Monday, April 28, 2008

Fournier's Gangrene

















It has been a while since I've seen a case like this one. An 83 year old diabetic male presented over the weekend with perianal pain, fevers, and a leukocytosis to 28,000. The surgeon on call performed an incisional drainage of a large abscess at bedside and intially he seemed to do well. WBC came down to 15 and fever curve improved. However, when I saw him this morning he seemed somnolent and his white count had bumped to 20k. Exam revealed several ominous pathonogmonic findings including a wide area of bruising and ecchymosis involving most of the gluteal skin, crepitus, and some skin changes over the base of the scrotum. I spoke to the surgeon from the weekend and apparently all these findings were new.

Fournier's Gangrene is a specific form of necrotizing fasciitis that afflicts the perineum. Classically, it involves the penis and scrotum and is usually described in textbooks as a "urological emergency". Jean Fournier was the eponymous French scientist who first described the disease in 1883. Nowadays, general surgeons get involved in more complicated Fournier's because often the underlying cause is related to a perianal/ischiorectal abscess gone wild. The tissue planes in the perineum and groin are all connected and the aggressive agents of destruction in necrotizing infections tend to spread along these planes unabated.

This is not a diagnosis you want. Not unless you're someone who would look forward to the idea of having your penis skinned as primary treatment. Because that's what often ensues. These patients all need to be in the OR as soon as you suspect it. The fundamentals of the surgery are quite simple: wide, extensive debridement of all non-viable or infected skin, fat, fascia, and muscle. The patient is usually left with large, gruesome wounds that can be very difficult to care for post-operatively.

My poor guy had one of the more extensive cases of Fournier's I've seen. Basically, the entire ischiorectal fossa (horseshoe abscess) was full of pus, deep to the necrotic skin and fat. Furthermore, the infectious process extended down into the scrotum and the right testicle was non-viable. Literally pounds of flesh were debrided and an orchiectomy was performed. I also had to excise most of the skin covering the scrotum and penis. Just a hideous, awful surgery. Finally, we turned him over so I could do a loop sigmoid colostomy to divert fecal contents away from the raw, exposed wound. It's going to be a long haul to get him through it all. Tomorrow I take him back for a second look, further debridement, lavage, etc.....

52 comments:

platensimycin said...

and mortality rate is nearly 80% when presented with septicemia.... no easy days for a surgeon and his patient.

rlbates said...

I saw a few of these as a resident. Happily, none in private practice. Not fun for anyone.

Buckeye Surgeon said...

Ramona... I actually have a plastic surgeon involved.... any ideas on wound coverage.... STSG versus flaps...

rlbates said...

Buckeye, it would depend ultimately on how much skin is missing and which deep layers. Also, on how loose the old guy's skin is. He might get lucky and be able to have a primary closure (think "lift"). That is always better than two wounds in a diabetic.

Dr. Val said...

Wow, I'm so sorry for that patient.

Sid Schwab said...

I only recall one case in my practice. Diabetic. I did the initial debridement and colostomy and sent him to where they had a hyperbaric chamber. (I admit it: I don't know for sure whether it works or not, but it's a good way to turf. On the other hand, they've advertised their service, including for necrotizing fasciitis. Funny thing is, whenever I've called them, they don't seem all that thrilled.) For whatever reason, he made it eventually came back for some final grafting (plastic surgeon) and colostomy closure.

Devorrah said...

I've started crossing my eyes when I check your blog for updates so I won't have to see that photo again! I feel so bad for the guy.

MedStudent said...

What was this patient's outcome?

Lou said...

I'm a nurse. The most "memorable" Fournier's patient I ever took care of was a man who had been found passed out by a roommate. The patient was lying in a tub of cool water to treat his fever. He was septic when he presented to the ED, but still of very sound mind once we got his fever down. He needed to be in surgery right then. I was shocked when the surgeon called me to the bedside to be a witness as he had the patient repeat what the patient had told him. He was refusing lifesaving surgery because he didn't want to have his "balls cut", not even if it was the only way to possibly save his life. He said "I'd rather be dead than have that surgery". After repeated questionings and confirmations of refusal of treatment, and having him sign forms to that affect, it took only about five hours (despite the most aggresive non-surgical treatment we could offer) for the infection to overtake his system, and for him to arrest and ultimately to die. He was only 40. It was horrifying for all involved.

This was the first time that I saw a refusal of treatment form state that the only outcome if the recommended treatment was refused would be "DEATH".

Buckeye Surgeon said...

Patient on the floor, eating everything in sight. Possibly might get skin grafted next week.

Anonymous said...

we thought he's diabetic....

Buckeye Surgeon said...

Anon-
He is. Diabetics are able to "eat everything in sight" just like you and me. You put him on a 2200 kcal ADA diet and watch him clean his plates. Diabetes isn't a disease that puts one on a starvation diet. As long as blood sugars are appropriately monitored and controlled with a combination of dietary measures and insulin, there isn't a problem....

Anonymous said...

oh i see; thanks for the clarification. my parents are both diabetic and i am likely to become one in far future. they have been on this silly dietary restriction for a great portion of their lives; that makes dinning in that much less interesting and dinning out almost an impossibility. the flip side is that they haven't suffered much from complications for the past 2 decades. great blog here, doc.

Nurse Bear said...

My very first patient on the first floor i've worked on had Fournier's. Approximately 80 year old male; our wound team was doing water pic treatments daily. I remember very vividly that all of the tissue had been cut away from his testicle; i'd never seen an exposed organ in a semi-private hospital room before. Very painful for the patient, and unpleasant all around.

Anonymous said...

my husband had fournier's back in december he is only 28, but admittedly overweight. he only had a single debridement and was treated via a hyperbaric chamber as well. unfortunately he continues to have problems with his surgery site now that it has "healed" he ahs had a single abcess fill and split open his surgery site on the scar line and now has recurrent "bursts" in which only large blood clots come out they have have done colonoscopies and found nothing and in two weeks will be putting a scope into his urethra to see if there are any fistulas reseeding his problems. I hope all goes better for your patient, we were never told to expect any of this....

Rose said...

My husband is in Maryland Shock Trauma right now with Fournier's. The pic in this article does him no justice. His genital area was easily the size of a cantaloupe. He was initially dx with a UTI. After 2 days of treatment the swelling and fever worsened and he was sent to the local hosp who almost immediately sent him to Shock Trauma. He had emer surgery in which they removed 400cc of infected fluid. He also lost his left testicle and the doctor initially said there was a 99% chance of losing the right and of getting a colostomy. That was Thursday night (6/12/08). They were supposed to go right back into surgery Friday morning to remove more necrotic tissue and do the colostomy. The doctor checked it Fri am and felt that it was clean enough to wait until Monday. They are also letting him eat something today, not sure what so I'm guessing the colostomy is not going to happen. I assisted the nurse in changing the dressing and packing yesterday so I knew what I was getting into when he comes home. The wound is all around his penis, both above and below. He has lost all of the scrotum and there is also a wound area on his right buttocks. He had necrotizing fasciitis in 1999 and has continued to have small recurrences of that when he has an injury of some kind to the same area (in that case his left buttocks). I wonder how much that has to do with this new problem.

Anonymous said...

My father is at the hospital at the moment getting treated for this it is so hard to see him crying from the pain. Does anyone know how long the healing process is ?

Anonymous said...

My mother also has been in ICU for almost 2 weeks now in critical condition with FG. I also would like to know if anyone has any idea of how long the healing process is. She had emergency surgery day 1, and 3 depriedments since. They just took her off the vent a day ago, She is just 60 years old.

Buckeye Surgeon said...

It can take months for the wounds to heal...depending on the extent of non-viable tissue that was intially debrided.

Anonymous said...

My dad is in the hospital right now. He's not a diabetic, not obese, however he is an alcoholic. How does alcoholism cause this awful infection to occur?

Anonymous said...

Totally unrelated to this particular post, but I was wondering if you'd be my gynecologist.

Damn.

NotANurseWife said...

My 46 year old husband has it right now (had his birthday in the hospital). He went to his general surgeon to have what was a recurring abscess drained; he drained that in his office, but sent him to the hospital that day. They put him on antibiotics overnight, with no thought to operate. (Later, the doctor indicated that these were 2 seperate infections) However, they operated the next morning, removing most of his scrotal bag; his penis is unaffected. He was in the hospital for 10 days until United Health Care said he couldn't stay anymore. They offered "extended care" at another facitily or Home care. (At first, UHC denied this treatment because the "wound was not severe enough!!) We went to the Extended care facility, and knew immediatly he would not be getting the care he needed. He is now at home. We give him Flagyl 250 mg pill every 6 hours and administer IV ampicillin sulbactum every 6 hours (we are just starting day 2) We keep the wounds covered but wet with Hydrogel packing,changing it once a day. He is able to have a bowel movement without endagering the area, but he was afraid to each much for the first week. The doctors have indicated a 2 step surgery, with possible plastic surgery for the second step. Any suggestions I might pass onto our doctor?

Buckeye Surgeon said...

notanurse-
Sounds like the plan for your husband is appropriate. Wish I had a magic formula for you. This problem takes time and patience. Good luck.

platensimycin said...

notanursewife -
sorry to hear what you and your husband are going through; hang in there!

Anonymous said...

i am 55 years old in september
I went to the er did emergency surgery for fournirs gangrene of the soctrum and rectal, 3 surgery all together, i am now recoperating
at home with a visting nurse.

healing is slow, but healing good
our question is
what happen to the exposed testicle
does it sink in and new tissue grows over to cover it or whould i need a skin graftingas the nurse says my dr. say it should heal by itself in time any comment?

Anonymous said...

My 51 y/o uncle recently had emergency surgery for Fournier's Gangrene. The debridement was quite aggressive. Tissue was taken from the abdomen, genital area, as well as the buttocks. In your experience, how long is the hospital stay for an advanced case of FG? Is it 2-3 months, or more? (I realize that all cases are different but I just wanted to know what your experience of the timeline has been.) He's out of the ICU and seems to be making steady progress.

Anonymous said...

My husband had fournier gangrene in2006. He was wonderful through it all. We learned to "pack" the wound area with Morphine and lydocaine the gauze was soaked in. WHAT a release from pain for him. I packed his wound area AND made sure his buttock was given a lotion to keep from irritation. He developed a fistula and passed away in May. He was a wonderful fighter. He also got colon rectal cancer. BOTH and his courage was an insperation for all the kids and myself. We were told he would never heal. He didn't.

Anonymous said...

yesterday i oerated a case of forniers gangrene dr prakash delhi

Tim said...

My dad (84)is in the hospital now with Fournier's. It is a little complicated but he had been admitted a week earlier for hallucinations, fever, and high WBC. His abdomen was very distended and they inserted a rectal tube for decompression and left it there for "fecal management". A week later to the day they tell us he has a serious wound on the scrotum, and he now has a huge gaping wound from his scrotum to anus after surgery to open & clean the infection.Is FG hard to see before it gets to this point? Just wondering.

Anonymous said...

my husband is a diabetic and had gotten Fournier's Gangrene as a result from an infection on his perinium. The gangrene was on his scrotum and one of his testicles. He had gone sepsis by the time we got to the er. They did emergency surgery. He had to have a colostomy and a skin graft. After about 2 months, he is doing much better and we are taking better care of his diabetes and making sure this does not happen again.

Anonymous said...

i am still recoveing from fourniers gangrene, from sept of 2008 my wound are almost hearled except i am still draining after 6 months and i had a fistaula plug put in 3 weeks ago to stop the drainage i had from my absess in step
my urogist plans to do more surgery on my srotum in spet if the drainage still draining unless
i decide to have it done earlier

this will be 8th surgery since sept of 08

as anyone else have a drainage after 6 months and any comments
tim

Anonymous said...

Is the gangrene contagious can it be contracted from using toilet facilities from an infected individual.

platensimycin said...

Fournier gangrene, or any gangrene, is not contagious by touch. Universal precautions (washing hands, wearing protection gears and so forth) are often indicated for the patient's sake and for your sake.

Anonymous said...

That is in deed the scariest thing ive ever seen. Can this dude still ejaculate??? God, help him.

Anonymous said...

I had fourniers gangrene back in september of 08 of the strotum and
abcess of the butt. it took over 6 weeks to heal and has not stoped
draining yet


i am going in on thursday for
a strotum explority surgery,
with strotumpltsy due too i', still
dripping from the incession on the bottom of the strotum.last week the
testicle has droped down from the
pouch the surgeon made and now is
in my strotum where it was originally not sure if this can cause a problem or not

also have a fistolcmpy done at the dame time 2nd time

any with an suggestion etc.

dr. porwal sanjay said...

i have experience of many such cases. i am preparing a list. i do wound excision,plan antibiotics iv,daily dressings with hydrogen peroxide and povidone iodine 5%;secondary closure is done later on. i have record of only 1 mortality,that too within a day.

em-xiah said...

caelp me about this Fournier's gangrene? im doing a case study about. a requirement in my course, nursing. :) anybody who would want to help can send me messages thru my mail. thanks! nicklejaiz21@yahoo.com

Anonymous said...

My Grandmother had Fourniers Gangrene. When she was taken to the hospital, they flew her to Cox's Hospital on Springfield Mo. After repeated surgeries, respatory failure followed by all of her other systems shutting down, she passed away. One of the nurses in the ICU said that it was the worst case she had ever seen. The doctors did everything possible including the hyperbaric treatments. She was 71 years old.

Anonymous said...

that is sofa king disgusting.

Anonymous said...

I'm 36 and this is very scary!

I have not been diagnosed yet, but the symthoms are just what I find on he Internet. I'm at the hospital recovering from a pyeloplasty, ureter surgery, and since yesterday I have this black wounds growing up in my scrotum.

My doctor didn't give importance to it, I'm waiting to talk to him today.

Sigh..

Anonymous said...

My brother was 28 years old when he was diagnosed with this disease. It was caused from kidney stones and scar tissue blocking and trapping urine in the urethra. After an eight hour surgery and two month hospital stay he came home. He was given a 20% chance to survive.
During the surgery the doctor had to remove his urethra, bladder and scrotum. He had to have a new bladder built out some of his large intestine. To this day he has to cath himself to urinate.

goobercat said...

My name is brian laird and I would like to tell you my story. In january of 2007 I started to have pain on my butt.Went to the doctor and was told nothing was wrong. I am a diabetic and my blood sugars were getting very hard to control and I had a fever. gave me keflex and dismissed me. Two days later my tasticles were the size of grapefruits and I was in agony. Still went to work and worked a 16 hour shift at work. When I was done I could hardly breathe my heart was racing I couldn't stop shaking. I went home on the subway(in Boston) I collapsed before I could get home. Yhey called an ambulance. the emts showed up and started to freak out. My temp was 105.2, my blood pressure was 60 over 4o and my heartrate was 220. They rushed me to Mass General hospital.They took one look at my scrotum and rushed me to cat scan. They did blood work and tolg me I had sepsis and was in septic shock. The doctors came back with two surgeons and told me I was going up for sugery in 15 minutes. The last thing I remember was signing the consent for the anasthesiologist and eas told it was going to be a four hour surgery. I was told I was in surgery for 9 hours and that my blood pressure bottomed out twice. I was the put in amediclly induced coma for 38 days. I also woke up with colostomy. Luckily I kept my scrotum and my penis. It took a year and a half for it to heal.I then got my clostomy reversed. Please, if you are a diabetic, if you have any pain in that area, GO TO THE ER!!!!! thank you drs. Mennici,Johnsen(TAKK), and Hurst.

Anonymous said...

Well, I think I'm very lucky after reading the comments.

I had FG in September 2008 on vacation in Quebec City. Woke up one morning in shock with sores around my rectum and testicles. Wife got me to ER and was told that I needed surgery immediately. Debridment, colostomy, debridment, debridment, debridment (4 surgeries total) placed in a burn unit to prevent infection and given massive intravenous antibiotics.

Day 8, back in surgery to apply VAC dressing on complete wound.

Day 14, was flown back to Ottawa by insurance company and transfered to the General Hospital in Ottawa.

For the next 3 months, VAC changes every 2 days and antibiotic intrevenous every 6 hours. After 3 months, everything was cured.

I was on pain killers only for the first 10 days and although the VAC dressing was awkward, I was able to walk around the hospital.

Today I'm completely OK, no plastic surgery, colostomy has been reversed and I'm fine.

What did the trick (I think) was the quick action by the Doctors in Quebec and the incredible performance of the VAC dressing. What a great tool to help in replacing the skin that was removed during debridment.

BTW, I am not diabetic and in relatively good shape.

Unknown said...

My brother is in Souix City Iowa right now and I've been told he's got this. e's a 54 male. He was being seen by his PA on tuesday the guy squeezed the absess on his rectum and told him to come back on friday and they would lance it. The pain was so bad he went to the ER on thursday night. Thank God they knew what he had and took him into surgery right away. He's been debrided again and he's lost a testilce. I'm very sad for my brother but so praying he'll live. He is on a ventilator and doesn't really know anything that has happened. But he's due to go for more debriding today. It is so hard being so far away, I'm in Az. They say he will be in intensive care for a week and then he will be in the hospital for another month as it stands right now. Thank you for any comments or encouragement.

Pyemae said...

I was diagnosed with Fourniers Gangrene recently and would like to share my experience.

I have Crohns Disease and the treatment for this made me immuno-suppressed and thus susceptible to infection. I developed an abscess in the perineum in early Aug 2011. Basically I had swelling around my urethra but I didn't know what it was.

I went to my Gastroentorologist (GE) Consultant thinking it was a flare up of my Crohns. He sent me for an 'inspection under anasthetic' in Sept, which was completed by a Colorectal Surgeon. He put me on a steroid enema to help reduce the swelling. The GE started me on a course of Infliximab. All these drugs did nothing to reduce the swelling, which by Dec had increased and I was taking 3 difene/day for the pain and in bed by 8pm every night. I just thought life was hard holding down a job and raising a baby and toddler. I never considered the fact that my Doctors had all misdiagnosed my condition. They were treating my Crohns with immunosuppressant drugs, instead of antibiotics for a simple abscess.

Anyway, a few days after Christmas the pain escalated and I went to A&E. They finally diagnosed a swelling of the urethra and said I had some bruising under my scrotum, asking if I had an impact there recently, which I didn't. The packed me off with an antibiotic and painkillers. Another lost opportunity to recognise the seriousness of my condition.

2 days later I was back in A&E because my scrotum had swollen to the size of a coconut, gone black and hard and was really painful. They did a CT Scan, blood tests etc and diagnosed Fourniers Gangrene. I was rushed to a larger hospital in Dublin by ambulance and was operated on that night.

In all I was in theatre 7 times in 2 weeks for debridements, wound dressing changes and skin graft. I had my scrotum removed, testicles remained intact and i didnt need a colostomy. I spent 30 days in hospital and I spent another 6 weeks recovering at home. The skin graft over my testicles is very slow to grow. I am not that keen on the idea of a skin flap where they take skin from your thigh and fashion a new scrotum! My balls sit very high as they recede during the healing process. Maybe in time they will sit lower.

My situation could have been a lot worse as I know the mortality rate is high, however this could have all been avoided if I had been treated correctly in the first place. Otherwise, I'm a very healthy 37 y.o. Olympian and I had an underlying condition which led the doctors off on the wrong diagnosis path.

So my suggestion to you is, don't accept the perceived wisdom of your doctor, get a second or third opinion, and if you have what looks like unexplained bruising, get it looked at immediately. Hours matter when this disease sets in.

AUTHOR KRISTINE CHENEY said...

I need help for my husband. He has suffered from the aftermath of Fournier Gangrene since 2004 and our lives have been Hell ever since. We have no health insurance and no ability to help him. He's has 5 surgeries and is in need of more debridement because he still has at least 2 abcess outbreaks a year (and is going through it again right now), which is agonizing torment for him. Are there any foundations or facilities that offer financial assistance for treatments to restore his life back to him? We are in Phoenix, Arizona. I appreciate any suggestions. God bless you.

Kristine Cheney
tisatrix@cox.net

Anonymous said...

Working on yet another Fournier's case at a university hospital. These actually if treated super aggressively do fairly well. It's a month long road of course, and loads of skin grafts, debridements, and the like, but I've had 3 patients go home and this is the 4th I'm working on. From an ICU nurse's perspective let us do the intensive dressing changes, we're really good at it! : )

Anonymous said...

My manfriend went to the Dr. on Thursday, May 17, 2012 because he had developed a boil that with hot compresses was not going away. The Dr. lanced it. Manfriend had to go back on Friday to have it checked and was driven in an ambulance to the hospital. They were getting ready to take him to surgery by the time I got to the hospital. After surgery, the surgeon told me he had F. G. and that he may lose a testicle and perhaps his penis. So far he has not lost his privates but has had 3 debridements and is facing skin grafts tomorrow.

Anonymous said...

Just heard my uncle was taken to the hospital with a flesh eating bacteria in his genitals. I couldn't get a lot of information but upon researching online, found this blog/post.

My uncle is morbidly obese (in the 550's or more) and has Type II Diabetes. He's had his testicles become the size of grapefruits previously but he got better on his own.

However, recently, he was very ill, dizzy and had to be taken to ER where they did surgery. They told him if he had waited 1 more day, he'd be dead. I stumbled upon Fournier's Gangrene when I googled flesh eating bacteria of the genitals.

I was scared silly when I heard this. He signed a DNR form if he goes downhill - he is only 55 but is tired of....well, everything. :(

Anonymous said...

I have been diagnosed with epididymytis in the left testicle. Had this pain before, but this has been different. I have lost everything in my life and resorted to smoking crack cocaine, on top of that I have candida and suffer from a spinal injury. My testicles were going numb for a few days with swelling in pubic area, right where my hernia surgery was done last april. I have not been using the bathroom right, and my stool looks odd. I was prescribed doxy, but my genitals, anus, stomach hurt. Small sores have developed on the glans of my penis, unable to get an erection, maybe due to pain? When I went to the e.r and told them about fourniers gangrene they didnt even look into it. I had trapped gas from the drugs, and now I am concerned my organs are shutting down. All craziness, I know, my life has been just that, that is why I feel death this time is deserving. I am on day 5, I get chills, pains behind left hip, I am also a kidney donor as well. Any advice would help, and I know, dont do drugs. This time of my life has been the worst, suicide was contemplated many times, I just may of done it with this afterall. My body is going through something. I guess, through all this, should I go back to the e.r and get tested, and if so for what to determine my condition. I have no outer discoloration as of yet, and my swelling has gone down. Still in a deal of pain, I feel septic, could just be my nerves? Any help would be appreciated

Anonymous said...

I am a 54 year old male with well-managed diabetes and my health is generally quite good. I spent two days in bed feeling very tired and very dry. I kept drinking fluids and sleeping but after two days went to hospital (Elliot Lake, Ontario) Dec. 23/12. The physician indicated my temperature was up and it was clear I was fighting an infection of some type however after much palpating, etc. could not find the source. He recommended I return home and continue with fluids and sleep but to return immediately if new symptom occurs. The next morning I noted swelling and some pain in my scrotum, however no colour changes. I returned to the hospital on Dec. 24 and was prescribed penicillin and an OTC pain killer. The next morning I noted significantly increased swelling (larger than a grapefruit), colour had changed to black and blue with blood oozing out and blood in urine. I reasoned that I had only had two servings of penicillin by this point and it needed more time. Things didn't improve on the 26th and I called an ambulance on the 27th. When the emergency room doctor saw the scrotum and penis he ordered immediate surgery. The surgery was conducted and the surgeon must have done an excellent job removing bad tissue, etc. I required one more surgery after about 8 days in ICU to remove any remaining bad tissue and was home two days later with home care. Seven weeks later, my testicles have both ascended (about three weeks ago) and the wound appears to be healing without skin graft. This is far beyond the expectation of my surgeon and if the wound seals on its own then I'll count myself extremely lucky and the beneficiary of excellent surgery and follow-up. Does anyone know if it is likely the testicles will descend again?

Anonymous said...

Further to my above comments from Elliot Lake, I was able to return to full-time employment on March 4 (and that's only because my HR Department held me back two weeks.) I was work-ready after 7 weeks and got there after 9. Skin graft consultations were cancelled as the wound is almost fully healed. I attribute my success to my surgeon, ICU and Home nurses. My Doctor ascribes much to my attitude. My surgeon is very confident the testicles will descend once the healing is completed so end result will be a smaller scrotum with everything else working fine.