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Fournier gangreneN49.8

Author:Prof. Dr. med. Peter Altmeyer

Co-Autor:Dr. med. Lydia König

All authors of this article

Last updated on: 15.12.2022

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Synonym(s)

Acute ulcerative genital gangrene; Erysipelas gangraenosum genitalium; Fournier gangrene; Fournier Gangrene; Fournier's gangrene; Gangraena acuta genitalium; gangraenosum ulcer; genital gangrene acute ulcer

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HistoryThis section has been translated automatically.

Baurienne, 1763; Fournier, 1883

DefinitionThis section has been translated automatically.

Life-threatening, fulminant, necrotizing inflammation of the male/female genitals, perineum or perianal region. The clinical picture corresponds to a foudroyant necrotizing fasciitis and requires immediate urological, proctosurgical or gynecological (intensive care) surgical intervention.

EtiopathogenesisThis section has been translated automatically.

Unclear, possible infection with streptococci ( Erysipelas gangraenosum genitalium, Erysipelas genitalium), fusiform bacteria, spirochetes etc. Possibly Sanarelli-Shwartzman phenomenon. Predisposing factors discussed are previous surgery or trauma (e.g. also after dental piercing: Ekelius L et al. 2004) and systemic diseases (e.g. diabetes mellitus).

In summer 2018 the FDA has included Fournier gangrene as a rare side effect in the technical information of SGLT2 inhibitors. A connection with therapeutically intended glucosuria is suspected.

ManifestationThis section has been translated automatically.

  • m:w=2:1
  • Age: between the 30th and 80th LJ.
  • Average age is given in larger studies as 59 years.
  • Less frequent in adolescents, children and infants.

LocalizationThis section has been translated automatically.

Perianal 40%; genital region: 40%;

Clinical featuresThis section has been translated automatically.

Sudden febrile onset, acute, very painful redness and swelling. Blistering with serous and haemorrhagic content, formation of a rapidly expanding necrosis, destruction of the skin of the penis, including the corpora cavernosa and the scrotal skin. Possibly exposed testicles. Mostly severe general complications up to septic shock.

HistologyThis section has been translated automatically.

Mostly a compact tumour penetrating the entire dermis with nests and strands of oval to polygonal, distended cells with eosinophil granulated cytoplasm. The cell nuclei are often pynotic. A characteristic feature of granular cell tumors is a distinctly acanthotic epidermis.

Immunohistochemistry: Tumor cells are positive for S100, neuron-specific enolase and myelin basic protein.

Differential diagnosisThis section has been translated automatically.

Cytomegaly - Ulcer

General therapyThis section has been translated automatically.

Immediate transfer to surgical intensive care unit! If necessary, surgical therapy with generous necrotic excision and drainage, temporary transfer of the testicles into a subcutaneous thigh pocket. After healing plastic reconstruction.

Internal therapyThis section has been translated automatically.

High-dose parenteral therapy with broad-spectrum antibiotics such as ampicillin (e.g., Binotal). Adults: 150-200 mg/kg bw/day, children > 1 year of age 100-400 mg/kg bw/day distributed over 4 ED, infants < 1 week of age 50-150 mg/kg bw/day distributed over 2-3 ED, infants > 1 week of age 100-300 mg/kg bw/day distributed over 3-4 ED.

Alternative: benzylpenicillin (e.g., penicillin Grünenthal), adults: 6 times 4 million IU/day i.v., infants > 1st week of life: 50,000-250,000 IU/kg bw/day distributed to 4-6 ED, infants < 1st week of life: 50,000-250,000 IU/kg bw/day distributed to 2 ED, infants > 1st week of life 75,000-350,000 IU/kg bw/day distributed to 4 ED.

Alternative: Gentamicin (e.g. Refobacin) Adults: 3-5 mg/kg bw/day distributed to 1-3 ED, infants > 1st year of life: 5-7 mg/kg bw/day distributed to 3-4 ED, infants < 1st week of life: 5 mg/kg bw/day distributed to 2 ED, infants > 1st week of life: 7.5 mg/kg bw/day distributed to 3 ED combined.

In case of penicillin resistance: 3rd generation cephalosporins, e.g., cefotaxime (Claforan) 3 times/day 2 g i.v.

In therapy resistance: combination of a cephalosporin with an aminoglycoside, e.g. Rocephin 2 g/day i.v. with Refobacin 1 time/day 240 mg i.v. or combination of Vancomycin (e.g. Vanco-Cell) 2 times/day 1 g i.v. with Gentamicin (see above).

Progression/forecastThis section has been translated automatically.

The lethality rate is 20-30%.

LiteratureThis section has been translated automatically.

  1. Bonner C et al (2001) Fournier gangrene as a rare complication after stapler hemorrhoidectomy. Case report and review of the literature. Surgeon 72: 1464-1466
  2. Eke N et al (2000) Fournier's gangrene: a review of 1726 cases. Br J Surg 87: 718-728
  3. Ekelius L et al (2004) Fournier's gangrene after genital piercing. Scand J Infect Dis 36:610-612.
  4. Fournier JA (1883) Gangrène foudroyante de la verge. La semaine médicale (Paris) 3: 345
  5. Pediment GD (2002) Comment on Ch. Bonner et al.: Fournier gangrene as a rare complication after stapler hemorrhoidectomy. Surgeon 73: 288
  6. https://www.aerzteblatt.de/nachrichten/97537/Diabetes-FDA-warnt-vor-Fournier-Gangraen-durch-SGLT2-Inhibitoren
  7. https://www.fda.gov/Drugs/DrugSafety/ucm617360.htm
  8. Kilic A (2001) Fournier's gangrene: etiology, treatment, and complications. Ann Plast surgery 47: 523-527
  9. McCormack M et al (2015) Fournier's gangrene: A retrospective analysis of 26 cases in a Canadian hospital and literature review. Can Urol Assoc J 9:E407-410
  10. Maguina P et al (2003) Split thickness skin grafting for recreation of the scrotum following Fournier's gangrene. Burns 29: 857-862
  11. Merino E (2002) Fournier's gangrene in HIV-infected patients. Eur J Clin Microbiol Infect Dis 20: 910-913
  12. Morpurgo E, Galandiuk S (2002) Fournier's gangrene. Surg Clin North Am 82: 1213-1224
  13. Nisbet AA, Thompson IM (2002) Impact of diabetes mellitus on the presentation and outcomes of Fournier's gangrene. Urology 60: 775-779
  14. Rouzrokh M et al (2014) Fournier's Gangrene in Children: Report on 7 Cases and Review of Literature. Iran J Pediatr 24:660-661
  15. Xeropotamos NS et al (2002) Fournier's gangrene: diagnostic approach and therapeutic challenge. Eur J Surg 168: 91-95
  16. Yılmazlar Tet al. (2014) Fournier's gangrene: review of 120 patients and predictors of mortality. Ulus Travma Acil Cerrahi Derg 20:333-337

Authors

Last updated on: 15.12.2022

Author: Prof. Dr. med. Peter Altmeyer

Co-Autor: Dr. med. Lydia König