Introduction

Fournier’s gangrene (FG) is a rare but deadly and life-threatening emergency resulting from an infection that rapidly destroys tissue in the genital, groin and anal areas. (I’m not sure if this whole sentence should be hyperlinked.) It was named after Jean-Alfred Fournier, a French dermatologist specialising in sexually transmitted diseases in 1883.¹ Generally, males are 40 times more affected than females, and over 30 to 40% of cases have diabetes as a major risk factor.^1-5 The infection that leads to FG is typically caused by a combination of different kinds of microorganisms which burrow into tissue through cuts or small injuries. FG spreads quickly and is associated with a high rate of deaths and poor health outcomes, therefore, immediate surgical intervention is crucial, and post-operative care following surgery is even more critical.

Post-operative care is necessary because it prevents debilitating complications, supports recovery, and enhances the overall quality of life.^1-4

Immediate operative care

Typically, once FG is diagnosed, a patient is hospitalised in the intensive care unit (ICU) and started on potent antibiotics with wide coverage in addition to other resuscitative measures such as fluids and painkillers administered through the veins and the management of high blood sugar levels.^4,5 This is because a majority of patients present with diabetic emergencies, in addition to infections capable of harming other vital organs in the body. These modalities are usually maintained while the patient is prepared for prompt surgery to help salvage healthy tissue and further prevent the spread of the infection. Antibiotics and fluids must be started even if confirmatory results from the lab are not yet available. It does help that diagnosing FG begins clinically.

The consensus is that the gold standard for treating FG is surgical, through an extensive removal of dead tissue, also known as debridement.^1,3-5 This is usually carried out in the emergency theatre, and most patients need several sessions of the procedure before post-operative modalities are started. The stitches must be loose, and the bandage following the procedure must be flat for easy monitoring and healing.³

Before, during and following the operative treatment of FG, continuous monitoring of the patient’s vital signs, including temperature, heart rate, blood pressure, respiration and blood oxygen levels, is mandatory.^1,3,4

At all the stages of management, routine tests including inflammatory markers, complete blood count, and kidney and liver function tests are conducted to keep track of management and promptly manage any complications that may arise at any stage.^1,3,4

Post-operative care

This stage is a multidisciplinary interplay of concurrent treatment modalities to balance the preservation of the dignity of patients and provide the best possible standard of care.³ Professionals here include general and plastic surgeons, urologists, intensivists, dietitians, physiotherapists, occupational therapists, anaesthetists, immunologists, counsellors, etc.

1. Sterile Wound Dressings

These repeated wound dressings start 24 to 48 hours following debridement to monitor the progress of the recovery process.³ They are usually carried out daily in the theatre after putting the patient to sleep for the first couple of days, depending on individual recovery. The ointments used in wound dressing differ across hospital settings and are usually prescribed based on patients’ circumstances.^3,4 Some studies have seen results with basic substances like honey.⁴

Other topical treatments included in some settings in the early days following surgery include fatty substances or calcium alginate with skin grafts or cover flaps, provided the infection risk is very low.³

2. Negative Pressure Wound Therapy

This therapy is known as vacuum-assisted closure (VAC), and it is a non-invasive system that utilises negative pressure to promote wound healing.³ It is ideally performed every 48 to 72 hours for maximum benefits.⁴

3. High-Pressure Oxygen Therapy

Hyperbaric oxygen therapy (HBOT) has been singled out as a game changer in the world of FG post-surgical management because of its recorded success in shortening recovery time and reducing the risk of death.^3,4,5 This high-pressure oxygen system functions to improve the regeneration of tissue and blood vessels while improving the penetration of antibiotics, and strengthening immune cells to fight off microorganisms. Additionally, HBOT decreases the need for many debridements and enhances a shorter drainage time.

4. Urinary and Faecal Management System

If the patient’s urinary outlet (urethra) is affected, a tube fastened to the bladder through the skin is inserted to divert urine and ensure faster wound healing and less pain.^4,5 On the other hand, if the anus or rectum is involved, a diverting outlet which empties into an external bag known as a colostomy or a faecal management system is created to prevent contamination of the surgical area.

These systems should, however, be used with caution and on a short-term basis because of their potential for complications and prolonging recovery.⁵

5. Psychotherapy

A holistic approach to reducing sickness and death tolls among FG patients has been proposed by Dr. Herbert Benson of Harvard Medical School.² He proposes that meditation is beneficial in the post-operative management period, as dealing with and recovering from FG is tough and long. Patients may also be screened for anxiety, depression and body image concerns and referred to mental health experts when necessary. Ongoing education for patients and their loved ones is also necessary throughout the management process.

6. Plastic Reconstruction

This is done when initial surgical wounds have healed and are pink, devoid of pus, significant bacterial count, and dead tissue.^1,3-5 Sometimes, biopsies from the wounds are taken at intervals to determine when the time is right for plastic reconstruction.³ Skin may be harvested from the thigh or other healthy surfaces of the body and used to close up the wound. Meshes and adhesives may also be incorporated in this process.

7. Nutritional Support

Patients must receive all their nutritional needs during the entire period of treatment and especially through the long recovery process to encourage and hasten wound healing.¹ Underlying nutritional or metabolic concerns, like glucose levels among diabetics, must be addressed.

8. Infection Control

In addition to antibiotics and regular wound dressings, patients may also be isolated from other patients in the ICU to prevent the spread of drug-resistant organisms.^1-5

9. Rehabilitation and Physical Therapy

As soon as physiotherapists determine, patients should be made to mobilise early to prevent blood clots from forming in their legs or ulcers on high-pressure areas in their buttocks.^1,4 Physical therapy should also be started to prevent stiffening joints, muscles or tendons.

10. Long-term Follow-up

Once discharged, the follow-up process is typically long, requiring regular clinic visits to the different members of the treatment team.^1-5 This ensures adequate monitoring of the healing process, adjusting medications, assessing for complications or additional treatment needs and managing underlying diseases to prevent relapse.

Conclusion

Fournier's Gangrene is a bacterial infection that rapidly destroys tissues of the external genitalia, resulting in the need for immediate treatment and subsequent post-operative care. Surgery and antibiotics are the main treatments administered to instantly prevent the infection from spreading.   Accordingly, careful multidisciplinary and individualised post-operative care for FG patients cannot be overemphasised as it ensures healing, prevents complications, and supports quick recovery.