malodor noted. Necrotic tissue, midline scrotum and dorsal penile shaft. No open lesions or active drainage. Erythema extending onto abdominal wall, perineum and bilateral proximal thighs with bogginess and crepitus.

Reconsider the Differential

Scrotal pain and swelling

Cellulitis

Gonococcal balanitis

Epididymitis or orchitis

Strangulated hernia

Scrotal abscess

Testicular torsion

Hydrocele or Varicocele

Vascular occlusion syndromes

Polyarteritis nodosa

Warfarin necrosis

Don’t Miss the Obvious!!!

Fever, lethargy, severe scrotal pain and swelling with erythema, crepitus +/- necrotic tissue should raise suspicion of necrotizing fasciitis of the genitalia, or…

Fournier’s Gangrene! Failure to examine the genitals, especially in diabetics or

immunocompromised patients, can result in misdiagnosis and delay in treatment!!!

Labs – Sepsis Workup

CMP: Na 133, K 4.1, Glucose 417, Cr 1.5, bicarb 26

CBC: WBC 15.5, Hgb 12.2, HCT 37.2 PLT 255

UA/UC: pending

INR: 1.2

Lactate: 1.6

Blood cultures x 2: pending

Imaging

Do not delay early surgical debridement for imaging studies. Delay will result in a negative impact on prognosis! 24-hour delay increases mortality rate by 11.5%, 6-day delay by

76%.

Fournier's Gangrene

First described in 1764 by Baurienne. Named after French venereologist, Alfred Jean Fournier, in 1883.

Aggressive, rapidly spreading infection of soft tissue, or necrotizing fasciitis, that affects the genitalia, perineal, and/or perianal regions.

Ten times more common in men, but can affect women and even children.

Rare, but life threatening!

High mortality rate (20-30%, some reports as high as 50%), despite advanced management.

Epidemiology and Etiology

Etiology

Perineal and genital skin infections (scrotal or anorectal abscess)

Urethral stricture

Anorectal, urogenital and perineal trauma (including genital piercing and intracavernosal cocaine injection)

Iatrogenic (indwelling catheter, traumatic catheterization, prostatic or rectal biopsy, anal dilatation, hemorrhoidectomy, vasectomy, penile implant, hydrocele aspiration)

Nidus typically from GI tract (30-50%), GU tract (20-40%), and cutaneous injuries (20%).

Associated Comorbidities:

DM (20-70%), alcoholism (25-50%), immunosuppression (including malnutrition, SLE, Crohn’s, chronic corticosteroid use, chemotherapy, HIV, liver disease, IVDA, and, less likely, bone marrow malignancy)

Onset to presentation, on average, 5 days.

Microbiology

Polymicrobial infections by aerobes and anaerobes: Enterobacter, esp. E coli

Klebsiella

Bacteroides

Streptococci

Staphylocci

Clostridia

Pseudomonas

Most are normal flora in the perineum and genitalia, most common E coli.

On average, at least 3 organisms cultured from each patient.

Pathophysiology

Microvascular thrombosis leading to cutaneous and subcutaneous necrosis, facilitating bacterial proliferation along fascial planes

Virulence in synergy promotes rapid spread and extensive tissue damage

Impaired host cellular immunity = favorable environment to permit infection

Portal of entry of microorganism into perineum/genitalia

Clinical Presentation

Most common presenting complaints: Fever, lethargy – first sign

Intense scrotal pain and tenderness with edema - hallmark

Cellulitis

Fetid odor

Crepitus/Fluctuance (gas producing organisms)

As inflammation worsens, necrotic tissue appears. Fascial necrosis is usually more extensive than visible gangrene suggests.

Infection can spread up the entire anterior abdominal wall, up to the clavicle.

Rapid progression to multi-organ failure secondary to Gm – sepsis, the most common cause of death.

Diagnosis

Primarily clinical (HIGH clinical index of suspicion)

Labs (CBC, CMP, Coag studies, Lactate, Blood cultures, Wound cultures – intraoperative)

Surgical consult

Imaging ???

Early surgical exploration and debridement of all necrotic tissue – definitive diagnosis

Clinical predictive values (LRINEC or FGSI)

Imaging

May be useful in atypical presentation or questionable true extent of disease.

Plain radiographs

May show air in tissue.

Ultrasonography

Differentiate intrascrotal abnormality; shows thickened, swollen scrotal wall containing gas.

CT and MRI

Diagnose or rule out retroperitoneal or intra-abdominal process.

LRINEC Score – Laboratory Risk Indicator for Necrotizing Fasciitis Score

Fournier’s Gangrene Severity Index (FGSI)

Clinical Predictive Scores

LRINEC can be used to risk stratify patients with cellulitis to determine the likelihood of necrotizing fasciitis being present.

A LRINEC score ≥ 6 should raise suspicion of necrotizing fasciitis among patients with severe soft tissue infections.

A LRINEC score ≥ 8 is strongly predictive of this disease.

FGSI is useful to help predict outcome.

A FGSI score > 9 is associated with a 75% death rate.

A FGSI score of < 9 is associated with 78% survival.

One study quoted, a FGSI score of > 10.5 is associated with 96% death and a score of < 10.5 is associated with 96% survival.

Treatment

Aggressive multimodal approach.

Hemodynamic stabilization – aggressive fluid resuscitation.

Broad spectrum triple antibiotics – cover Gm +, Gm – and Anaerobes (Zosyn and Vanco , PLUS Clindamycin for anti-toxin effects against toxin-elaborating strains of strep and staph). Narrowed based on culture and sensitivities.

Early surgical debridement - primary component of treatment (Average 3.5 procedures per patient).

Treatment cont.

Hyperbaric Oxygen – believed to be effective adjunct, though no conclusive evidence regarding effectiveness.

Neutralizes anaerobes, improves neutrophil function, increased fibroblast proliferation, promotes angiogenesis.

Honey ??? – natural antimicrobial, digests necrotic tissue, accelerates healing by stimulating growth and multiplication of epithelial cells.

Wound VAC – minimizes contamination and skin defects, as well as speeds tissue healing.

Plastics Reconstruction – split-thickness graft to repair perineal and scrotal defects.

Fournier’s Gangrene: Report of Thirty-Three Cases and a Review of the Literature

Group 1

21 patients, mean age 57

Broad spectrum antibiotics

Broad debridement (avg 3)

Exhaustive cleaning

Split-thickness skin grafts or delayed closure

Group 2

12 patients, mean age 48

Broad spectrum antibiotics

One debridement per patient

Unprocessed honey daily

Own new scrotal skin (4 patients) or secondary suturing (8 patients)

Results

Group 1

Older, multiple comorbidites, more extensive disease

Longer hospitalization (4.5 weeks)

Three patients died – severe sepsis

Worse clinical and cosmetic results

Group 2

Younger, healthier, more localized disease

Shorter hospitalization (4 weeks)

No deaths

Better clinical and cosmetic results

Back to the Case

Started on Zosyn/Vanc/Clindamycin

2L IVF resuscitation

NPO

To OR for emergent debridement

LRINEC score 7 (intermediate risk for necrotizing fasciitis)

FGIS score 8 (>78% chance of survival)

After Debridement

Plastics Reconstruction

Summary

Fournier's Gangrene is BAD. Mortality rates remain high, despite aggressive management. Long term complications for those who survive (pain, sexual dysfunction, infertility, extensive scarring).

HIGH clinical index of suspicion, especially in diabetics, alcoholics, and patient’s with immunosuppression.

Low threshold for Surgical consult and early operative intervention.

Broad spectrum antibiotics.

+/- Hyperbaric oxygen therapy.

Honey – reduce cost, morbidity and mortality ???

Clinical predictive scores useful to help predict outcome.

Questions ???

References

Burch DM, Barreiro TJ, Vanek VW. Fournier’s gangrene: Be alert for this medical emergency. JAAPA Nov 2007; 20(11):44-47.

Kessler CS, Baum J. Non-Traumatic Urologic Emergencies in Men: A Clinical Review. West J Emerg Med. Nov 2009; 10(4): 281-287.

Mallikarjuna, MN. Vijayakumar, A, Patil, VS, et al. Fournier’s Gangrene: Current Practices. ISRN Surgery, Vol. 2012, Article ID 942437, 8 pages, 2012.

Pastore, et al. A multistep approach to manage Fournier’s gangrene in a patient with unknown type II diabetes: surgery, hyperbaric oxygen, and vacuum-assisted closure therapy: a case report. Journal of Medical Case Reports 2013, 7:1.

References cont.

Rahmaz L, Erdemir R, Kibar Y, et al. Fournier’s gangrene: Report of thirty-three cases and a review of the literature. International Journal of Urology, 12: 960-967.

Stevens, DL, Baddour, LM. (2014). Necrotizing soft tissue infections. In: UpToDate, Sexton DJ, Edwards MS, (Ed), UpToDate, Waltham, MA, 2014.

Thwaini A, Khan A, Malik A, et al. Fournier’s gangrene and it’s emergency management. Postgrad Med J. Aug 2006; 82(970):516-519.