Overview
Fournier's Gangrene
Topic Overview
Summary
Fournier's gangrene is a necrotising fasciitis of the perineum, genitalia, and perianal region. It is a urological and surgical emergency with high mortality (20-40%). It typically arises from genitourinary or anorectal sources and is polymicrobial. The hallmark is rapid progression with tissue necrosis and severe systemic toxicity. Treatment is emergency surgical debridement, broad-spectrum IV antibiotics, and intensive care support. Delay in surgery dramatically increases mortality.
Key Facts
- Definition: Necrotising fasciitis of perineum/genitalia
- Mortality: 20-40% (higher if delayed surgery)
- Organisms: Polymicrobial (aerobes + anaerobes)
- Key feature: Rapid spread, crepitus, tissue necrosis
- Treatment: Emergency surgical debridement + IV antibiotics + ICU
Clinical Pearls
Fournier's is necrotising fasciitis of the perineum — same principles apply
Pain out of proportion to examination findings is an early sign
FGSI score (Fournier's Gangrene Severity Index) helps predict mortality
Why This Matters Clinically
Fournier's gangrene is rapidly fatal without surgery. Every hour of delay increases mortality. A high index of suspicion, early recognition, and immediate surgical debridement are life-saving.
Visual Summary
Visual assets to be added:
- Fournier's gangrene clinical progression
- Anatomical spread pathways
- FGSI scoring table
- Management algorithm
Epidemiology
Incidence
- 1.6 per 100,000/year
- Increasing due to ageing population and comorbidities
Demographics
- Male predominance (10:1)
- Mean age: 50-60 years
- Can occur in females (vulva, perineum)
Risk Factors
| Factor | Notes |
|---|---|
| Diabetes mellitus | Present in 40-60% of cases |
| Immunocompromise | HIV, chemotherapy, steroids |
| Obesity | |
| Chronic alcohol use | |
| Renal failure | |
| Malignancy | |
| Recent surgery/procedure |
Sources of Infection
| Source | Examples |
|---|---|
| Anorectal | Perianal abscess, fistula (30-50%) |
| Genitourinary | UTI, urethral stricture, catheter, trauma (20-40%) |
| Skin | Local trauma, pressure sores |
| Idiopathic | 20% |
Pathophysiology
Mechanism
- Entry of bacteria through skin/mucosa
- Bacterial synergy (aerobes + anaerobes)
- Infection spreads along fascial planes (Colles', Scarpa's, dartos)
- Obliterative endarteritis → thrombosis of vessels
- Tissue ischaemia and necrosis
- Systemic toxicity → septic shock
Organisms — Polymicrobial
| Type | Examples |
|---|---|
| Gram-positive | Streptococci, Staphylococci, Enterococci |
| Gram-negative | E. coli, Klebsiella, Pseudomonas |
| Anaerobes | Bacteroides, Clostridium, Peptostreptococcus |
Anatomical Spread
- Scrotum → anterior abdominal wall (via Scarpa's fascia)
- Perineum → buttocks, thighs
- Does NOT typically involve testes (separate blood supply)
Clinical Presentation
Early Symptoms
Late Signs (Do Not Wait For These)
Examination Findings
Red Flags
| Finding | Significance |
|---|---|
| Pain out of proportion | Early sign |
| Crepitus | Gas-forming organisms |
| Skin necrosis | Late — needs immediate surgery |
| Septic shock | Very high mortality |
Perineal/scrotal pain and swelling
Common presentation.
Fever, malaise
Common presentation.
Pain OUT OF PROPORTION to examination
Common presentation.
Clinical Examination
General
- Toxic, unwell
- Fever or hypothermia
- Tachycardia, hypotension
Local
- Scrotal/perineal swelling
- Erythema with indistinct margins
- Crepitus
- Necrosis
- Foul smell
Rectal Examination
- May identify anorectal source
Investigations
Blood Tests
| Test | Finding |
|---|---|
| WCC | Often very high or very low |
| CRP | Markedly elevated |
| Lactate | Elevated |
| U&E, creatinine | AKI |
| Glucose | Hyperglycaemia (diabetics) |
| Blood cultures | Essential |
FGSI Score (Fournier's Gangrene Severity Index)
- Based on vital signs and lab values
- Score over 9: Higher mortality
- Helps prognostication
Imaging
| Modality | Findings |
|---|---|
| CT pelvis | Gas in soft tissues, fascial thickening |
| X-ray | May show subcutaneous gas |
| Ultrasound | Scrotal gas, abscess |
Important: Do NOT delay surgery for imaging if clinical diagnosis is clear
Classification & Staging
By Source
- Anorectal origin
- Genitourinary origin
- Cutaneous origin
- Idiopathic
By Severity
- Localised
- Extensive (spreading to abdominal wall, thighs)
Management
Resuscitation
| Action | Details |
|---|---|
| IV access | Large bore |
| IV fluids | Aggressive resuscitation |
| Blood cultures | Before antibiotics |
| ICU referral | Often needed |
IV Antibiotics — Broad-Spectrum
| Regimen | Notes |
|---|---|
| Piperacillin-tazobactam | Broad-spectrum |
| + Clindamycin | Toxin inhibition |
| + Vancomycin | If MRSA risk |
| Or meropenem + clindamycin | Alternative |
Emergency Surgery — CRITICAL
| Principle | Details |
|---|---|
| Timing | IMMEDIATE — do not delay |
| Debridement | Wide excision of ALL necrotic tissue |
| Re-look | Return to theatre every 24-48h |
| Repeat debridement | Until healthy tissue |
| Stoma | May be needed (faecal diversion) |
| Urinary diversion | May be needed |
Supportive Care
- ICU admission
- Organ support
- Nutritional support
- Wound care (VAC therapy)
Reconstruction
- Once infection controlled
- Skin grafting
- Flap reconstruction
Complications
Acute
- Septic shock
- Multi-organ failure
- Death (20-40%)
Long-Term
- Disfigurement
- Sexual dysfunction
- Psychological impact
- Chronic pain
Prognosis & Outcomes
Mortality
- 20-40% overall
- Higher with delayed surgery, age, comorbidities
Prognostic Factors
- Time to surgery (most important)
- FGSI score
- Extent of disease
- Comorbidities
Evidence & Guidelines
Key Evidence
- Early surgery reduces mortality
- Broad-spectrum antibiotics essential
- FGSI score predicts mortality
Guidelines
- No specific national guideline
- Management based on expert consensus and case series
Patient & Family Information
What is Fournier's Gangrene?
Fournier's gangrene is a very serious infection of the skin and tissues around the genitals and bottom. It spreads very quickly and needs emergency surgery.
Symptoms
- Severe pain in the groin or genital area
- Swelling and redness
- Skin turning black
- High fever
- Feeling very unwell
Treatment
- Emergency surgery to remove dead tissue
- Strong antibiotics
- Intensive care
Outcome
- This is a life-threatening condition
- Multiple operations are often needed
- Recovery takes time
Resources
References
Key Reviews
- Eke N. Fournier's gangrene: a review of 1726 cases. Br J Surg. 2000;87(6):718-728. PMID: 10848848
- Singh A, et al. Fournier's gangrene: a clinical review and overview. Eur Urol Focus. 2019;5(3):421-427. PMID: 29042201
FGSI Score
- Laor E, et al. Outcome prediction in patients with Fournier's gangrene. J Urol. 1995;154(1):89-92. PMID: 7776464