Monday, April 28, 2008
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.....