Fournier's gangrene in diabetic and renal failure patients.

Abstract

To report our experience in the management of 9 patients with Fournier's gangrene seen in our institute, to identify the most common prognostic variables in our patients, and to evaluate the outcome of aggressive management in patients with Fournier's gangrene.
We reviewed the medical records of 9 patients admitted to King Abdul-Aziz University Hospital (KAUH) in Jeddah, Kingdom of Saudi Arabia from November 1999 until November 2002. Their age, sex, clinical presentation, predisposing factors, microbiology testing, management and prognosis were studied.
Nine male patients were diagnosed and treated. The mean age was 68 years, 6 patients (66.6%) were diabetics and one of them had renal insufficiency not requiring dialysis, while 3 patients were on regular hemodialysis. Bacterial culture results revealed a single organism in 44.4%, and more than one organism in 55.6% of the cases. No anaerobes could be cultured, and one patient had Candida albicans. All patients had temporary suprapubic catheter diversion while stool diversion by colostomy was required in only one patient. In 7 patients, aggressive debridement and parental antimicrobial were successful to eradicate the infection, whereas 2 patients (22.2% of the cases) died of uncontrolled sepsis.
Fournier's gangrene is a very serious disease, understanding the criteria of early recognition of the disease, referral to the specialist, and aggressive debridement with the use of appropriate antimicrobial therapy will improve the outcome of the patients and decrease the mortality rate.

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than one organism in 55.6% of the cases. No anaerobes could
be cultured, and one patient had Candida albicans. All
patients had temporary suprapubic catheter diversion while
stool diversion by colostomy was required in only one patient.
In 7 patients, aggressive debridement and parental
antimicrobial were successful to eradicate the infection,
whereas 2 patients (22.2% of the cases) died of uncontrolled
sepsis.
Conclusion:
understanding the criteria of early recognition of the disease,
referral to the specialist, and aggressive debridement with the
use of appropriate antimicrobial therapy will improve the
outcome of the patients and decrease the mortality rate.
Fournier’s gangrene is a very serious disease,
Saudi Med J 2003; Vol. 24 (10): 1105-1108
ournier's gangrene is a necrotizing soft tissue
infection, usually highly lethal. In 1764 Baurienne
and then in 1983 Fournier described idiopathic rapidly
progressing necrotizing fasciitis of the penis and the
scrotum in 5 otherwise, healthy young males as
idiopathic cases.1,2 Further international reports can no
longer consider Fournier's gangrene as idiopathic. Cases
have been reported in patients with renal failure, diabetes
mellitus (DM), alcoholics,
immunosuppressed individuals,
hospitalization, malnutrition, malignancy, after penile
self injection with cocaine, Varicella infection,
transrectal biopsies and vasectomy.2-6 Fournier's
gangrene may occur at any age.7,8 Fournier's gangrene is
debilitated,
prolonged
F
ABSTRACT
Fournier’s gangrene in diabetic and renal
failure patients
Abdulmalik M. Tayib, FACHARTZ, FEBU, Hisham A. Mosli, FRCSC, FACS, Mohamed H. Abdulwahab, MBBCh,
Mahmoud A. Atwa, MD, FACS.
a rapidly spreading bacterial infection that accounts for a
relatively small proportion of infections, but is
aggressive in nature and nearly uniformly fatal if
untreated. Patients usually present with scrotal swelling,
skin necrosis, hyperemia, fever and there may be a
subcutaneous crepitus, foul smelling discharge, black or
green plaques, and shock.2 Eke9 reviewed 1726 world
wide reported cases through the medline database and
relevant references lists in publications from January
1950-September 1999. This review revealed that
Fournier's gangrene occurs worldwide, most reported
cases are in United States of America and Canada. The
major sources of sepsis were the local skin, colon, anus,
rectum, the lower urinary tract, colonic and rectal
Objectives:
9 patients with Fournier’s gangrene seen in our institute, to
identify the most common prognostic variables in our patients,
and to evaluate the outcome of aggressive management in
patients with Fournier’s gangrene.
To report our experience in the management of
Methods:
admitted to King Abdul-Aziz University Hospital (KAUH) in
Jeddah, Kingdom of Saudi Arabia from November 1999 until
November 2002. Their age, sex, clinical presentation,
predisposing factors, microbiology testing, management and
prognosis were studied.
We reviewed the medical records of 9 patients
Results:
The mean age was 68 years, 6 patients (66.6%) were diabetics
and one of them had renal insufficiency not requiring dialysis,
while 3 patients were on regular hemodialysis. Bacterial
culture results revealed a single organism in 44.4%, and more
Nine male patients were diagnosed and treated.
From the Department of Urology, King Abdul-Aziz University, Jeddah, Kingdom of Saudi Arabia.
Received 18th May 2003. Accepted for publication in final form 22nd June 2003.
Address correspondence and reprint request to: Dr. Abdulmalik M. Tayib, Assistant Professor and Consultant, Department of Urology, King Abdul-Aziz
University Hospital, PO Box 80205, Jeddah 21589, Kingdom of Saudi Arabia. Tel. +966 (2) 6408440. Fax. +966 (2) 6408347. E-mail: srraaams@hotmail.com

1105

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1106 Saudi Med J 2003; Vol. 24 (10)www.smj.org.sa
Fournier’s gangrene ... Tayib et al
sources were shown to carry the worst prognosis, and the
diagnosis is made usually on clinical grounds.
Urethrogram and proctoscopy are important in the
evaluation of all patients with Fournier's gangrene to rule
out massive urinary extravasations
suprapubic diversion, or to reveal the source of infection,
as well as the extent of anal and rectal involvement to
determine the need for
Ultrasound, computerized tomography (CT) and
magnetic resonance imaging (MRI) may play a role in
the early diagnosis of Fournier's gangrene and in
determination of the extent of the disease as they can
detect subcutaneous gas and define the source of the
infection which helps in planning debridement.10-12 Early
aggressive debridement and the systemic administration
of antimicrobials are essential measures in improving the
success rate of the treatment.9
necessitating
diverting colostomy.2
Methods. The charts of all patients with Fournier’s
gangrene admitted to King Abdul-Aziz University
Hospital (KAUH) in the period between November 1999
until November 2002 were reviewed. The data collected
included the date of birth, sex, site of the infection, time
before presentation to KAUH, clinical presentation, and
predisposing factors. All bacteriological results,
antibiotics used, suprapubic catheters, description and
number of debridement sessions required for each
patient, necessity for orchiectomy, colostomy for stool
diversion, and pathology results were also reviewed.
The data collected included the need for further plastic
surgery, and the length of hospital stay, methods used to
screen the patient for any urological, or recto-anal
pathology such as ascending urethrogram, proctoscopy
and CT scan of the pelvis and perineum to evaluate the
extent of such disease. The outcome of the management
was also evaluated.
Results. Nine patients were diagnosed and treated for
Fournier’s gangrene over 3 years. The mean age was 68
years old, all patients were admitted from the emergency
room and all the patients were males. We considered
delayed presentation to be 5 days or more from the start
of the evidence of the disease, 2 patients presented early,
while 7 patients presented late 5-8 days from the start of
the illness, the mean was 6 days. Three of the patients
(33.3%) had concomitant renal failure, 6 patients
(66.6%) with DM one of them with renal insufficiency,
one patient had heart failure, and 3 patients were
smokers. All patients presented with strong offensive
foul smelling odor of the scrotum or the perineum,
scrotal swelling, while 7 patients presented with both
scrotal and perineal swelling (77.7%), and in 5 patients
the penis was also involved. Six patients (66.6%) were
febrile with attacks of chills at the time of presentation,
2 of them had uncontrolled sepsis, while crepitation
underneath the scrotal and perineal skin was founded in
4 cases. Ascending urethrogram was required in 3
patients with a severe urethral stricture; proctoscopy for
all 7 patients presenting with perineal involvement was
normal. Computed tomography scan of the pelvis and
perineum was required in 3 cases (33.3%) with
extensive perineal involvement (Figure 1). Swabs from
the gangrenous or necrotic tissue and from the discharge
taken preoperatively and postoperatively, all cases
showed definite organisms, 4 showed growth of
Escherichia coli (E.coli), while 2 patients with
Staphylococcus aureus and E.coli, one with Klebsiella
and Streptococci, one with Staphylococcus hemolyticus
and Klebsiella, and one with Candida species (Table 1).
Suprapubic urinary diversion was performed in all cases
while stool diversion by temporary colostomy was
performed in 2 cases. All gangrenous and necrotic
tissues were aggressively debrided in all cases within the
first 12 hours of presentation; orchiectomy was only
required in one patient. Antimicrobials against gram
positive, and gram negative, and anaerobes were
commenced for all patients in the emergency room using
intravenous second generation cephalosporin,
Figure 1 - Extensive Fournier’s gangrene of the penis, scrotum and
perineum.
Bacteria, fungal
E.coli
Staph.aureus, E.coli
Klebsiella, Streptococci
Staph.hemoliticus, E.coli
Candida albicans
Overall E.coli
n
4
2
1
1
1
7
(%)
(44.4)
(22.2)
(11.1)
(11.1)
(11.1)
(77.7)
Table 1 - Results of microbiology cultures
E.coli - Escherichia coli,
Staph.aureus - Staphylococcus aureus,
Staph.hemoliticus - Staphylococcus hemoliticus

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Fournier’s gangrene ... Tayib et al
mitronidazole and aminoglycoside if there was no renal
impairment. The diagnosis of Fournier’s gangrene was
confirmed in all cases by histopathology results.
Postoperatively all patients underwent daily dressing and
wound cleaning with povidone iodide, hydrogen
peroxide, and local dressing with honey was used in 5
patients which showed definite accelerating effect in
wound care. Six patients underwent skin grafts, 5 healed
well, while one still needed further grafting. Two
(22.2%) out 9 patients died from uncontrolled sepsis.
Discussion. Fournier’s gangrene is a rapidly
progressive, fulminant infection of the scrotum,
perineum and the abdominal wall, it was originally a rare
disease that has become more frequent, and in our study
the death rate was 22.2%, which is within the average
international reported death rate ranging between
16-67%.9,13,14 Nine male patients of Fournier’s gangrene
seen in KAUH over the last 3 years; all had one or more
risk factors. Previous attempts to classify Fournier’s
gangrene into primary, for example. Fournier’s gangrene
of the external genitals or secondary due to loco-regional
injury has not been successful, Fournier’s gangrene may
occur in both sexes but is less reported in females.9,15
Diabetes mellitus is one of the most common medical
problems in our country, 66.6% of the patients in this
study were diabetics. Baskin et al16 explained the high
incidence of Fournier’s gangrene in diabetics, as DM
affects the small vessels and leads to tissue ischemia;
also it increases the incidence of urinary tract infection
via obstruction of the urinary outlet and the defective
phagocytosis. Worldwide DM is the most common
medical comorbidity condition in Fournier’s gangrene.17
Early clinical identification of Fournier’s gangrene is
essential for better prognosis of the patients; the
presence of swelling in the genital or perineal area with
black purplish discoloration indicates the need for
immediate debridement. The early diagnosed and
managed cases had shorter hospital stay and did not
necessarily require skin graft. Positive bacterial culture
confirms infection, and many types of organisms, single
or in combination are encountered in Fournier’s
gangrene and represent a polymicrobial infection. Our
study cultured one or 2 organisms and no anaerobic
infection could be cultured. Ralph2 in his large series
found that the average number of organisms recovered
by culture ranged from 1.3-3.9; and in a combination of
all series the average was 2.7. Anaerobes may be
difficult to culture but should be suspected and treated in
all cases.2 Positive Candida infection occurred in our
series in one patient only. Fournier’s gangrene caused
by Candida species as the primary organism is rare, and
infrequently reported in renal transplantation.18,19 All our
patients underwent 2-5 debridement sessions in the
surgical theater with mean of 3 sessions, hydrogen
peroxide and povidone iodide were used routinely for all
the cases; none of our cases required the hyperbaric
oxygen chamber. Smith in his review in 1998 stated that
prompt radical aggressive debridement is essential, with
close monitoring of the wound as the surgeon must be
prepared to return to the theatre if there is any doubt
about tissue viability.20 Several retrospective studies
support the role of hyperbaric oxygen in the treatment of
Fournier’s gangrene, but it should not delay definite
surgical treatment, it is probably best reserved for
patients who remain toxic despite maximal debridement
or for patients with clinical or microbiological evidence
of anaerobic infection.21,22 The histopathological
findings in our patients were predominantly gangrene
with extensive necrosis, vascular thrombosis and abscess
formation.
References
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M et al. Fourniers Gangrene: can aggressive treatment save life.
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AB et al. Fournier's Gangrene: report of 2 cases and review of
the literature. Arch Ital Urol Androl 1999; 71: 31-34.
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gangrene: report of 30 cases. Observed at Abidjan. Med Trop
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GS. Outcome analysis in patients with primary Necrotizing
fasciitis of the male genitalia. Urology 2000; 56: 31-35.
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Okada Y. Fournier's gangrene caused by Candida species as the
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Fournier’s gangrene ... Tayib et al
Saudi MedBase CD-ROM contains all medical literature published in all medical journals in the Kingdom of Saudi
Arabia. This is an electronic format with a massive database file containing useful medical facts that can be used for
reference. Saudi Medbase is a prime selection of abstracts that are useful in clinical practice and in writing papers for
publication.
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Candida fasciitis following
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Urol 1998; 81: 347-355.
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Search Word: gangrene

Authors:
Institute:
Title:
Source:
Abdulmajeed A. Mohammed, Mohammed K. Alam
Riyadh Medical Complex, Riyadh, Kingdom of Saudi Arabia
Management of foot lesions in 310 diabetics
Saudi Med J 1998; 3: 301-305
Abstract

Objective:
experience with other local and international experiences. Methods:
Medical Complex, Riyadh, Saudi Arabia, with foot lesions between September 1986 to August 1991 were studied retrospectively. Data
of 310 patients, who completed the treatment were collected for gender, age, duration of diabetes mellitus, nature of foot lesions,
presence of peripheral vascular disease, peripheral neuropathy, predisposing factors, concurrent medica illness, microbial flora, types and
numbers of surgical procedures, duration of hospital stay, morbidity and mortality. Results:
Saudis (70%), over fifty years of age (84%), and known diabetics (92%). History of trauma preceding foot complications was present in
23% of patients. Peripheral neuropathy was the main predisposing factor (58%). Toe gangrene (29%) and foot abscess (24%) were the
most common form of presentation. Wound swabs were positive for bacterial culture in 94% of patients, 59.4% of them were
polymicrobial. Lower limb amputations at different levels were the most common (51%) surgical procedures, 25% of them were major
amputations. There were 14 deaths (4.5%) in the study group, mainly due to uncontrolled sepsis with concurrent medical illnesses.
Conclusions:
We conclude that foot complications is a common problem in elderly Saudi diabetics, particularly males. Peripheral
neuropathy is the most common redisposing factor. Foot infections are usually polymicrobial. Majority will need some form of
amputation, a quarter of them, will end up having major limb amputations.
To study epidemiology of foot complications in diabetics with a view adding to the local data and comparing our
Medical records of 325 diabetic patients admitted to Riyadh
The majority of patients were males (69%),
Related Abstract
Source: Saudi MedBase