Fournier's Gangrene in a Patient with Erectile Dysfunction Following Use of a Mechanical Erection Aid Device

Implants, mechanical devices, and vascular surgery for erectile dysfunction

INTRODUCTION

The field of erectile dysfunction (ED) is evolving and there is a need for state-of-the-art information in the area of treatment. Aim. To develop an evidence-based, state-of-the-art consensus report on the treatment of erectile dysfunction by implants, mechanical devices, and vascular surgery.

METHODS

To provide state-of-the-art knowledge concerning treatment of erectile dysfunction by implant, mechanical device, and vascular surgery, representing the opinions of 7 experts from 5 countries developed in a consensus process over a 2-year period.

MAIN OUTCOME MEASURE

Expert opinion was based on the grading of evidence-based medical literature, widespread internal committee discussion, public presentation, and debate.

RESULTS

The inflatable penile prosthesis (IPP) is indicated for the treatment of organic erectile dysfunction after failure or rejection of other treatment options. Comparisons between the IPP and other forms of ED therapy generally reveal a higher satisfaction rate in men with ED who chose the prosthesis. Organic ED responds well to vacuum erection device (VED) therapy, especially among men with a suboptimal response to intracavernosal pharmacotherapy. After radical prostatectomy, VED therapy combined with phosphodiesterase type 5 therapy improved sexual satisfaction in patients dissatisfied with VED alone. Penile revascularization surgery seems most successful in young men with absence of venous leakage and isolated stenosis of the internal pudendal artery following perineal or pelvic trauma. Currently, surgery to limit venous leakage is not recommended.

CONCLUSIONS

It is important for the future of the field that patients be made aware of all treatment options for erectile dysfunction in order to make an informed decision. The treating physician should be aware of the patient's medical and sexual history in helping to guide the decision. More research is needed in the area of revascularization surgery, in particular, venous outflow surgery.

Vacuum therapy in erectile dysfunction--science and clinical evidence

Vacuum therapy (VT) utilizes negative pressure to distend the corporal sinusoids and to increase the blood inflow to the penis. Depending on its purpose, VT could be used as vacuum constriction device (VCD), with the aid of an external constricting ring which is placed at the base of penis to prevent blood outflow, maintaining the erection for sexual intercourse. Also, as a vacuum erectile device (VED), without the application of a constriction ring, just increases blood oxygenation to the corpora cavernosa and for other purposes. The emerging of phosphodiesterase 5 inhibitors (PDE(5)I) for the treatment of erectile dysfunction (ED) eclipsed VCD as therapeutic choice for ED; however, widespread usage of VED as part of penile rehabilitation after radical prostatectomy and other purposes rekindle the interest for VT. The underlying hypothesis is that the artificial induction of erections shortly after surgery facilitates tissue oxygenation, reducing cavernosal fibrosis in the absence of nocturnal erections, and potentially increases the likelihood of preserving erectile function. Due to its ability to draw blood into the penis regardless of nerve disturbance, VED has become the centerpiece of penile rehabilitation protocols. Herein, we reviewed the history, mechanism, application, side effects and future direction of VT in ED.

[Complete necrosis of the penis and testes by strangulation in a psychotic patient]

Complete necrosis of the penis and scrotum due to strangulation of the external genitalia is unusually encountered in urologic emergencies. Urological conservative management is recommended. Delayed presentation is a major source of complications. We report the case of a psychotic patient, who was transferred from the emergency department in a context of complete necrosis of the external genitalia. This patient's history included chronic psychotic disorder and positive HIV serology, but he refused to take either neuroleptic or antiretroviral therapy. Complete amputation of the penis and bilateral orchidectomy were performed. We report the first six months of medical management.

Fournier's gangrene: report of thirty-three cases and a review of the literature

BACKGROUND

Fournier's gangrene (FG) is an extensive fulminant infection of the genitals, perineum or the abdominal wall. The aim of this study is to share our experience with the management of this difficult infectious disease.

METHODS

Thirty-three male patients were admitted to our clinic with the diagnosis of FG between February 1988 and December 2003. The patient's age, etiology and predisposing factors, microbiological findings, duration of hospital stay, treatment, and outcome were analyzed. The patients were divided into two groups. The first 21 patients (Group I) were treated with broad-spectrum triple antimicrobial therapy, broad debridement, exhaustive cleaning, and then they underwent split-thickness skin grafts or delayed closure as needed. The other 12 patients (Group II) were treated with unprocessed honey (20-50 mL daily) and broad-spectrum triple antimicrobial therapy without debridement. Their wounds were cleaned with saline and then dressed with topical unprocessed honey. The wounds were inspected daily and the honey was reapplied after cleaning with normal saline. Then, the patients' scrotum and penis were covered with their own new scrotal skin. The mean age of the patients was 53.9 +/- 9.56 years (range = 23-71).

RESULTS

The source of the gangrene was urinary in 23 patients, cutaneous in seven patients, and perirectal in three patients. The predisposing factors included diabetes mellitus for 11 patients, alcoholism for 10 patients, malnutrition for nine patients, and medical immunosuppression (chemotherapy, steroids, malignancy) for three patients. The mean duration of hospital stay was 41 +/- 10.459 (range = 14-54) days. Two patients in Group I died from severe sepsis. The clinical and cosmetic results were better in Group II than Group I.

CONCLUSION

Necrotizing fasciitis of the perineum and genitalia is a severe condition with a high morbidity and mortality. Traditionally, good management is based on aggressive debridement, broad-spectrum antibiotics, and intensive supportive care but unprocessed honey might revolutionize the treatment of this dreadful disease by reducing its cost, morbidity, and mortality.

Der unsachgemäße Gebrauch eines Penisringes aus Titan

Constricting devices placed on the penis to improve sexual performance present a challenge to urologists. Various metallic and nonmetallic objects have been described -- plumbing cuffs, bull rings, wedding rings, plastic or rubber rings -- which usually could be removed by the combination of medical and operative treatment (decompression of the penis and glandular puncture) and craftsmen's techniques. We describe the case of a titanium thumb ring of 2 mm thickness which only could be removed by using an electric cutting tool.

Fournier's gangrene associated with sparganosis in the scrotum

Fournier's gangrene is a necrotizing fasciitis of the scrotum or perineum that may extend by way of the fascial planes to the penis and the anterior abdominal wall up to the clavicles, buttocks, or lower extremities. It is a life-threatening progressive disease that requires aggressive antibiotic therapy and early radical debridement. Sparganosis is a parasitic infection that occurs principally in cats and dogs, but human infestations have been reported, albeit rarely. Recently, we experienced a case of Fournier's gangrene associated with sparganosis in the scrotum, which was treated with antibiotics and extensive debridement including removal of a white, flat, shiny sparganum worm.

[Fournier's gangrene: anatomo-clinical features in adults and children. Therapy update]

Fournier's gangrene is a skin infectious-necrotising process in the peri-neogenital area affecting males, usually in their sixties or seventies. Isolated flora from cultures of the necrotic lesion is commonly multi-microbial. In a majority of cases both aerobic and anaerobic micro-organisms are found in the cultures, Escherichia coli being the most commonly identified germ. Although considered in the past an idiopathic condition, in most patients today a genitourinary, anorectal or dermal triggering factor can be identified. There are a series of systemic host debilitating disorders such as diabetes mellitus, chronic alcohol abuse, and malignant neoplasia that are associated to this condition and may be considered risk factor to suffer this disease. Fournier's gangrene in children show specific bacteriological, pathogenic, clinical, therapeutic and prognostic features that distinguish it from that in adults. The most extensively accepted management for this condition includes therapy with broad-spectrum parenteral antibiotics and early and aggressive surgical debridement of the necrotic areas. Mortality continues to be high, ranging between 10-80% in the various series. Finally, a group of 7 patients with Fournier's gangrene is analyzed (1991-1998) aiming to establish a comparison between our results and those seen in recent series.

Vacuum constriction and external erection devices in erectile dysfunction

The development of external erection devices has evolved as the social stigma surrounding the treatment of erectile dysfunction has gradually disappeared during the late twentieth century. Although the success of surgical and medical therapy for erectile dysfunction has been documented, especially since the introduction of sildenafil citrate, patient demand for an effective, noninvasive, drug-free management of erectile dysfunction has remained. As the population continues to age, acquiring the comorbidities commonly associated with erectile dysfunction, such as hypertension, diabetes mellitus, and atherosclerotic vascular disease, the demand for such treatment should persist. This article examines the development, mechanism of action, efficacy, and patient satisfaction with regard to vacuum constriction and external erection devices.

Fournier's gangrene: a review of 1726 cases

BACKGROUND

Although there is much consensus, certain controversies exist regarding the management of Fournier's gangrene.

METHOD

Publications in English on Fournier's gangrene from January 1950 to September 1999 were obtained through the Medline database and relevant reference lists in publications. It was possible to identify 1726 cases for study. Data extracted for review included country of reported cases, number of patients in each report and relevant clinical features.

RESULTS

Fournier's gangrene occurs worldwide. However, its definition has generated considerable controversy as efforts are made to refine the original description in the light of increasingly understood aetiological factors. Attempts to classify the disease into primary and secondary forms have not been successful. The basic pathological process, necrotizing fasciitis, has been identified in the perineum of women and children, although the disease afflicts the male more often than the female. Most reported cases have occurred in the USA and Canada. The major sources of sepsis are the local skin, colon, anus and rectum, and the lower urinary tract. Colonic, anal and rectal sources carry the worst prognosis. Diabetes mellitus is important in aetiological terms. Rare causes include vasectomy and circumcision. Investigations are essential to define the cause of an episode but not for the diagnosis of the disease. Early aggressive treatment of Fournier's gangrene and underlying conditions is essential. Hyperbaric oxygen and honey are treatment modalities yet to be universally adopted. Risk of death, 16 per cent overall in this series, is related to the patient's condition at presentation.

CONCLUSION

Controversies over the definition of Fournier's gangrene persist but these do not affect the treatment options. The diagnosis is made on clinical grounds. The occurrence of the disease in women is under-reported and may go unrecognized by some clinicians. Some treatment options, such as hyperbaric oxygenation and radical excision, remain controversial.

Fournier's disease

Fournier's gangrene is an aggressive synergistic fasciitis of the perineum. The disease can no longer be considered to be idiopathic; in most cases a urologic, colorectal, or cutaneous source can be identified. Despite antibiotics and aggressive debridement, the mortality rate remains high, particularly in the elderly, in patients with renal failure, and in patients with extensive disease. The presentation is highly variable, necessitating a high index of suspicion. High-risk patients include diabetics, alcoholics, and debilitated and immunosuppressed individuals. As the AIDS population increases, the incidence of Fournier's gangrene may increase as well. In questionable cases, imaging modalities should be performed to allow early diagnosis and to reduce missed diagnoses. Broad-spectrum antibiotics and aggressive debridement remain the hallmarks of treatment. Hyperbaric oxygen therapy and improved local wound care may decrease the extent of tissue destruction. Reconstructive techniques afford better cosmetic results. With early recognition, prompt treatment, improved wound care, and reconstructive efforts, the mortality rates and cosmetic results should continue to improve.

[Fournier's gangrene. Our clinical experience, etiopathogenesis and management]

We report 12 cases of Fournier's Gangrene treated over an 19-month period; at Division Urology of the Hospital Gral. de Agudos Dr. José M. Ramos Mejia. We emphatized 58.3% of the patients had an urology origin. We considered diagnostic and therapeutic issues, and bibliografic review.

Unusual complications of the vacuum erection device

OBJECTIVES

The vacuum erection device (VED) is usually well tolerated and very effective for patients with erectile dysfunction. When used correctly, VEDs carry low morbidity and few recognized complications. We report on 5 patients who developed unusual complications associated with VED use, including two previously unreported complications of urethral bleeding and capture of scrotal tunica within the penile shaft.

METHODS

Patient 1: a 38-year-old diabetic man with significant peripheral neuropathy and an 8-year history of erectile dysfunction developed penile skin necrosis at the ring site after leaving the penile ring on for an excessive length of time (6 hours). Patient 2: a 76-year-old diabetic man who used a VED correctly for 3 months developed severe urethral bleeding. Patient 3: a 75-year-old diabetic man who enjoyed satisfactory erections with a VED for 14 months developed a 3 x 3-cm penile cystic mass located on the proximal right side of the penile shaft. This mass was not present in the flaccid state and was seen only with VED use. Patient 4: a 65-year-old man developed Peyronie's disease after 4 years of correct VED use. Patient 5: a 62-year-old man with neurogenic impotence following a radical prostatectomy developed penile ecchymoses acutely following placement of a smaller constriction ring. He subsequently developed a dorsal penile plaque with mild dorsal curvature.

RESULTS

Patient 1 did well with local skin care and no longer uses a VED. Patient 2 underwent cystoscopy and was found to have prominent urethral vessels (varicosities) in the midurethra, compared with a normal cystoscopy 9 months previously. This patient no longer uses a VED and now denies any urethral bleeding at 15-month follow-up. Patient 3 underwent corpora cavernosography and contrast injection of the cystic mass. These radiographic studies showed that the mass did not communicate with either corpora cavernosa or the corpus spongiosum. A retrograde urethrogram failed to show a urethral diverticulum. The patient was surgically explored, and the penile cystic mass was found to be scrotal tunica vaginalis. Subsequently, a hydrocele repair was performed, yet postoperatively the patient developed testicular migration into the ipsilateral penile shaft. Testicular fixation was not feasible secondary to a childhood herniorrhaphy, and an orchiectomy was performed. Patient 4 underwent implantation of a penile prosthesis and is doing well at 3-year follow-up. Patient 5 experiences mild dorsal penile curvature with erections induced by transurethral prostaglandin E1. The penile curvature does not interfere with intercourse and will be managed conservatively.

CONCLUSIONS

We describe unusual side effects associated with VEDs. Although thousands of men use VEDs successfully and without morbidity, the urologist must be aware of unusual complications associated with VED use.

Fournier's gangrene: Report on two cases

– Fournier's gangrene is a rare pathology that generally occurs in weakened patients with chronic diseases, like diabetes, which imply tissue ischemia and even today a high mortality rate. Two cases are presented, one of which is interesting for its pathogenesis. The authors confirm that first choice treatment should be surgical associated with antiobiotics and hyperbaric oxygenation whenever possible.