Fournier’s Gangrene

Staphylococcus, Peptostreptococcus, B. fragilis, Enterococcus, and C. perfringens.101,104 E. coli is the most commonly isolated bacteria in Fournier’s patients, although the infectious process tends to be polymicrobial.99,100 Candidal infections have been reported to cause Fournier’s gangrene in immunocompromised patients.105

Clinical Signs and Symptoms

Typical symptoms of Fournier’s gangrene include scrotal swelling, pain, and fever. The average duration of symptoms prior to seeking medical care is 3–5 days. 84% of patients with Fournier’s gangrene have bilateral scrotal involvement.99 There is typically erythema and crepitus in the area of necrosis. There may be visible areas of gangrene or skin blistering as well. Nearly 10% of patients are unconscious on presentation. Sepsis can be seen in 43% of patients with Fournier’s gangrene, and there is a 50% mortality rate among patients with sepsis. More commonly, necrotizing fasciitis has a rapid onset with a fulminant course, although less commonly it can have an insidious onset and slower progression.100 Secondary complications of Fournier’s that portend a higher risk for mortality are respiratory failure, renal failure, septic shock, hepatic failure, and disseminated intravascular coagulopathy.101

Diagnostic Evaluation

Diagnostic evaluation should begin with a thorough history and physical examination. The diagnosis of Fournier’s gangrene is made by careful clinical evaluation. Diagnostic imaging can be helpful when the diagnosis is not clear from the clinical evaluation.6 Plain film radiography, scrotal ultrasound, and computed tomography (CT) may be helpful in uncertain cases if gas is identified in the tissues (18–62% of cases). Subcutaneous gas in the scrotum is the most useful radiological finding to aid in the diagnosis.106 Other helpful findings on imaging include scrotal wall edema with normal testicular and epididymal echotexture. This must be differentiated from an inguinal scrotal hernia with gas in the bowel lumen protruding into the scrotum.6 CT may be helpful by demonstrating asymmetric fascial thickening, subcutaneous emphysema, and fluid or abscess formation.107

A Fournier’s severity index to determine prognostic factors influencing survival has been constructed and validated. If the overall severity score is less than 9, the patient has a 96% chance of survival; whereas if the score is 9 or greater, the mortality rate increases to 46%.108 Prognostic factors included in the Fournier’s severity index include temperature, heart rate, serum sodium, serum potassium, serum creatinine, hematocrit, white blood cell count, and serum bicarbonate. The severity index may be useful in the