Fourniers Gangrene

Question 1

What is fourniers gangrene?

Answer 1

• Necrotising fasciitis that affects perineum
• Urological emergency
• Can be mono or polymicrobial

Question 2

Necrotising fasciitis - what is it?

Answer 2

Rapidly spreading necrosis of subcutaenous tissues and fascia

Question 3

Causative organisms of fourniers gangrene

Answer 3

• Group A streptococcus - eg streptococcus pyogenes
• Clostridium perfringens
• Escherichia coli

Question 4

Anatomical barriers to the spread of fourniers gangrene

Answer 4

• Dartos fascia of penis and scrotum
• Colles fascia of perineum
• Scarpa fascia of anterior abdominal wall
• SO testes and epididymis often unaffected by fascitits

Question 5

RF for fourniers gangrene

Answer 5

• Diabetes mellitus
• Excess alcohol intake
• Poor nutritional state
• Excess steroid use
• Haematological malignancies
• Recent trauma to region - protective outer layers to perineum breached

Question 6

Symptoms of fourniers gangrene

Answer 6

• Severe pain out of proportion to clinical signs
• Pyrexia
• Non-specific - not quite right for simple cellulitis

Question 7

Signs on skin of fourniers gangrene

Answer 7

• Creptitus
• Skin necrosis
• Haemorrhagic bullae
• Sensory loss on overlying skin
• Rapid deterioration and become very unwell –> septic and septic shock

Question 8

Investigations for fourniers gangrene - bedside and bloods

Answer 8

• Diagnosis usually clinical - suspected cases should go straight for surgical exploration
• FBC, CRP, U&E, LFT, clotting
• HbA1C - underlying diabetes?

Question 9

CT signs of fourniers gangrene

Answer 9

• Less specific and should NOT delay surgical intervention but:
• Fascial swelling and soft tissue gas

Question 10

Risk scores for necrotising fasciitis

Answer 10

• Laboratory risk indicator for necrotising fasciitis (LRINEC)
• Based on lab factors, score 6 or more reasonable to consider diagnosis with results alone

eg Hb, CRP, WCC, Na, Crt, glucose

Question 11

Management of fourniers gangrene

Answer 11

• Urgent surgical debridement - often extensive, may involve orchidectomy
• Debrided tissue sent for MC&S
• Pus sent for fluid MC&S too
• Abx - broad spec
• Transferred to high dependency setting
• Further surgical looks and debridement are needed until completely free of necrotic tissue

eg Meropenem/Tazocin

Question 12

Management of wound created by surgical debridement

Answer 12

• Secondary closure with skin grafts
• Long process to early involvement of Plastic surgeons needed