Cath Lab Digest

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  A 52-year-old man presented to the emergency room with a 4-day history of scrotal pain, edema, and the rapid development of black, foul-smelling, moist lesions on his scrotum and penis. Blood values revealed an increased white blood cell count and an increased creatine phosphokinase consistent with necrosis of muscle tissue. A urologist saw the patient and quickly made the diagnosis of Fournier’s gangrene (FG).
  An uncommon but life-threatening urologic emergency, FG is an infectious necrotizing fasciitis that involves the perineum, genitalia, and perineal areas.¹ The onset is caused by a polymicrobial infection of aerobic and anaerobic organisms. Historically, FG has been seen primarily as a condition that strikes men; however, more recent evidence suggests that women are at increased risk of rapid spread of the condition to the retro peritoneum with fatal outcomes.²
  Usually, local trauma or instrumentation creates a portal that allows the skin flora to enter the subcutaneous tissue, which results in infection.³ Predisposing risk factors include diabetes mellitus, recent surgery, morbid obesity, trauma, HIV, Crohn’s disease, malignancy, IV drug use, and chronic steroid use.³
  Reported mortality rate for FG varies widely from 4% to 75%.¹
Patients with FG require a multidisciplinary team, including a urologist, general surgeon, internist, and wound care specialist. Multiple debridements in the operating room may be required to effectively remove all necrotic tissue. Large scrotal, perineal, penile, and abdominal wall skin defects may be present, requiring intensive wound care. Initially, dressing changes are performed frequently to assess the wound for further necrotic tissue and infection and drainage control. As the wound heals, granulation tissue increases and the risk for infection decreases so dressing change frequency can be decreased. As the patient becomes stable, wound care is usually continued in a tertiary facility or in the home health setting.

References
1. Marynowski M, Aronson A. Fournier Gangrene: Follow Up. eMedicine Emergency Medicine. Available at: http://emedicine.medscape.com/article/778866-followup>.
2. Czmek R, Frank P, Limmer S, et al. Fournier’s gangrene: is the female gender at risk? Langenbecks Surg. 2010;395:173–180.
3. Ribo JC, Boucher B, Merwarth D, Olive J. Case report: implications for a patient diagnosed with Fournier’s gangrene. WOUNDS. 2002;10(19):340–347.