Introduction

Fournier gangrene is a rare, severe infection of the perineum (the region between the anus and genitals). It usually begins with redness and swelling affecting the groin, known as cellulitis.¹

The aim of reconstructive surgery is to restore the appearance and function of damaged tissues. This can have a positive psychological impact and improve the quality of life for patients. 

 There are a number of challenges in treatment, including attempting to restore the aesthetic appearance of the genitals.² This article will provide insights into the specific treatments for Fournier gangrene and how patients can be supported after surgery. 

What are the causes of Fournier gangrene?

Fournier gangrene is necrotising fasciitis of the anal and perineal area. Necrotising fasciitis is considered a life-threatening medical emergency due to its rapid progression. 

Causes and risk factors

The risk of Fournier gangrene is higher in individuals with certain underlying conditions, such as:

• Diabetes
• A weakened immune system
• Obesity
• Chronic alcoholism
• Human immunodeficiency virus (HIV)
• Malnutrition³
• Liver cirrhosis
• Crohn’s disease 
• Lupus⁴

It is thought that the poor healing seen in diabetic or malnourished individuals plays a role in the development of Fournier gangrene.⁵ In addition, medication for type 2 diabetes can inadvertently encourage bacteria to grow in the groin region. 

How does Fournier gangrene develop? 

Bacterial infection is the primary cause of Fournier gangrene. The bacteria associated with Fournier gangrene are usually related to the gut or may be found in the skin around the groin. 

Open wounds present an opportunity for bacteria to flourish. Interventions, such as genital piercings or trauma after surgery, are a potential route for the entry of bacteria. Different types of bacteria release toxins, causing clots to form and the blood supply to be restricted. This results in tissue death and means oxygen cannot be transferred to the tissues for repair. 

Consequently, a hypoxic (low oxygen) environment is created which encourages the growth of harmful bacteria, and more cell death.⁴

Initial management and surgical debridement

Emergency care

Fournier gangrene requires emergency treatment including immediate wound debridement and antibiotic therapy.⁶ 

Early diagnosis and surgical intervention are essential, as the disease can progress rapidly.

Debridement procedures

Surgical debridement is the primary focus of Fournier gangrene treatment.⁶ This involves cleaning the wound and removing dead tissue, and other debris, to allow the remaining healthy tissue to heal. Aggressive surgical debridement is often required. 

Other methods of debridement involve using:

• Chemical agents (chemical debridement)
• Maggots (biosurgical debridement)
• Mechanical debridement (cleansing the wound with saline fluid)
• Naturally-occurring enzymes (autolytic debridement)⁷

Following debridement, reconstructive surgery is often needed to restore the normal appearance of the genitals and anal area. 

Goals of reconstructive surgery

Reconstructive surgery has three primary goals:

• Restoring urinary, sexual and bowel function
• Aesthetic reconstruction of the genital and perineal area, aiming to minimise visible scarring 
• Improve the patient’s body image and self-esteem, with added psychological support and counselling if needed

Types of reconstructive surgery

There are multiple different reconstructive procedures to treat Fournier gangrene, depending on the size and severity of the wound.

Skin grafting

In this method, a healthy area of skin is used to replace missing or destroyed tissues. The grafts used in Fournier gangrene reconstructive surgery include split-thickness skin grafts (also known as partial-thickness grafts), and full-thickness skin grafts. 

Split-thickness grafts are the best option to cover perineal and scrotal skin defects.⁶ 

Flap reconstruction

Flap reconstruction similarly uses the patient’s tissue, but in this instance with its original blood supply, to improve the appearance of the affected region. 

Local flaps adjacent to the wound are often used, however, for more extensive defects, free flaps can be taken from the skin further from the wound site.⁸

Tissue expansion techniques

Tissue expansion uses the stretchy properties of the skin to cover more area. Next to the area to be treated, a silicon balloon expander is pumped gradually over time which makes the skin “grow”.⁹ This extra expanded tissue can be used to reconstruct the damaged region.

An advantage of this method is that it avoids the use of external material, which can cause unwanted immune reactions. 

On the other hand, areas next to tissue expanders have the potential to become necrotic, especially in the case of Fournier gangrene.¹⁰

Genital reconstruction

If the genitalia are extensively damaged, reconstruction using phalloplasty may be an option, but research specifically in patients with Fournier gangrene is limited.¹¹

The procedure involves reconstruction of the penis and scrotum, but complications related to the blood vessels can arise. Flap selection is crucial for a successful surgical outcome.¹²

Post-operative care and rehabilitation

Post-operative care begins immediately and continues after the patient has been discharged from the hospital.

Wound care management

To ensure the wound heals properly, the patient is advised on how to manage the bandage dressings, including guidance on how to prevent future infections.

Psychological effects

Reconstructive surgery may help return the functioning of the urine and bowels, however, patients may feel additionally distressed about sexual health. 

The rarity of Fournier gangrene makes research into the quality of life post-surgery challenging.¹³ If you or a loved one is concerned, you should reach out to your healthcare provider. 

Prognosis and long-term outcomes

Survival 

Due to advances in clinical management, survival in Fournier gangrene has improved over time, although the mortality rate remains high at 7.5%.¹⁴ 

Long-term complications

Fournier gangrene has a number of potential long-term complications including:

• Infection risk
• Failure of the graft or flap
• Wound reopening (dehiscence)

Strategies to reduce infection and aid healing include maintaining good hygiene around the wound site and ensuring wound dressings are applied as indicated by your doctor.

Summary

Fournier gangrene is a life-threatening condition that can progress rapidly. Timely reconstructive surgery, combined with adequate antibiotic therapy, promotes wound healing.

Advanced surgical techniques, including flap reconstruction, can improve outcomes and quality of life for patients in the long term.