Fournier Gangrene (FG) otherwise called acute fasciitis is an extremely severe and life-threatening condition in urological practice.
Jean Alfred Fournier, a French dermatologist, reported five
patients with a atypical gangrene of the penis & scrotum in 1882
. This condition is a gangrenous infectious process that involves
the external genitals and perineum after infestation of the traumatized
tissues of the mentioned areas. FG is most frequently caused
by a combination of several microorganisms, such as staphylococci,
streptococci, enterobacteria, anaerobic bacteria and fungi. Due
to that this disease very rapidly progresses, causing tissue skin,
subcutaneous fat and muscles necrosis. Staphylococci condense the blood, thus decreasing the oxygen content in the adjacent tissues.
Anaerobic bacteria divide rapidly in oxygen-poor media, producing
molecules that enhance the chemical reactions, which, in turn, facilitates
the spread of the infectious process. Fournier gangrene can be
lethal if infection disseminates into the bloodstream .
The likelihood to develop FG is 10 times larger in males than
in females. The most susceptible population are males aged 60-
80 years. Fournier gangrene is much less likely to infest children;
in pediatric patients it is usually a consequence of burns, circumcision
or insect bites .
There are three main groups of the etiological factors that
lead to the development of FG, depending on the anatomical
location of the infectious process:
1. Anorectal FG: infection is present in the perineal glands
due to colorectal trauma, tumors or diverticulae; apendicities.
2. Location along the genitourinary tract: infection in the
bulbourethral glands; urethral trauma; iatrogenic trauma due
to manipulations upon the urethral strictures; infections of the
lower urinary tracts.
3. Dermatological conditions: hydradenitis, ulceration, trauma,
piercing, complications of surgical interventions.
An important precondition for FG development is suppression
of the immune system, which frequently occurs in such
conditions as diabetes mellitus, liver cirrhosis, vascular diseases
of the pelvic organs, malignant tumors, alcoholism, injection
drug abuse, low socio-economical status .
The complex anatomical structure of the area (scrotal skin,
tunica dartos, Colles fascia, the external seminal fascia, cremasteric
fascia, the internal seminal fascia, the fasciae of the anterior
abdominal wall) and rich vascularization of the scrotum promote
fast spreading and deepening of the inflammatory process .
The main clinical stages of Fournier gangrene are:
fever (duration 2-7 days);
by the edema of the surrounding skin;
augmentation of pain and tenderness with progressing skin erythema;
pigmentation of the skin above the lesion, subcutaneous crepitation (Fig. 1);
obvious gangrene of the genitals, purulent wound discharge.
Lethality in FG estimates 30-40% and is directly proportional
to the area of the tissues involved. In case when one or both
testes are involved in necrosis process, lethality constitutes 60-
Materials and methods
The authors have studied the course, complications and
remote results after the treatment of 13 cases of FG that
occurred between 1982 and 2007 on the basis of the Lviv
municipal clinical hospital of the emergency aid & Lviv regional
clinical hospital. The severity of the disease was measured using
the Fournier Severity Index (FSI, suggested by Laor et al.), which
included evaluation of physical data, laboratory values, ultrasonography,
tomography and radiological findings. Surgical treatment
was retrospectively studied and analysis of patient records
All 13 patients were admitted to the Urology Department
on emergency indications. 7 were admitted in the first hours
after onset, 4 patients were admitted between 6-8 hours from
onset and 2 patients sought medical aid 24 hours after onset.
The average FSI was 9.1 (ranging from 0 to 15). The average FSI
of survivors was 8.6, and the mean FSI of the demised patients
Inspection revealed that in 6 cases only scrotum was involved
with minor involvement of adjacent tissues (Fig. 3), in 4 cases
penis was affected, in 2 cases the anterior abdominal wall was
involved and in 1 case the inner surface of the thigh was compromised.
In most cases the disease had a fulminate course, with area
of the lesion rapidly increasing, affecting the adjacent structures.
In one of the patients the scrotal lesion was 5 cm in diameter on
admission, and 30 minutes later, at the beginning of the surgery,
the whole scrotum was involved which manifested as a skin
pigmentation over the infected area.
In the patient with anterior abdominal wall involvement,
X-ray detected free gas in abdominal wall tissues (Fig. 4).
In ultrasonography, free gas in scrotal tissues was detected
in 9 patients (Fig. 5).
Tomography, performed in 3 patients, detected large volume
of free gas in the tissues of the scrotum, which was spread over
to the tissues of pelvis minor (Fig. 6,7).
Results and discussion
All patients underwent surgery within 1 hour after admission.
The volume of the surgical removal has been determined
according to the following criteria:
1. Excision of all necrotized tissues including the fasciae;
2. Crepitation of the tissues is an unconditional indication to their extended removal;
3. The margins of the intact tissue are characterized by a more active bleeding;
4. If soft tissues can be separated bluntly from the fasciae, this indicates the presence of fasciitis; therefore such tissues must be excised.
After removal of all necrotized tissues, the testes were kept
naked and moisturized (Fig. 8). Drainage tubes were introduced
into the surgical wounds. Immediately after the surgery the
patients began to receive a potent antibacterial therapy.
2 patients admitted 24 hours after onset with propagation
of the process to the anterior abdominal wall and involvement
of the internal thigh surface died on the first day postoperatively.
Death was caused by the infectious-toxic shock.
The condition of the patient with involvement of the anterior
abdominal wall and inner surface of the thigh, admitted 6-8
hours after onset on the 2nd day after surgery, rapidly deteriorated:
despite potent antibiotic therapy the patient developed
necrosis with the decay of the glans penis with spreading on the
scrotal tissues, anterior abdominal wall and inner thigh surface
(Fig. 9). A repeated surgery was performed, but nevertheless he
died shortly after.
In 10 patients the postoperative period was uneventful.
Since Fournier gangrene is caused by a combination of different microorganisms, the authors
have used the following schedule, employing the broad-spectrum antibiotics:
«Step-wise» antibacterial therapy in Fournier Gangrene:
1. Immediately on admission Zanocyn is administered I.V. 200 mg t.i.d. for 5-6 days, it is effective against multiresistant microorganisms;
2. Next step is Klabaks 500 mg I.V. b.i.d. for 5-6 days;
3. Cyfran 500 mg P.O. b.i.d. for 10 days; Desintoxication therapy was performed at all times. Before the surgery and intraoperatively 100 ml of metronidazole is added I.V. to Zanocyn.
9 patients had a two-stage plastic surgery of scrotal restoration (after B.A. Vitsyn), performed in two stages. Longitudinal incisions were performed along the left and the right Poupart ligaments 10-12 cm long. The seminal cord was prepared to the external inguinal ring and a tunnel was made in the subcutaneous fat at this level where the testis was placed. An incision 6-8 cm below the umbilicus was made, at the
apex of the tunnel; penis was guided through that incision. The prepucial sac was sutured to the edges of the transverse incision
wound. Sutures were applied to the borders of the perineum and to the mobilized skin fragment in the lower abdomen.
The second stage of the surgery was performed in 1-2
months. A skin fragment was excised from the abdominal wall
to cover the penis; the skin fragment was separated from the
anterior abdominal wall. After that the penis was covered by the
excised piece, the excess of skin was excised and the edges of the
piece were sutured on the back of the penis. The skin defect on
the anterior surface was closed by shifting the pieces from the
lateral surfaces. After healing of the wound testis was formed
from the excised piece of the perineum and cutaneous pieces
from the inner surface of the thigh with feeding pedicles turned
upwards (Fig. 10).
1. Fournier gangrene is a very dangerous infectious condition
with fulminant course that requires immediate surgical
intervention in combination with therapy by potent broad-spectrum
2. The prognostic likelihood of a lethal outcome is proportional
to the area of lesion, time from onset to hospitalization,
promptness and radicalism of surgical treatment, which
should be performed according to the criteria developed by the
3. Surgical treatment should be radical in its nature.
Postoperative lethality can be caused by inadequacy of the
intervention, when necrotized tissues are left in the wound and
a large area of the lesion.
4. Scrotum restoration surgery can be performed later, but
spontaneous closure of the tissue defect is also possible.