Rigi10™ Malleable Penile Prosthesis
Also Known As
Necrotizing fasciitis of the perineum, Genital necrotizing fasciitis, Perineal necrotizing fasciitis, Streptococcal gangrene of the scrotum, Idiopathic gangrene of the scrotum, Fournier disease, Meleney ulcer (sometimes used broadly for necrotizing infections, though more specific to a type of synergistic gangrene), Synergistic necrotizing cellulitis of the perineum.
Definition
Fournier gangrene is a rare but rapidly progressive and potentially fatal form of necrotizing fasciitis that affects the perineal, genital, or perianal regions. It is characterized by a polymicrobial infection that leads to thrombosis of the subcutaneous blood vessels, resulting in gangrene of the overlying skin and subcutaneous tissues. The infection spreads along fascial planes, often leading to widespread tissue destruction and sepsis if not promptly and aggressively treated. While it can occur in otherwise healthy individuals, it is more commonly seen in patients with underlying immunocompromising conditions, such as diabetes mellitus. The condition was first described by Jean Alfred Fournier, a French venereologist, in 1883, initially as an idiopathic gangrene of the penis and scrotum in young men, but it is now understood to have identifiable causes in most cases, often originating from anorectal, urogenital, or cutaneous sources. The primary purpose of recognizing and defining Fournier’s gangrene is to facilitate early diagnosis and prompt, aggressive surgical debridement combined with broad-spectrum antibiotics and supportive care, which are crucial for improving patient outcomes and reducing mortality. The infection involves a synergistic action of aerobic and anaerobic bacteria, which produce enzymes that cause tissue destruction and impair local blood supply, leading to necrosis. The rapid spread of the infection, sometimes as fast as an inch per hour, underscores the urgency of intervention.
Clinical Context
Fournier’s gangrene is a severe and rapidly progressing necrotizing fasciitis that primarily affects the perineal, genital, and perianal regions. It is considered a surgical emergency requiring prompt and aggressive intervention. Clinically, Fournier gangrene is often seen in patients with predisposing conditions such as diabetes mellitus (the most common comorbidity, present in 20-70% of cases), chronic alcohol abuse, immunosuppression (e.g., HIV infection, chronic steroid use, chemotherapy), peripheral vascular disease, obesity, and local trauma or infection.¹ The infection typically originates from an anorectal source (e.g., perianal abscess, anal fissure), a urogenital source (e.g., urethral stricture, urinary tract infection, indwelling catheter), or a cutaneous source (e.g., skin infection, hidradenitis suppurativa, minor trauma to the perineal area).¹
Patient selection for aggressive treatment is broad, as any patient presenting with signs and symptoms suggestive of Fournier gangrene should be considered for immediate intervention. These symptoms can include severe pain and tenderness in the affected area (often disproportionate to visible skin changes), swelling, erythema, crepitus (a crackling sensation due to subcutaneous gas), fever, chills, and signs of systemic toxicity such as tachycardia, hypotension, and altered mental status.¹ Early diagnosis is crucial, as delays significantly increase morbidity and mortality. The mortality rate for Fournier gangrene remains high, reportedly ranging from 20% to 40%, and can be as high as 88% with delayed treatment.¹
The cornerstone of management is early and aggressive surgical debridement of all necrotic and infected tissue. This often requires multiple operations. The surgical procedure involves wide excision of all non-viable skin, subcutaneous tissue, fascia, and sometimes muscle, extending until healthy, bleeding tissue is encountered.¹ Testicular involvement is relatively rare due to their separate blood supply, and orchiectomy is usually not necessary unless the testes are directly involved in the necrotic process.¹ In cases of extensive perineal involvement or fecal soilage, a diverting colostomy or fecal management system may be necessary to protect the wound and facilitate healing.¹
In addition to surgical debridement, patients require broad-spectrum intravenous antibiotics, typically a combination covering gram-positive, gram-negative, and anaerobic organisms. Empiric therapy often includes a carbapenem or piperacillin-tazobactam, clindamycin (to inhibit toxin production) and vancomycin (to cover MRSA).¹ Antibiotic therapy is later tailored based on wound and blood culture results. If needed, hemodynamic support with intravenous fluids, vasopressors, and correction of electrolyte abnormalities and hyperglycemia are also critical management components.¹
Expected outcomes depend heavily on the speed of diagnosis and intervention, the extent of the disease, and the patient’s underlying comorbidities. Patients who undergo prompt and aggressive debridement have a better prognosis. However, even with optimal treatment, Fournier gangrene can lead to significant morbidity, including extensive tissue loss requiring complex reconstructive surgery (e.g., skin grafts, flaps), chronic pain, sexual dysfunction, fecal or urinary incontinence, and psychological distress.¹ The recovery timeline can be prolonged, often involving multiple surgical procedures, extended hospital stays, and long-term wound care. Success rates, in terms of survival, have improved with modern surgical techniques and critical care, but the condition remains life-threatening. Early recognition and a multidisciplinary approach involving urologists, general surgeons, plastic surgeons, infectious disease specialists, and critical care physicians are essential for optimizing outcomes.¹