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

Fournier's Gangrene Secondary to Perforated Sigmoid Adenocarcinoma Within an Incarcerated Inguinal Hernia

Colon cancer is the third most common cancer worldwide. Approximately one-fifth of colon cancers will present emergently due to obstruction or perforation. Necrotizing soft tissue infection is a rare presentation of perforated colon cancer and represents a surgical emergency due to high mortality rate.  A man in his 80s presented with several days of scrotal pain and weakness. On physical exam he was found to have scrotal edema and erythema and bilateral inguinal hernias. Imaging revealed a large scrotal abscess and concern for necrotizing soft tissue infection. He was taken to the operating room for surgical debridement and exploration and was discovered to have perforated colon within an incarcerated inguinal hernia. He underwent exploratory laparotomy with sigmoid resection and end colostomy creation. Pathology returned demonstrating invasive sigmoid adenocarcinoma. Fournier's gangrene requires a high index of suspicion. It is a rapidly progressing infection associated with high mortality. Early initiation of antibiotics and surgical debridement are mainstays of treatment. When associated with perforated colonic malignancy, workup must include imaging of the chest, abdomen, and pelvis as well as carcinoembryonic antigen (CEA) level to complete staging. Fournier's gangrene secondary to perforated sigmoid adenocarcinoma is a unique presentation. Treatment first involves antibiotics and aggressive surgical debridement. Once the patient is stabilized, further oncologic workup should be completed to determine treatment course.

Prognostic determinants and treatment outcomes of Fournier's Gangrene treatment in a resource-limited setting: A retrospective study

BACKGROUND

Fournier's gangrene (FG) is a destructive necrotizing infection with a generally poor prognosis. This study aims to share our experience in handling FG patients in a resource-limited setting and identify prognostic factors for FG mortality.

METHODS

A retrospective study of thirty-six patients diagnosed with FG and treated at our teaching hospital between Jun 2010 to Oct 2022 was conducted. Laboratory and nonlaboratory data and patients' outcomes were gathered. A univariate analysis was computed for identifying prognostic factors for FG mortality.

RESULT

The main age was 68.30 ± 5.61years and most (69.4%) were older than 65 years. The overall survival was 63.9% and the mortality rate was 36.1%. Univariate analysis showed that advanced age (p = 0.02), delayed in hospital presentation (p = 0.024), involvement of larger area (p = 0.001), a history of diabetes mellitus (p < 0.006), end-stage renal disease (p = 0.018), heart failure (p = 0.005), cerebrovascular accident (p = 0.003), liver cirrhosis (p = 0.001), presence of multiple comorbidities (p = 0.001), septic conditions at admission (p = 0.048), need for mechanical ventilation (p = 0.001), hypoalbuminemia (p < 0.001), and elevated blood urea nitrogen (p = 0.002) were found to be risk factors for mortality in patients with FG.

CONCLUSIONS

Fournier's gangrene is a fulminant condition with a high mortality rate, especially in resource-limited settings. In this study, the mortality rate was 36.1%. Advanced age, delayed in hospital presentation, involvement of larger area, a history of diabetes mellitus, end-stage renal disease, heart failure, cerebrovascular accident, liver cirrhosis, presence of multiple comorbidities, septic conditions at admission, need for mechanical ventilation, hypoalbuminemia, and elevated blood urea nitrogen were associated with FG mortality.

Treatment outcome of Fournier's gangrene and its associated factors: A retrospective study

INTRODUCTION

Fournier's gangrene (FG) is a rapidly progressive necrotizing infection that affects the perineal and abdominal regions and is known for its high mortality rate. This study aims to present the practical experience of managing FG patients and identify factors that may affect their clinical outcomes.

MATERIALS AND METHODS

A retrospective study was conducted from April 2009 to December 2020 at General Military Hospital in Sana'a, Yemen including 26 patients who were diagnosed with FG and treated on. Data on demographic characteristics, time to admission, surgical intervention, and treatment outcomes were collected. Univariate analysis was performed to determine factors that affect patient outcomes.

RESULT

The mean age of the patients was 65.77 ± 5.04 years, and 65.4% of them were over the age of 65. Most patients (57.7%) presented after five days of experiencing symptoms, and 65.4% were in septic conditions. Of the patients, 17 (65.4%) survived, and the total mortality rate was 34.6%. Univariate analysis showed that delayed presentation (p = 0.001), a history of diabetes mellitus (p < 0.001), end-stage renal disease (p < 0.001), heart failure (p < 0.001), cerebrovascular accident (p = 0.032), liver cirrhosis (p < 001), presence of multiple comorbidities (p < 001), involvement of lager area (p < 001), septic conditions (p = 0.009), advanced age (p = 0.018), and intensive care unit admission (p = 0.002) were found to be risk factors for mortality in patients with FG.

CONCLUSIONS

FG is a potentially life-threatening medical condition, even with aggressive and specialized treatment. Our study revealed a mortality rate of 34.6%. Factors such as older age, the presence of multiple comorbidities, septic conditions, the abdominal spread of the disease, intensive care unit admission, and delayed presentation contribute to higher mortality rates.

The role of quick Sepsis-related Organ Failure Assessment score as simple scoring system to predict Fournier gangrene mortality and the correlation with Fournier's Gangrene Severity Index: Analysis of 69 patients

Objective

Fournier's gangrene is a rare but life-threatening infection disease with high mortality rate. The quick Sepsis-related Organ Failure Assessment (qSOFA) is a new and simpler scoring system that may identify patients with suspected infection who are at greater risk for a poor outcome. The purpose of this study was to find out role of qSOFA in determining prognosis of Fournier's gangrene patients.

Methods

This study is a case control with retrospective review of Fournier's gangrene patients treated at Hasan Sadikin Hospital from January 2013 to December 2017 who met inclusion criteria. Participants were divided into two groups according to qSOFA score as high qSOFA (2-3) and low qSOFA (0-1).

Results

From 69 patients, the mortality rate was 24.6%. The sensitivity of qSOFA score to predict mortality was 88.2%; the specificity was 94.2%; positive predictive value was 83.3%; negative predictive value was 96.1%; positive likelihood ratio was 15.2; negative likelihood ratio was 0.12; and the area under the receiver operating characteristic curve of qSOFA was 94.2%. There was significant association between qSOFA scale and mortality with p-value of 0.0001. The qSOFA score has strong positive correlation with Fournier's Gangrene Severity Index (p<0.0001, r=0.704).

Conclusion

qSOFA scoring system has a high prognostic value and can be used to determine prognosis of Fournier's gangrene patients.

Anorectal emergencies: WSES-AAST guidelines

Anorectal emergencies comprise a wide variety of diseases that share common symptoms, i.e., anorectal pain or bleeding and might require immediate management. While most of the underlying conditions do not need inpatient management, some of them could be life-threatening and need prompt recognition and treatment. It is well known that an incorrect diagnosis is frequent for anorectal diseases and that a delayed diagnosis is related to an impaired outcome. This paper aims to improve the knowledge and the awareness on this specific topic and to provide a useful tool for every physician dealing with anorectal emergencies.The present guidelines have been developed according to the GRADE methodology. To create these guidelines, a panel of experts was designed and charged by the boards of the World Society of Emergency Surgery (WSES) and American Association for the Surgery of Trauma (AAST) to perform a systematic review of the available literature and to provide evidence-based statements with immediate practical application. All the statements were presented and discussed during the WSES-AAST-WJES Consensus Conference on Anorectal Emergencies, and for each statement, a consensus among the WSES-AAST panel of experts was reached. We structured our work into seven main topics to cover the entire management of patients with anorectal emergencies and to provide an up-to-date, easy-to-use tool that can help physicians and surgeons during the decision-making process.

Manuka Honey: Feasibility and Safety in Postoperative Neurosurgical Wound Care

OBJECTIVE

To date, no reports have been published on active Leptospermum manuka honey (ALH) feasibility as a postoperative topical wound supplement in neurosurgical patients. The objective of the study is to present the authors' initial experience with using ALH in postoperative neurosurgical patients.

METHODS

A single-surgeon retrospective case series review of cranial and spinal operations between 2018 and 2020 was performed in patients with nonhealing wounds or wounds deemed "at risk" as defined by grade 1 Sandy surgical wound dehiscence grading classification. An ALH gel or ointment was applied to these incisions once a day for 2 to 4 weeks. Patients were followed up in the clinic every 2 weeks until incisions had healed.

RESULTS

Twenty-five postoperative patients (12 cranial, 13 spinal) were identified to be at high risk of operative debridement. All 25 patients were prescribed a topical application of ALH, which was easily adopted without patient-related adverse events. Seven (four cranial, three spinal) patients required operative debridement and treatment with long-term antibiotic therapy.

CONCLUSIONS

In this small case series of neurosurgical patients who were at risk of poor wound healing, the application of medical-grade ALH was well tolerated without patient-reported adverse events. The ALH may have prevented the need for operative debridement in the majority of patients. Further prospective studies are necessary to establish its efficacy in wound healing in the neurosurgical population.

Fournier gangrene: pictorial review

Fournier gangrene is an emergency condition that is associated with a high mortality rate. It is defined as a rapidly progressing infective necrotizing fasciitis of the perineal, perianal, and genital regions. Early diagnosis, broad-spectrum antibiotic coverage, and adequate surgical debridement are crucial and lead to better prognosis and patient survival. There is increasing utilization of computed tomography (CT) in the initial evaluation of Fournier gangrene. CT can confirm the diagnosis in equivocal cases, determine the source of infection, and evaluate the disease extent. In this pictorial review, we discuss the pathogenesis of Fournier gangrene and display the imaging spectrum with an emphasis on CT findings, including asymmetrical fascial thickening, soft tissue stranding, soft tissue gas, collection, and abscess formation. The infection originating from colorectal pathology, the affected anatomy, and the involvement of the abdominal wall are important predictors of mortality. The familiarity of the varied imaging appearance of Fournier gangrene is necessary to provide an accurate diagnosis, and evaluation of disease extent is crucial for optimal surgical debridement.

WUWHS 2020 Global Healing Changing Lives, Abu Dhabi, UAE March 8-12

The abstract book contains the abstracts of keynote lectures, global gelebration, focus sessions, symposia, regional view, workshops, sponsored symposia, oral presentations, posters and the index.

Pattern and outcome of management of Fournier's gangrene in a resource-constraint setting

INTRODUCTION

Fournier's gangrene (FG) is a necrotizing fasciitis of the external genitalia and perineum but may involve upper thigh and anterior abdominal wall.

PATIENTS AND METHODS

This is a retrospective study of 47 patients managed for FG at Usmanu Danfodiyo University Teaching Hospital from January 2001 to June 2017. Data were entered into a semi-structured pro forma and analyzed using SPSS version 20.0.

RESULTS

The mean age of the patients was 42.7 ± 19.4 years, with age range of 7 weeks to 72 years. All the patients were male. The patients had underlying urologic conditions in 27.6%, 15.0% were postoperative, 4.2% had anorectal diseases, 10.6% had medical conditions, and 42.6% were idiopathic. After resuscitation, all the patients had serial debridement, Hypertonic saline bath, broad spectrum antibiotics and wound dressing. The wound healed by secondary intention in 34.0% and 32.3% of the patients had wound closure ± skin graft. The treatment was successful in 68.0% of the patients, 15.0% left against medical advice, and 17.0% died of severe sepsis.

CONCLUSION

FG mainly affects men with existing urologic conditions in our environment. Aggressive debridement, hypertonic saline sitz bath, broad-spectrum antibiotics, and appropriate wound care are associated with good outcome.

Benign tumours leading to total penile denudation treated with Manuka honey dressings: A case report and review of literature

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Penile denudation can be treated either with reconstructive surgery or conservatively using Manuka honey dressings.

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Split-, full-thickness skin graft or local skin flap are surgical reconstructive possibilities regarding penile denudation.

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Methylglyoxal is responsible for the antibacterial activity in Manuka honey contrarily to other types of honey.

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Manuka honey treatment requires a minimum of medical training and be used in the out-patient clinic.

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A wide variety of wound types can benefit from Manuka honey dressings.

Introduction

Penile denudation is a devastating condition often reconstructed with a split-thickness skin graft(STSG). As this kind of reconstruction is challenging, we present an non-invasive treatment using Manuka honey dressings with a satisfying result. This was performed as a salvage procedure after failed STSG.

Case

A 55-year-old non-smoking male was admitted from his general practitioner with a newly onset of phimosis and lower urinary tract symptoms. Benign tumours complicated with infection were found on all segments of the penis causing dehiscence of the skin. After surgical removal of tumours and an unsuccessful STSG, Manuka honey dressings was used. Full sexual function was regained, and the patient was satisfied with the result.

Discussion

Alternatives to STSG are full-thickness skin graft using the inguinal or scrotal borrowing method, or using a dermal matrix before a STSG.

A rediscovered method is using Manuka honey, with its unique combination of bactericidal, anti-inflammatory and healing-promoting properties. A wide range of wound types may benefit from Manuka honey dressings.

A recent Danish in vitro study on honey derived from various Danish floras even shows high antibacterial effect superior to commercial medical grade honey. Considering a growing resistance to antibiotics, medical honey may contribute as a alternative to extensive wound care.

Conclusion

We successfully treated a penile denudation with Manuka honey following a failed STSG. Wounds, ulcers, and burns may be infected, and can be challenging, time consuming, and expensive to treat. Manuka honey may be a good alternative to reconstructive surgery and can be managed on an out-patient basis.

Fournier's gangrene: prospective study of 34 patients in South Indian population and treatment strategies

Introduction

Fournier's gangrene (FG) is a fulminant necrotizing fasciitis of the perineum and genitalia. The objective of this study was to study the etiology and microbiology associated with FG and to study the debridement and reconstructive procedures required in these patients.

Methods

This was a prospective follow up study conducted from September 2011 to November 2012 at Coimbatore medical college hospital, Coimbatore, India. Patients presenting to the outpatient department and emergency department with the clinical diagnosis of FG were included in the study.

Results

A total of 34 patients were studied in the study period. The mean age of presentation in years was 50±11.13. The male to female ratio was 33:1. The source of the infection was most commonly anorectal. Diabetes mellitus was the most common co morbid factor associated. Most commonly the disease was polymicrobial with escherichia coli being the commonest grown organism. The average number of wound debridement required was 2.9±1.42. Primary closure of the scrotal skin defect was the most common reconstructive procedure performed. Mortality associated with the disease in our series was 11.8%.

Conclusion

Although FG is a relatively rare disease, it is still prevalent in Indian population. Incidence of FG in HIV patients is high, even though it is not the commonest of the co morbid condition. The mortality can be kept to minimal with aggressive medical and surgical management. Extensive raw area following the infection and wound debridement can be managed by simple reconstructive procedures with good outcome.

The Antibacterial Effect In Vitro of Honey Derived from Various Danish Flora

The mechanism behind the biologic actions of honey as a wound remedy has been intensively studied; however, there is no published data regarding any antibacterial effect of honey derived from Danish flora. We surveyed 11 honeys of various Danish floral sources for their antibacterial activity and compared them to a culinary processed commercial honey (Jakobsens) and a raw and a medical grade Manuka (Leptospermum scoparium) honey using the agar-well diffusion method. We tested the effect on three gram-positive bacteria (two strains of Staphylococcus aureus and one strain of Staphylococcus epidermidis) and two gram-negative bacteria (Pseudomonas aeruginosa and Escherichia coli). All samples, except the commercial honey, exhibited antibacterial activity, and samples derived from Water Mint (Mentha aquatica), Organic 2 (mixed organic flora), and Linden (Tilia cordata) honey had consistent effects on all bacteria tested and showed greater effect than medical grade and raw Manuka (L. scoparium) honey. The content of methylglyoxal was low in the Danish honey (< 2 μg/mL) and significantly (p<0.05) higher in both the raw and the medical grade Manuka (L. scoparium) honey, where the concentrations were, respectively, 6.29 μg/mL and 54.33 μg/mL. The antibacterial effect of Danish honeys was mostly due to hydrogen peroxide. We conclude that honeys derived from Danish flora possess antibacterial effect, probably by a hurdle effect of viscosity, osmolality, acidity, bioactive peptides, and most importantly the content of hydrogen peroxide. These findings indicate that honeys of various Danish floral sources may have clinical potential, although further studies are necessary to elucidate this in order to determine whether the results of our in vitro experiments also apply to a clinical setting.

Scrotal reconstruction and testicular prosthetics

Scrotal surgery encompasses a wide-variety of surgical techniques for an even wider variety of indications. In this manuscript, we review our indications, techniques, and pit-falls for various reconstructive scrotal surgeries as-well-as surgical tips for placement of testicular prostheses. Penoscrotal webbing (PSW) is an abnormal, often-problematic distal insertion of scrotal skin onto the ventral penile shaft. There are several effective and straightforward techniques used to revise this condition, which include simple scrotoplasty, single- or double-Z-plasty, or the VY-flap scrotoplasty. Reconstruction is also commonly indicated following scrotal skin loss caused by infection, trauma, lymphedema, hidradenitis, and cancer. Although initial management of these conditions often involves scrotal skin removal, repair of expansive scrotal skin loss can be technically difficult and can be accomplished by using one of several skin flaps or skin grafting. Split-thickness skin grafting of scrotal defects can be accomplished easily, and provides durable results.

Factitious Disorder Presenting with Attempted Simulation of Fournier's Gangrene

Fournier's gangrene is a severe polymicrobial necrotizing fasciitis of the perineal, genital, or perianal regions. The classic presentation is severe pain and swelling with systemic signs. Crepitus and cutaneous necrosis are often seen. Characteristic CT findings include subcutaneous gas and inflammatory stranding. Unless treated aggressively, patients can rapidly become septic and die. Factitious Disorder is the falsification of one's own of medical or psychological signs and symptoms. Many deceptive methods have been described, from falsely reporting physical or psychological symptoms, to manipulating lab tests, or even injecting or ingesting foreign substances in order to induce illness. We present a case of a 35-year-old man with factitious disorder who attempted to simulate Fournier's gangrene by injecting his scrotum with air and fluid. We will review the clinical presentation and diagnosis of Factitious Disorder, as well as Fournier's gangrene.

Honey: A Therapeutic Agent for Disorders of the Skin

Problems with conventional treatments for a range of dermatological disorders have led scientists to search for new compounds of therapeutic value. Efforts have included the evaluation of natural products such as honey. Manuka honey, for example, has been scientifically recognised for its anti-microbial and wound healing properties and is now used clinically as a topical treatment for wound infections. In this review, scientific evidence for the effectiveness of honey in the treatment of wounds and other skin conditions is evaluated. A plethora of in vitro studies have revealed that honeys from all over the world have potent antimicrobial activity against skin relevant microbes. Moreover, a number of in vitro studies suggest that honey is able to modulate the skin immune system. Clinical research has shown honey to be efficacious in promoting the healing of partial thickness burn wounds while its effectiveness in the treatment of non-burn acute wounds and chronic wounds is conflicted. Published research investigating the efficacy of honey in the treatment of other types of skin disorders is limited. Nevertheless, positive effects have been reported, for example, kanuka honey from New Zealand was shown to have therapeutic value in the treatment of rosacea. Anti-carcinogenic effects of honey have also been observed in vitro and in a murine model of melanoma. It can be concluded that honey is a biologically active and clinically interesting substance but more research is necessary for a comprehensive understanding of its medicinal value in dermatology.

Evaluation of LRINEC Scale Feasibility for Predicting Outcomes of Fournier Gangrene

BACKGROUND

Fournier gangrene (FG) is a fulminant necrotizing infection of the perineal, perianal, and periurethral tissues. The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) scale is used for diagnosis of necrotizing fasciitis. However, data on its relevance and usefulness in FG are lacking. The aim of this study was to evaluate the utility of the LRINEC scale in predicting the outcome of FG.

METHODS

This retrospective case study included 41 patents with FG treated at our institution from 2000 to 2013. The patients were divided into survivors and non-survivors.

RESULTS

The mortality rate was 22%. The median age (75 vs. 62.5 y; p = 0.013), rate of co-existing diabetes mellitus (66.7% vs. 3.1%; p < 0.001), and median affected skin surface (4% vs. 1%; p < 0.001) were greater in the non-survivors. Seven of nine patients (77.8%) who did not survive (compared with 37.5% who survived) had a polymicrobial infection (p = 0.032). Of all the causative pathogens isolated, Proteus mirabilis was more common in non-survivors (55.6% vs. 6.3%; p = 0.001). The median calculated LRINEC score for survivors was 5 compared with 10 for the non-survivors (p < 0.001). Regression analysis showed that all the aforementioned variables, except for polymicrobial culture, were significant risk factors for predicting death. The area under the receiver operating characteristic curve for the LRINEC score was the highest, 0.976 (95% confidence interval 0.872-0.999; p < 0.0001), and the cut-off value was ≥9 with 93.7% specificity and 100% susceptibility for the prediction of a lethal outcome.

CONCLUSIONS

The LRINEC score could be used for prediction of disease severity and outcomes. A threshold of 9 could be a high-value predictor of death during the initial evaluation of patients with FG.

Post-bariatric abdominoplasty resulting in wound infection and dehiscence-Conservative treatment with medical grade honey: A case report and review of literature

INTRODUCTION

Wound complications in post-bariatric patients undergoing body-contouring surgery after massive weight loss are not uncommon and often, surgical debridement or conservative management is necessary. Honey is one of the most ancient remedies for wound care and it is also considered to possess debriding effects. Current research has demonstrated promising results showing that honey can improve wound granulation and epithelialization, reduce exudate and shorten healing times.

METHODS

This case report has been reported in line with the CARE criteria.

PRESENTATION OF CASE

A 40 year-old female suffered wound infection and dehiscence after undergoing post-bariatric abdominoplasty. The patient was not interested in surgical revision and split skin grafting. Therefore, conservative wound treatment with topical Manuka honey was instituted resulting in significant clinical improvement and effective healing concurrently with good patient satisfaction.

DISCUSSION

Surgical wound complications in post-bariatric patients undergoing abdominoplasty are common and often require surgical revision or conservative wound treatment. No previous publication has addressed outpatient treatment of post-bariatric abdominoplasty wound complications with medical grade honey.

CONCLUSION

Although more research is needed for definitive conclusions of honey's efficacy, it is safe and as presented in our case, it may under certain circumstances reduce the need of surgical wound debridement and serve as a remedy for conservative treatment.

Contemporary diagnosis and management of Fournier's gangrene

Fournier's gangrene, an obliterative endarteritis of the subcutaneous arteries resulting in gangrene of the overlying skin, is a rare but severe infective necrotizing fasciitis of the external genitalia. Mainly associated with men and those over the age of 50, Fournier's gangrene has been shown to have a predilection for patients with diabetes as well as people who are long-term alcohol misusers. The nidus for the synergistic polymicrobial infection is usually located in the genitourinary tract, lower gastointestinal tract or skin. Early diagnosis remains imperative as rapid progression of the gangrene can lead to multiorgan failure and death. The diagnosis is often made clinically, although radiography can be helpful when the diagnosis or the extent of the disease is difficult to discern. The Laboratory Risk Indicator for Necrotizing Fasciitis score can be used to stratify patients into low, moderate or high risk and the Fournier's Gangrene Severity Index (FGSI) can also be used to determine the severity and prognosis of Fournier's gangrene. Mainstays of treatment include rapid and aggressive surgical debridement of necrotized tissue, hemodynamic support with urgent resuscitation with fluids, and broad-spectrum parental antibiotics. After initial radical debridement, open wounds are generally managed with sterile dressings and negative-pressure wound therapy. In cases of severe perineal involvement, colostomy has been used for fecal diversion or alternatively, the Flexi-Seal Fecal Management System can be utilized to prevent fecal contamination of the wound. After extensive debridement, many patients sustain significant defects of the skin and soft tissue, creating a need for reconstructive surgery for satisfactory functional and cosmetic results.

Fournier's Gangrene: A Summary of 10 Years of Clinical Experience

We aimed to present our clinical experience with FG treatment. Fournier's gangrene (FG) is a rare but serious disease characterized by progressive necrosis in the genitourinary and perineal region. The retrospective study included 43 patients. Patients were divided into 2 groups as survivors and nonsurvivors. Included in the analysis were data pertaining to demographics, predisposing factors, comorbidities, results of bacteriologic analyses, number of debridements, duration of treatment, FG Severity Index (FGSI) score, fecal diversion methods (trephine ostomy or Flexi-Seal Fecal Management System-FMS), and dressing methods (wet or negative aspiration system). In the nonsurvivor group, urea, WBC, and age were significantly higher, whereas albumin, hematocrit, platelet count, and length of hospital stay (LOHS) were significantly lower compared to the survivor group. Mean FGSI was lower in survivors in comparison with nonsurvivors (5.00 ± 1.86 and 10.00 ± 1.27, respectively; P < 0.001). We conclude that FGSI is an important predictor in the prognosis of FG. Vacuum-assisted closure (VAC) should be performed in compliant patients in order to enhance patient comfort by reducing pain and the number of dressings. Fecal diversion should be performed as needed, preferably by using FMS. The trephine ostomy should be the method of choice in cases where an ostomy is necessary.

[Our experience in Fournier's gangrene with severe septic shock]

Fournier's gangrene is a rare, rapidly progressing necrotizing fasciitis, which involves the genital area and perineum, progresses towards the thighs and abdominal wall through fascial plains. In our surgical department we treated seven patients with Fournier's gangrene between 2007 and 2011. Early diagnosis, immediate radical surgical debridement, necrosectomy, appropriate antibiotics and intensive care are all required and necessary for the successful treatment. Despite appropriate therapy, two patients were lost in septic shock.

Skin and soft tissue infections in the military

Skin and soft tissue infections (SSTI) are common in military populations regularly living and training in close contact with each other. The majority of such infections are simple and can be easily treated with antibiotics and appropriate infection control practices. Some, however, can progress to become complex and even life threatening, such as Panton-Valentine Leukocidin (PVL)-associated staphylococcus aureus pneumonia, or Streptococcus pyogenes necrotising fasciitis, which carry a mortality rate of up to 65% and 30%, respectively. This review focuses on the most important SSTIs and those more commonly affecting military personnel with advice on how they are best managed.

Necrotizing fasciitis: eight-year experience and literature review

Objectives

To describe clinical, laboratory, microbiological features, and outcomes of necrotizing fasciitis.

Methods

From January 1, 2004 to December 31, 2011, 115 patients (79 males, 36 females) diagnosed with necrotizing fasciitis were admitted to Mackay Memorial Hospital in Taitung. Demographic data, clinical features, location of infection, type of comorbidities, microbiology and laboratory results, and outcomes of patients were retrospectively analyzed.

Results

Among 115 cases, 91 survived (79.1%) and 24 died (20.9%). There were 67 males (73.6%) and 24 females (26.4%) with a median age of 54 years (inter-quartile ranges, 44.0–68.0 years) in the survival group; and 12 males (50%) and 12 females (50%) with a median age of 61 years (inter-quartile ranges, 55.5–71.5 years) in the non-surviving group. The most common symptoms were local swelling/erythema, fever, pain/tenderness in 92 (80%), 87 (76%) and 84 (73%) patients, respectively. The most common comorbidies were liver cirrhosis in 54 patients (47%) and diabetes mellitus in 45 patients (39%). A single organism was identified in 70 patients (61%), multiple pathogens were isolated in 20 patients (17%), and no microorganism was identified in 30 patients (26%). The significant risk factors were gender, hospital length of stay, and albumin level.

Discussion

Necrotizing fasciitis, although not common, can cause notable rates of morbidity and mortality. It is important to have a high index of suspicion and increase awareness in view of the paucity of specific cutaneous findings early in the course of the disease. Prompt diagnosis and early operative debridement with adequate antibiotics are vital.

A unique case of penile necrotizing fasciitis secondary to spontaneous corpus cavernosal abscess

Corpus cavernosal abscess and necrotizing fasciitis occur rarely, and precipitating factors can usually be elicited with careful history and examination. Whilst both conditions share common risk factors such as diabetes mellitus, this is the first reported case of penile necrotizing fasciitis secondary to spontaneous corpus cavernosal abscess in an otherwise healthy patient. A 32-year-old man presented with 4-day history of swollen, painful penis, with ultrasound confirming corpus cavernosal abscess. Biopsies were taken and the cavity aspirated, but, despite intravenous antibiotics, he developed penile necrotizing fasciitis necessitating open cavernostomy and debridement. The overlying skin defect healed by secondary intention, but the patient experienced persistent postoperative erectile dysfunction, so he was referred for penile prosthesis insertion.

Fournier's gangrene in a patient with obesity and B-lymphoma

We present a case of Fournier's gangrene disease in a young obese patient with coexistent B-lymphoma. It remains controversial if obesity constitutes a predisposing factor for an individual to develop necrotizing fasciitis. On the other hand, only few cases of patients with coexistence of B-lymphoma and Fournier's gangrene disease have been reported. A 30-years-old obese man was admitted to emergency department with fever (38.7 °C), pain, erythema and swelling extended from the left scrotum to the left lower abdominal quadrant. He was confused, with low urinary excretion and septic shock's signs. The clinical findings were characteristics of Fournier's gangrene disease. Furthermore during physical examination a massive, painless and motionless mass in the left breast was revealed. The patient required urgent surgical debridement of the affected area and pus drainage. Biopsies of the breast mass were received by excision. Pus and blood cultures yielded Staphylococci coagulase(-), Klebsiella and Proteus sp. Intravenous antibiotic treatment with Meropeneme and Clindamycine started immediately. Repeated debridement was often performed. Pathology examination of the massive tissue revealed a diffuse B-lymphoma of large cells (Germinal center B-cell like- GCB). The patient was discharged from the hospital 35 days later. Afterwards, he was treated with chemotherapeutic agents for malignant lymphoma at the oncological department. The aim of this case's presentation is to mention that young obese patients with Fournier's gangrene disease should be particularly investigated due to the possible occurrence of another not obvious predisposing factor, such as a malignant disease.

Fournier's gangrene

Fournier's gangrene (FG) is a synergistic polymicrobial gangrenous infection of the perineum, scrotum and penis which is characterised by obliterative endarteritis of the subcutaneous arteries, resulting in gangrene of the subcutaneous tissue and the overlying skin. FG affects all ages and both genders, with a male preponderance. It is a rare but life-threatening disease, and despite therapeutic advances in recent years, the mortality rate is 3%-67%, with an incidence of 1:7500-1:750,000. Anorectal, genitourinary and cutaneous sources of infection are the most common causes of FG, with diabetes mellitus being the most common risk factor. The clinical condition presents evolution from 2 to 7 days and is characterised by uneasiness, local swelling and discomfort, fever, crepitus and sometimes frank septic shock. Current imaging techniques for initial evaluation of the disease include radiography, Ultrasonography (USG), Computed Tomography (CT) and Magnetic Resonance Imaging (MRI). However, the diagnosis of FG is usually clinical and imaging can be helpful in uncertain diagnosis and when clinical findings are ambiguous. Treatment of FG is based on a multimodal approach which includes intensive fluid resuscitation to stabilise the patient and correction of electrolyte imbalance, if any. This is followed by extensive debridements and resections in order to remove all necrotic and infected tissue, wide spectrum antibiotics and reconstructive surgery, whenever required. However, despite all the advances in treatment today, FG remains a surgical emergency, hence, early recognition with aggressive haemodynamic stabilisation, parenteral broad spectrum antibiotics and urgent surgical debridement are the mainstay of treatment.

Management of unusual genital lymphedema complication after Fournier's gangrene: a case report

Background

Fournier’s gangrene is a bacterial infection characterized by necrotizing fasciitis, skin and soft tissue involvement, and eventually myositis of the perineal region. Aggressive debridement of devitalized tissue and overlying skin is of paramount importance, but often leaves large defects to be reconstructed. The present case reports successful extensive perineal defects coverage following Fournier’s gangrene and management of subsequent penile lymphoedema impairing sexual function in a young patient.

Case presentation

Following perianal abscess drainage, a healthy young man presented with scrotal pain. Fournier’s gangrene was diagnosed and treated with multiple surgical debridements. Tissue excision extended through the entire perineal area, base of the penile shaft, lower abdominal region, the inner thighs, and gluteal region, corresponding to 12% of the total body surface area. After serial debridements and negative pressure dressings, the defect was covered by two stages of skin grafting. Graft take was 90%. Healing was achieved without hypertrophic or retractile scar. However, chronic penile lymphedema remained and was first treated with compressive garments for 2 years. Upon failure of this conservative approach, we performed a circumcision, but only a “penile lift” allowed a satisfactory esthetical and functional result.

Conclusion

Fournier’s gangrene can be complicated by a chronic lymphedema of the penis. Conservative treatment is likely to fail in severe cases and can be treated surgically by “penile lift”.

Fournier gangrene: description of 37 cases and analysis of associated health care costs

BACKGROUND AND OBJECTIVES

Fournier gangrene is a urological emergency associated with a high mortality. It is a necrotizing fasciitis caused by polymicrobial infection originating in the anorectal or genitourinary area. The aim of this study was to analyze the epidemiological and clinical characteristics of Fournier gangrene along with the variables that influence disease course and mortality in patients treated in our department.

MATERIAL AND METHODS

We carried out a retrospective study of 37 patients diagnosed with Fournier gangrene between January 2001 and October 2010.

RESULTS

All the patients were men, 43.2% had diabetes, and the mean age of the patients was 57.68 years. Statistically significant differences were observed between the age of surviving patients and that of patients who died (55.8 and 69.6 years, respectively). The mean hospital stay was 27.54 days and 32.4% of patients required admission to the intensive care unit. Etiology was unknown in 39.8% of cases. Polymicrobial infection was observed in 59.5% of cases. The mean health care cost associated with a patient diagnosed with Fournier gangrene admitted to intensive care and requiring at least 1 procedure in the operating room was €25,108.67. Mortality was 13.5%. Based on analysis of individual comorbid conditions, only ischemic heart disease displayed a statistically significant association with mortality due to Fournier gangrene; ischemic heart disease was also associated with longer hospital stay.

CONCLUSIONS

Fournier gangrene is associated with high mortality despite appropriate early treatment. Although the condition is infrequent, the high associated health care costs suggest that primary and secondary prevention measures should be implemented.

Fournier's Gangrene: Conventional Dressings versus Dressings with Dakin's Solution

Purpose. Fournier's gangrene is a fulminant and destructive inflammation of the scrotum, penis, and perineum. The objective of this study was to compare 2 different approaches to wound management after aggressive surgical debridement. Methods. Data from 14 patients with Fournier's gangrene were retrospectively collected (2005–2011). Once the patients were stabilized following surgery, they were treated with either daily antiseptic (povidone iodine) dressings (group I, n = 6) or dressings with dakin's solution (sodium hypochloride) (group II, n = 8). Results. The mean age of the patients was 68.2 ± 7.8 (55–75) years in group I and 66.9 ± 10.2 (51–79) years in group II. Length of hospital stay was 13 ± 3.5 (7–16) days in group I and 8.9 ± 3.0 (4–12) days in group II (P < 0.05). The number and rate of mortality was 1/6 (16.7%) in group I, and 1/8 (12.5%) in group II. Conclusions. The hospitalization time can be reduced with the use of dakin's solution for the dressings in the treatment of FG. Also, dressings with dakin's solution seems to have favorable effects on morbidity and mortality. Consequently dakin's solution may alter the treatment of this disastrous disease by reducing cost, morbidity and mortality.

Recent advances in the treatment of necrotizing fasciitis

With four types of necrotizing fasciitis (NF) now recognized, the diagnosis and management of NF becomes more challenging as physicians face more unusual pathogenic and atypical presentations. With few published guidelines and little evidence base to justify therapies, much of the literature is pragmatic or provides limited evidence with small underpowered studies and disparate case reports.

Fournier gangrene: our approach and patients

AIM

This retrospective analysis presents our experience in treating Fournier gangrene (FG) and aims to bring in focus diagnostic and therapeutic problems as well as early and aggressive treatment.

PATIENTS AND METHODS

A total of 16 male patients were included in the study. The gastrointestinal form was seen in 5 and the urogenital form in 11 patients. The subjects ranged in age from 39 to 74 years (average 61) for the urogenital, and from 48 to 72 (average 58) for the gastrointestinal form. Other conditions were seen in 9 patients (diabetes mellitus was most common). Most patients were infected with several bacteria. We performed colostomy in 1 patient, orchidectomy in 2 patients, cystostomy in 2 patients and penis amputation in 1 patient. Ultrasound-guided biopsy or aspiration, and CT was also used. Aggressive surgical necrectomy and aggressive antimicrobial therapy was used.

RESULTS

Treatment was successful in 14 of 16 patients (87.5%). The length of hospitalization was 19-58 days (average 48) for the urogenital form and 24-56 days (average 41) for the gastrointestinal form. Mortality was 12.5%. A lethal outcome was recorded in two patients infected with methicillin-resistant Staphylococcus aureus. The average time between onset and hospitalization was 3-11 days (5 on average) for urogenital FG and 4-10 days (average 6) for gastrointestinal FG. Treatment was significantly longer in patients with a comorbidity, such as diabetes or liver cirrhosis due to alcohol abuse.

CONCLUSION

Early diagnosis as well as intensive and aggressive treatment are key to successful treatment of FG. Comorbidity increases length of therapy and lowers the chance for recovery. Disease can be seen again several years after the initial outburst.

Honey and wound healing: an overview

Honey has been used to treat wounds throughout the ages. This practice was rooted primarily in tradition and folklore until the late 19th century, when investigators began to characterize its biologic and clinical effects. This overview explores both historic and current insights into honey in its role in wound care. We describe the proposed antimicrobial, immunomodulatory, and physiologic mechanisms of action, and review the clinical evidence of the efficacy of honey in a variety of acute and chronic wound types. We also address additional considerations of safety, quality, and the cost effectiveness of medical-grade honeys. In summary, there is biologic evidence to support the use of honey in modern wound care, and the clinical evidence to date also suggests a benefit. However, further large, well designed, clinical trials are needed to confirm its therapeutic effects.

Fournier's gangrene in a patient receiving treatment for idiopathic thrombocytopenic purpura

We report the case of a 68-year-old man who was diagnosed with Fournier's gangrene (FG), which developed during immunosuppresive treatment for idiopathic thrombocytopenic purpura (ITP). The patient was administered steroids for ITP but on the 36th day, he developed FG and septic shock. We initiated antibiotic treatment and drained a periproctal abscess immediately. On day 53, extensive drainage to progressive FG and a splenectomy was performed, following which both FG and thrombocytopenia improved. This is the first case of FG has developing in a ITP patient. It appears that high-dose immunoglobulin therapy and splenectomy should be considered earlier especially for a patient complicated with FG.

[Affections of the external genitalia and their management]

The diagnosis of genital lesions is in most cases the result of clinical inspection. In many cases, special genital trauma or severe infections indicate immediate treatment in order to achieve good clinical results and post-surgical quality of life. Here we present representative cases and their urological management from the last 12 months. Our work focuses on the acute scrotum, genital trauma and cancer of the external genitalia.

Diagnosis and treatment of perianal necrotizing fasciitis

Perianal necrotizing fasciitis (PNF) is a serious infectious disease that results from a synergistic action of multiple bacteria and has a high mortality rate. In the early stage of PNF, symptoms are highly variable. Early diagnosis and adequate treatment are important for the prognosis of PNF. Therapeutic measures for PNF include surgical removal of necrotic tissue, drainage, debridement and full dose of broad-spectrum antibiotics. In this article, we will review the recent advances in the diagnosis and treatment of PNF.

Fournier's gangrene: an analysis of 80 patients and a novel scoring system

BACKGROUND

To create a better scoring system for outcome prediction for patients with Fournier's gangrene in order to design more appropriate and feasible management strategies.

METHODS

Using logistic regression, the medical records of 80 patients who underwent surgery for Fournier's gangrene in the last 10 years were reviewed using a prospectively maintained database, and a novel scoring system was adopted combining this data with the Fournier's gangrene severity index (FGSI). The new system consists of a physiological score, an age score, and an extent of gangrene score.

RESULTS

The mortality rate of the 80 patients was 21%. Using the new scoring system (UFGSI), at a threshold value of 9, there was a 94% probability of death with a score greater than 9 and an 81% probability of survival with a score of 9 or less (P < 0.001). The receiver operating characteristics (ROC) analysis concluded that the new scoring system was more powerful than the FGSI (P = 0.002).

CONCLUSIONS

The power of the novel scoring system introduced in this study proves that in patients with Fournier's gangrene, the extent of the gangrene as well as the patient's age and physiological status have a significant effect on the outcome.

[The profile urological emergencies at the Conakry University Teaching Hospital, Guinea]

OBJECTIVE

To stick out the profile urological emergencies at the Conakry University Teaching Hospital, Guinea.

PATIENTS AND METHODS

This retrospective study, carried out over a period of 3 years (January 2005-December 2007), included 757 urological emergencies admitted to the urology department of the university hospital of Conakry, Guinea.

RESULTS

The mean age of patients was 56 years. These patients had an age equal to or higher than 60 years in 58% of the cases. The sex ratio (M/F) was 16.6. According to the social profession, the farmer (40,6%) and workers (21%) were the dominant patients. The most frequent illness was vesical urinary retention (73.9%), hematuria (9.6%) and genito-urinary system trauma (7%). The most performed procedures were the installation of a urethral catheter (55.25%) and the installation of a suprapubic catheter (24.14%).

CONCLUSION

The most frequent urological emergency in our country was vesical urinary retention, the hematuria and genito-urinary system trauma are not rare there.

Fournier's gangrene: a dreadful disease

BACKGROUND

Although there is much consensus, certain controversies still exist regarding the pathology of Fournier's gangrene. The purpose of this study was to determine the prevalence of the disease in the catchment area of the three teaching hospitals, to identify the systemic predisposing factors and local aetiological factors, and to assess the recommended role of aggressive surgical debridement as a part of treatment.

MATERIALS AND METHODS

This prospective study was conducted in the surgical departments of three tertiary care hospitals of the Khyber Medical University, Peshawar, Pakistan, from 1 January 2002 to 30 June 2007. Detailed history and examination of all patients were carried out to reach the diagnosis of Fournier's gangrene. After initial resuscitation, patients were treated aggressively, including surgical debridement.

RESULTS

Sixty patients were studied in the study period. The male to female ratio was 5:1. The age range was 20-75 years with mean 47+17.4 (SD) years. The socioeconomic status of patients was poor (the average income was less than $50 per week) in 36 (60%) and 24 (40%) were middle class (the average income being $50-100 per week). Thirty-nine patients (65%) presented in the hot humid months of the year. Extent of the disease was scrotum in 18 patients (30%), perineum in 30 (50%) and abdominal wall in 12 (20%). Systemic predisposing factors identified in our study were diabetes mellitus in 20 (33.33%) patients, chronic alcohol abuse in two (3.33%) and long-standing steroid therapy in four (6.67%) while in 34 patients (56.67%) no cause was identified. The local aetiological origin of Fournier's gangrene was urogenital in 14 (23.33%) patients, anorectal in 10 (16.67%) and cutaneous in 8 (13.33%) and no local pathologies could be identified in 28 (46.67%) patients. The mean time interval between first symptom and initial treatment was 2.5 days with a range of 1-7 days. Number of debridement sessions per patient was 2-6 (mean, 3.15). Mean hospital stay was 31+7 (SD) with a range of 10-50 days. Morbidity was 80%. Four patients (6.67%) died. Three of these patients presented to hospital 5-6 days too late.

CONCLUSION

Fournier's gangrene is not an uncommon disease in South Asia. Systemic predisposition such as diabetes mellitus, long-standing steroid therapy, chronic alcoholism and even the hot humid season can contribute to this dreadful disease. Local causes in the form of urogenital, anorectal and cutaneous disorders may trigger this disease in some patients. Early recognition of disease and aggressive surgical debridement are the main treatments.

New insights into the epidemiology and etiology of Fournier's gangrene: a review of 33 patients

BACKGROUND

Fournier's gangrene is a necrotizing fasciitis involving the perineal and genital regions. Even today, this often polymicrobial infection still carries a high mortality rate and continues to be a major challenge to the medical community. The purpose of this study was to report our experience with this condition and to compare it with those reported in published studies. We also introduce our approach to treatment.

METHODS

We analyzed data from 33 patients with Fournier's gangrene who were managed in our hospital from 1996 to 2007, focusing on patient gender, age, etiology, predisposing conditions, comorbidities, bacteriology, sepsis, blood results, mortality, and spread of gangrene.

RESULTS

18 (54.5%) of the 33 patients had been referred to our department by smaller district hospitals. The patient cohort consisted of 23 men and ten women with a median age of 59 years (range 40-79 years). The median time between the onset of symptoms and progression to gangrene was 6 days (range 2-28 days). An underlying cause was identified in 27 patients (81.8%). The commonest etiological events were perianal and perirectal abscesses (n = 13; 39.4%). Predisposing factors included diabetes mellitus in 12 cases (36.4%), chronic alcoholism in ten cases (30.3%), immunosuppression in six cases (18.2%), and prolonged immobilization in five cases (15.2%). 17 patients (51.5%) had a body mass index (BMI) of 25 or higher, and 13 patients (39.4%) had a BMI of 30 or higher. Positive cultures were obtained in 30 cases (90.9%). In 26 cases (78.8%), multiple microorganisms were recovered, including nine cases (27.3%) with both aerobes and anaerobes. Sepsis was present in 26 patients (78.8%). The mortality rate was 18.2%.

CONCLUSION

Fournier's gangrene remains a major challenge with a high mortality. Our results suggest that women are more commonly affected than has generally been assumed. Contrary to published reports, we found that anorectal sources appear to account for more cases of Fournier's gangrene than urological sources.

Les gangrènes des organes génitaux externes: à propos de 102 cas

Buts

Rapporter les aspects épidémiologiques, cliniques, biologiques et thérapeutiques d’une série de 102 cas de gangrènes pénoscrotales et périnéales et en identifier les facteurs pronostiques.

Matériel et méthodes

Nous avons effectué une étude rétrospective colligeant 102 cas de gangrènes pénoscrotales et périnéales, admis au service d’urologie-andrologie du CHU Aristide-Le-Dantec de Dakar, entre janvier 2001 et décembre 2007.

Résultats

L’âge moyen de nos patients était de 50,0 ± 15,7 ans (extrêmes: 20–93 ans). La durée moyenne d’hospitalisation était de 8,0 ± 7,1 jours (extrêmes: 1–33 jours). Les lésions intéressaient le scrotum dans 61,8 % des cas, le scrotum et la verge dans 17,6 % des cas et la verge isolément dans 3,9 % des cas. Le périnée était atteint dans 14,7 % des cas. Il s’agissait d’une gangrène de Fournier (idiopathique) dans 26 cas (25,5 %) et d’une gangrène secondaire, à rétrécissement urétral, dans 70 cas (68,6 %). Les principaux facteurs de comorbidité associés étaient le diabète non insulinodépendant (13,7 %), l’hypertension artérielle (HTA) [5,9 %] et l’insuffisance rénale chronique (5,9 %). À la biologie, 79,4 % des patients avaient une concentration de leucocytes supérieure à 12 000/ml. Le taux d’hémoglobine était en moyenne de 9,8 ± 2,8 g/dl (extrêmes: 3,3–13,9 g/dl). L’antibiothérapie la plus utilisée associait une céphalosporine de troisième génération, un aminoside et la métronidazole (46,1 %). Les principaux gestes chirurgicaux réalisés ont été un débridement dans 21 cas (20,6 %), un débridement plus cystostomie dans 81 cas (79,4 %). Le taux de mortalité était de 15,7 %. Les principaux facteurs de mauvais pronostic chez nos patients étaient l’age, le caractère secondaire de la gangrène, l’étendue des lésions et l’association à un diabète et/ou à une HTA.

Conclusion

La gangrène des organes génitaux externes et du périnée reste une affection fréquente et grave. Son traitement doit être multidisciplinaire.