This disease was first described in 1883 by the Parisian dermatovenerologist J. A. Fournier. He observed how several healthy young men developed rapidly progressive gangrene of the penis and scrotum. This disease is defined as polymicrobial necrotizing fasciitis of the perineum and perianal region. This condition is most common in older men, although it can be diagnosed at any age. Very rarely, Fournier's gangrene occurs in women.
Due to the rarity of the pathology, it has not been studied well enough, and data about it in the medical literature may be contradictory. Previously, it was believed that gangrene occurs as a result of trauma, at present, the introduction of an endogenous or exogenous infection is not excluded. Its spread is facilitated by diseases of the genitourinary system or the lower intestine.
- Clinical manifestations
- Diagnostics of the Fournier gangrene
- Conservative therapy and surgery
- Prognosis of patients' condition after treatment
Forms of infection based on the localization of the disease and the reasons for its occurrence:
Anorectal form - arises as a result of anal fissures, purulent inflammation of the lower intestine, rectal perforation, and also as a complication of colorectal cancer or trauma to this gastrointestinal tract;
Urogenital form - occurs due to infection of the genitourinary tract and genital skin, trauma to the urethra (with long-term catheterization).
Other causes of Fournier's gangrene:
- Genital piercing;
- Penile injections;
- Steroid enemas
- Superficial damage to the genital organs;
- Foreign body in the rectum.
Localization of the disease is due to the structural features of the corresponding area of the human body. The epithelium of the external genital organs and perineum is very loose, as well as the adipose tissue of the subcutaneous tissue. The skin of this area contains many sweat and sebaceous glands, hair follicles.
The scrotum and the anal region are equipped with a dense network of veins and a few arteries. With inflammation in this place, blood flow slows down, which further impairs the blood circulation of tissues. Ischemia spreads along the fascia, causing skin gangrene. The membranes of the scrotum become necrotic, edema and micro-abscesses occur in them.
Any disease or condition that lowers the level of general immunity exacerbates the risk of developing Fournier's gangrene.
Increased risk factors:
- Cirrhosis of the liver;
- HIV infection;
- Violation of blood circulation in the pelvic organs;
- Taking glucocorticosteroids;
- Malignant tumors;
- Chemotherapy sessions;
- Crohn's disease.
The wider the volume of damaged tissues, the more severe the manifestations of the disease.
The most striking of them are the symptoms of intoxication:
Additionally, heart palpitations, arterial hypotension can be diagnosed.
Local symptoms of Fournier's gangrene:
- The appearance of ulcers on the skin of the scrotum and on the penis;
- Hyperemia, edema, itching;
- Tissue necrosis;
- Foul odor from the wound;
- Difficulty urinating;
- Pain syndrome;
- Discharge of gas bubbles, pus from the wound.
The duration of the disease does not exceed 5-8 days, although cases of a fulminant course of the disease are described in medical practice. With the development of the clinical picture of Fournier's gangrene, the tissues of the scrotum and the area near the anus become black. When they are palpated, crepitus (crisp sound) appears. This symptom signals the death of genital tissues. The inflammation can spread to the inner thighs, groin and lower abdomen.
Diagnostics of the Fournier gangrene
To diagnose the disease, you should consult a urologist. In the early stages, the doctor can detect only edema and hyperemia of the genitals, at the late stage of gangrene formation, a crunch and symptoms of intoxication are recorded. The symptoms of Fournier's gangrene are differentiated from urological diseases and other pathologies.
Diseases with similar manifestations:
- Balanitis of a patient with diabetes mellitus;
- Gangrenous balanitis;
- Inguinal lymphogranulomatosis;
- Gangrenous diabetic vulvitis and acute vulvar ulcers in women.
Laboratory and instrumental research:
- General analysis of blood and urine for the presence of leukocytes, ESR;
- Blood clotting test;
- Blood test to determine the level of gases;
- Analysis for disseminated intravascular coagulation;
- X-ray of the pelvic organs;
- Bacteriological examination of blood and urine;
- Ultrasound of the testicles - allows you to exclude urological pathologies.
If necessary, a histological examination of the tissues of the affected area is carried out.
Histological signs of gangrene:
- Fascia necrosis;
- Fascia vascular thrombosis;
- Coagulation of fibrin in the lumen of the vessels;
- Signs of bacterial tissue infection;
- Infiltration of tissues.
Conservative therapy and surgery
Treatment of patients with such a diagnosis takes place in the surgical department, in the intensive care unit. The main direction of treatment is drug therapy using antibiotics.
Preparations for monotherapy and combined treatment:
- Protected penicillins;
- Clindamycin + Ciprofloxacin;
- Cephalosporin + Metronidazole.
At the same time, the patient is being prepared for surgery. During the operation, the surgeon excises the tissue affected by gangrene.
Stages of the operation:
- Skin incision in the groin area;
- Removal of necrotic tissue with the capture of intact areas.
- Cleansing tissue from pus;
- Antiseptic treatment of the scrotum and peritoneum;
- Pumping out exudate;
- Suturing an operating wound.
Most often, it is not possible to do with one operation, it becomes necessary to carry out plastic surgery of the genitals. For this, autodermoplasty, muscle and pedicle plastic and other modern reconstruction methods are used. Excision of a large area can lead to edema of the penis due to impaired lymph circulation.
Prognosis of patients' condition after treatment
After therapy, scars remain at the site of gangrenous manifestations, and the genitals can be severely deformed. If the surgery is performed at an early stage, the scrotum regenerates very quickly. Having genital scars can make an erection painful. Such manifestations are observed in half of men who have undergone such treatment. Death, according to medical statistics, is recorded in 7-45% of cases of diseases, the treatment of which began too late.
Insufficient knowledge of the pathology and an uncertain prognosis with many complications makes Fournier's gangrene a very dangerous disease.
The author of the article: Volkov Dmitry Sergeevich | c. m. n. surgeon, phlebologist
Education: Moscow State University of Medicine and Dentistry (1996). In 2003 he received a diploma from the Educational and Scientific Medical Center of the Presidential Administration of the Russian Federation.