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Introduction

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 [1]. 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 [2].

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 [3].

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 [4].

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 [5]. 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- 90%.

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 was performed.

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 was 12.4.

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).

Conclusions

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 antibiotics.

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 authors.

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.

1. Vick R, Carson CC: Fournier's disease. Urol Clin North Am 1999, 26 (4), 841-849.
2. Chen CS, Liu KL, Chen HW et al: Prognostic factors and strategy of treatment in Fournier's gangrene: a 12-year retrospective study. Changgeng Yi Xue Za Zhi 1999, 22 (1), 31-36.
3. Asci R, Sarikaya S, Buyukalpelli R, et al: Fournier's gangrene: risk assessment and enzymatic debridement with lyophilized collagenase application. Eur Urol 1998, 34 (5), 411-418.
4. Basoglu M, Gul O, Yildirgan I et al: Fournier's gangrene: review of fifteen cases. Am Surg 1997, 63 (11), 1019-1021.
5. Benchekroun A, Lachkar A, Bjijou Y, et al: Gangrene of the external genital organs. Apropos of 55 cases. J Urol (Paris) 1997; 103 (1-2): 27-31.
6. Benizri E, Fabiani P, Migliori G et al: Gangrene of the perineum. Urology 1996, 47 (6): 935-939.

Alexander Shulyak
Lwow
Boguna 6/6
Ukraine 7901
sash@meduniv.lviv.ua