Fournier Gangrene in the Emergency Department: Diagnostic Dilemmas, Treatments and Current Perspectives

Abstract

Fournier gangrene (FG) is a rare and life-threatening urosurgical emergency characterized most often by a polymicrobial infection of the perineal, genital, or perianal region. FG has an increased incidence in male patients, patients with alcoholism, and patients with immunocompromise including human immunodeficiency virus (HIV) and uncontrolled diabetes. FG often begins as a simple abscess or cellulitis with progression to necrotizing soft tissue infection (NSTI). Delays in diagnosis and treatment confer high mortality. Early recognition and high clinical suspicion are important in making a timely diagnosis, as early manifestations are often subtle. The most significant modifiable risk factor associated with NSTI mortality is delay to surgical intervention. Coordination of both inpatient medical and surgical teams to implement appropriate therapy is vital to successful outcomes. The emergency medicine clinician must be vigilant for this condition and be aware of risk factors, prognostic indicators, and proper treatment protocols to recognize FG early and initiate appropriate management. The objective of this review is to provide updated and relevant information regarding recognition, diagnosis, and management of FG for the emergency medicine provider.

Keywords: emergency; infectious disease; necrotizing fasciitis; necrotizing soft tissue infections.

Figure 1

Physical examination findings of Fournier Gangrene. Note a large area of necrosis (white arrow) as well as soft tissue edema and erythema (yellow arrow).

Figure 2

Anterior-Posterior Radiography of the Pelvis. Note the diffuse scrotal swelling with extensive soft tissue gas formation (white arrows) tracking along the right groin (R). Case courtesy of Dr Ahmed Abdrabou. Fournier gangrene. Radiopedia.org; rID:30310. Available from: https://radiopaedia.org/cases/fournier-gangrene-5?lang=us.

Figure 3

Sagittal Computed Tomography (CT) Image of the Perineum. Note the subcutaneous and fascial emphysema tracking from the rectum throughout the perineum and scrotum (white arrows). Case courtesy of Dr Chris O’Donnell. Fournier gangrene - spontaneous perforation of rectal cancer. Radiopedia.org; rID: 16849 . Available from: https://radiopaedia.org/cases/fournier-gangrene-spontaneous-perforation-of-rectal-cancer?lang=us.

Figure 4

Point of care ultrasound image of the scrotum. Note the diffuse subcutaneous edema and subcutaneous gas adjacent to the testicles (white arrows). Case courtesy of Praveen Jha. Fournier gangrene. Radiopedia.org. rID: 18695. Available from: https://radiopaedia.org/cases/fournier-gangrene-1?lang=us.