Fournier gangrene
Background
- Necrotizing fasciitis of the perineum, genitalia, and/or perianal area
- A life-threatening surgical emergency with mortality 20-40%[1]
- Polymicrobial infection: aerobic + anaerobic organisms (E. coli, Bacteroides, Streptococcus, Clostridium, S. aureus)
- Rapidly progressive — tissue destruction can advance centimeters per hour
- Source: perianal (most common), urogenital, or cutaneous infection
Risk Factors
- Diabetes mellitus (present in 40-60% of cases)
- Immunosuppression (HIV, malignancy, chemotherapy, transplant)
- Obesity
- Chronic alcohol use
- Peripheral vascular disease
- Perianal abscess, urethral stricture, urinary tract instrumentation
- Recent surgery or trauma to the perineum
Clinical Features
- Severe perineal/genital pain (often out of proportion to examination findings early on)
- Erythema, edema, and tenderness of perineum/scrotum/vulva
- Rapid progression: skin changes from erythema → dusky → bullae → necrosis → gangrene
- Crepitus on palpation (subcutaneous gas — pathognomonic but not always present)
- Fever, tachycardia, systemic toxicity / septic shock
- Scrotal swelling with disproportionate pain
- May appear deceptively benign early in the course
Evaluation
- Clinical diagnosis — do not delay surgical consultation for imaging
- Labs: CBC (leukocytosis often >15,000), BMP, lactate, blood cultures, CRP
- CT with contrast: subcutaneous gas, fascial thickening, fat stranding, abscess formation
- CT has high sensitivity (~90%) but should not delay surgery[2]
- LRINEC score may help risk-stratify (see LRINEC score calculator)
- X-ray: may show subcutaneous emphysema
Management
- Emergent surgical debridement — the single most important intervention
- Often requires multiple return trips to OR for serial debridement
- Early surgery correlates with decreased mortality
- Broad-spectrum IV antibiotics
- Vancomycin (or Linezolid) +
- Piperacillin-tazobactam (or Meropenem) +
- Clindamycin (for toxin suppression and synergistic coverage)
- Aggressive IV fluid resuscitation and vasopressors for septic shock
- Tetanus prophylaxis
- Wound care: vacuum-assisted closure (VAC) after debridement
- Consider hyperbaric oxygen therapy (HBO) as adjunct (limited evidence)
Disposition
- ICU admission with emergent surgical consultation
- Urology and/or general surgery
- High mortality — early recognition and aggressive surgery are key