What is Fournier's Gangrene & How is it Treated?

Understanding Fournier's Gangrene

Overview of Fournier’s Gangrene and Necrotizing Fasciitis

Fournier gangrene is a rare type of necrotizing fasciitis (flesh-eating disease). It is a rapidly progressive, life-threatening bacterial infection that affects the superficial and deep tissues of the perineum, anal, and genital regions, including the penis and scrotum. In severe cases, the infection can spread to the thighs, anterior abdominal wall, and chest. Fournier’s gangrene is a medical emergency that requires prompt surgical treatment and antibiotic therapy. 

What Are Necrotizing Soft Tissue Infections?

Necrotizing soft tissue infections are flesh-eating diseases. They are life-threatening bacterial infections that destroy soft tissues, including the arteries (blood vessels), nerves, and muscles in multiple fascial planes (layers of tissues). Early diagnosis and treatment are vital in patients with necrotizing fasciitis to limit the amount of necrotic tissue (dead tissue) and save the person’s life.

Gangrene is the medical term for tissue death from a lack of blood supply or severe bacterial infection. Fournier’s gangrene is named after the French physician Jean Alfred Fournier who discovered this life-threatening disease in 1883. 

Epidemiology: Fournier Gangrene Prevalence

Fournier gangrene cases occur at an annual rate of 1.6 out of 100,000 males. This condition is 10 times more common in men than in women. The incidence of Fournier’s gangrene increases with age, peaking in men aged 50 to 79 years.

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Causes and Risk Factors: How Do People Get Fournier's Gangrene?

Common Causes 

Bacteria can enter the genital and rectal areas in many ways, such as:

• Anal fistula

• Perineal abscess 

• Diverticulitis

• Genital piercing

• Urinary tract infection or bladder infection

• Injuries to the perineal area, such as burns or scratches

• Insect bites

• Sexual activity

• Genital ulcers

• Rectal cancer

• Circumcision in children

Both anaerobic bacteria and aerobic bacteria can cause Fournier's gangrene. This serious infection is polymicrobial (caused by multiple bacteria) in 80% of the cases.

Aerobic organisms that can cause Fournier’s gangrene include:

• E. coli (Escherichia coli)

• Streptococcus

• Staphylococcus

• Proteus

• Klebsiella

Anaerobic organisms that can cause necrotizing gangrene include:

• Clostridium

• Bacteroides

• Peptostreptococcus

Risk Factors

Anyone can develop Fournier’s gangrene, but some people are at a higher risk. Factors that increase the risk of Fournier’s gangrene include:

• Male gender

• Age above 50 years

• Diabetes mellitus (high blood sugar levels)

• Alcohol abuse

• Obesity

• Smoking

• Medical conditions such as cardiovascular disease, hypertension, cirrhosis, acute kidney injury, renal failure, HIV (human immunodeficiency virus)

• Weakened immune system

• Medical treatments such as chemotherapy, steroids, and certain diabetes medications called sodium-glucose cotransporter-2 (SGLT2) inhibitors (for example, canagliflozin, dapagliflozin, ertugliflozin, and empagliflozin)

• Bone marrow transplantation

• Trauma to the external genitalia from injuries, surgical procedures, or genital piercings

Is Fournier's Gangrene an STD?

No, Fournier’s gangrene is not an STD (sexually transmitted disease). It does not spread from person to person through sexual activity. This bacterial infection affects the tissues of the genital area, but it is not contagious. 

Is Fournier's Gangrene Caused By Poor Hygiene?

Like all infectious diseases and skin infections, hygiene can play a role in the development of Fournier’s gangrene, especially in children. But poor hygiene is not the only cause of Fournier’s gangrene. More common risk factors include trauma to the genital area such as from a genital piercing, diabetes, and alcohol use disorders.

Symptoms and Complications: Early and Advanced Signs of Fournier’s Gangrene

Early Fournier’s Gangrene Symptoms

Fournier’s gangrene is a medical emergency. Seek immediate medical care if you have the following early symptoms in your genitals or perineum (the area between your rectum and genitals):

• Dull or sharp pain that is moderate to severe in intensity

• Redness 

• Tenderness 

• Swelling

It’s important to seek timely medical care for the early symptoms of Fournier’s gangrene. This is a rapidly progressive condition that can cause severe damage within hours. Flesh-eating bacteria can affect not only overlying skin, but also subcutaneous tissue under the skin as well as deeper tissues, including the arteries, muscles, and nerves in patients with Fournier’s gangrene. Therefore, time is of the essence in seeking care for this life-threatening disease. 

Systemic Symptoms of Fournier’s Gangrene

In addition to local symptoms at the site of infection, other Fournier’s gangrene symptoms may include:

• A fever of 100.4 degrees F or higher

• Malaise (generally feeling unwell)

• Chills

• Low energy

• Dehydration (dry mouth, reduced urine output)

• Mental status changes

• Inflammation and pain in the abdominal area

• Nausea and vomiting

• Putrid smell (bad odor)

• Sepsis (a life-threatening condition in which the immune system overreacts to an infection)

Respiratory and Cardiovascular Symptoms of Fournier’s Gangrene

Additional complications of Fournier’s gangrene may include effects on the heart, lungs, and blood vessels, such as: 

• Fast heart rate

• Low blood pressure

• Anemia (low red blood cells)

• Disseminated intravascular coagulation (DIC), a serious condition associated with abnormal blood clotting and a risk of life-threatening bleeding throughout the body

• Acute respiratory distress syndrome

Skin Symptoms of Fournier’s Gangrene

In addition to inflammation and pain in the affected area, Fournier’s gangrene can cause itching and crepitus (a crackling or popping sound when you rub the area). 

Urinary Symptoms of Fournier’s Gangrene

• Urinary tract infections

• Urinary extravasation (leakage of urine outside the urinary tract due to tissue damage)

• Urethral obstruction (a blockage in the urinary tract)

Complications of Late-Stage Fournier’s Gangrene

• Blood clots and resultant tissue hypoxia (lack of blood supply) in gangrenous tissue

• Inflammation of the blood vessel linings through the spread of the infection to deeper tissues

• Spread of bacteria and necrotic tissue byproducts through blood, resulting in septic shock, low blood pressure, and multiple organ failure

How Do Doctors Diagnose Fournier’s Gangrene?

As mentioned, Fournier’s gangrene is a medical emergency. There is often no time to do tests. Immediate, life-saving surgical intervention is necessary in patients with Fournier’s gangrene. 

Clinical Evaluation, Imaging, and Lab Tests

If there’s time, some of the tests healthcare providers may do to rule out the differential diagnosis and confirm a diagnosis of Fournier’s gangrene include:

• Imaging tests such as ultrasound, X-rays, or CT scan (computed tomography scan) to identify the source of infection, find out how far the infection has spread, and find air, gasses, and fluids in the body.

• Blood tests, including a complete blood count (CBC) and comprehensive metabolic panel (CMP) to check for an elevated white blood count, kidney function, electrolyte abnormalities, and arterial blood gas.

Treatment And Management

Immediate Medical Interventions

Surgical debridement is the immediate and main treatment for Fournier’s gangrene. Depending on the urgency and severity, doctors sometimes skip diagnostic testing and go straight to surgery to remove the damaged tissues (debridement). Surgical debridement might need to be done through multiple operations, including rectal surgery and genital surgery. If the surgeons cannot remove enough dead tissue to prevent the bacterial infection from spreading, the entire penis and scrotum may need to be surgically removed (this is rare).

Antibiotic Therapy

After surgical intervention, treatment of Fournier’s gangrene consists of broad-spectrum antibiotics to kill the bacteria. Treatment with anticoagulants may be necessary to decrease the risk of blood clots in Fournier gangrene patients who have sepsis.

Hyperbaric Oxygen Therapy

Hyperbaric oxygen therapy involves breathing pure oxygen in a pressurized cabin. This treatment helps in promoting wound healing, limiting blood vessel damage, and stopping the growth of bacteria in affected skin. 

Surgical Procedures and Postoperative Care

After emergency surgical treatment is over, reconstructive surgery is done to improve the appearance of the perineum, scrotum, and penis. This may involve procedures such as split-thickness skin grafts.

Recovery From Fournier’s Gangrene

Fournier gangrene patients typically spend 3-6 weeks in hospital. The post-hospital recovery period varies depending on the severity of the tissue damage in the anorectal and genital areas. 

Prognosis and Survival Rates

Factors Affecting Prognosis

Doctors use scoring systems such as the Fournier’s Gangrene Severity Index (FGSI) and the Charlson Comorbidity Index (CCI) to predict outcomes in patients with this life-threatening condition. These scores are calculated based on various prognostic factors. The higher the score, the higher the risk of death. Studies have shown:

• An average Fournier Gangrene Severity Index (FGSI) score on admission of 2 in survivors and 6 in non-survivors.

• An average Charlson Comorbidity Index (CCI) score of 2 in survivors and 6.5 in non-survivors.

What Is The Survival Rate of Fournier Gangrene?

Survival rates in patients with Fournier’s gangrene can range from 97% to 50%. In other words, some studies suggest up to half of all patients with Fournier’s gangrene die. Fournier’s gangrene mortality rate varies with the severity of the condition. It also depends on how soon a person gets treatment for Fournier’s gangrene in an emergency department.