Fournier's gangrene (FG) is a serious skin infection that affects the area between the legs, the scrotum, and the penis. It happens because of a mix of different germs that causes the blood vessels under the skin to get blocked, leading to damage and death of the skin and tissue in that area. FG can happen to anyone, regardless of age or gender, but it is more common in persons assigned male at birth (AMAB).

The disease simply cannot be neatly divided into a primary or secondary entity. Most persons assigned female at birth (AFAB) and children have developed the disease necrotising fasciitis because it is more common in AMAB individuals, with a focus on vaginal or anal regions. While most have been reported in the U.S. and Canada, cases are also being noted elsewhere.¹

Differential diagnoses

FG shares clinical features with various conditions, making accurate diagnosis crucial. Conditions that may present similarly to FG include:

• Cellulitis
• Strangulated hernia
• Scrotal abscess
• Streptococcal necrotising fasciitis
• Vascular occlusion syndromes
• Herpes simplex
• Gonococcal balanitis and oedema
• Pyoderma gangrenous
• Allergic vasculitis
• Polyarteritis nodosa
• Necrolytic migratory erythema
• Warfarin necrosis
• Ecthyma gangrenosum

Treatment options

Fournier’s Gangrene is a medical emergency that requires immediate and multidisciplinary treatment, including antibiotic therapy, surgical debridement, wound management, and supportive care.²

Antibiotic therapy

Once a clinical diagnosis is made, fluid and electrolyte imbalances must be corrected quickly.³ Broad-spectrum antibiotics are administered before culture and sensitivity results.

Common initial antibiotic therapy includes:

• Penicillin G: If Clostridia species are suspected
• Metronidazole: Targets anaerobic bacteria
• Third-generation cephalosporins: Effective against Staphylococcus and Enterobacteriaceae
• Aminoglycosides, clindamycin, and chloramphenicol: Often used initially

Antibiotic therapy is adjusted based on microbial culture results.⁴

Surgical interventions

Debridement (tissue removal)

Once patients are examined and stabilised with fluid resuscitation, they are administered broad-spectrum antibiotics(e.g. third-generation cephalosporin and metronidazole). After the removal of dead tissue, samples are sent for microbiological and histological analysis.

The wound is then dressed with hydrogen peroxide or povidone-iodine solution, and debridement is repeated every 1-2 days as necessary. In cases of extensive necrosis, further tissue removal is required.⁵

Negative pressure wound therapy or vacuum-assisted closure

A vacuum-assisted closure (VAC) dressing contains foam with perforations, sealed over the wound with an adhesive film. The VAC pump creates a negative pressure environment, promoting tissue healing and reducing infection risk. This method is particularly beneficial for large wounds requiring surgical intervention or skin grafting.⁶

Reconstructive surgery

Once the infection is controlled, reconstructive surgery is necessary to:

• Ensure wound healing
• Prevent complications
• Improve aesthetic and functional outcomes

Options for soft tissue reconstruction include:

• Thin or thick skin grafts
• Local flaps (moving nearby skin)
• Scrotal grafts (skin taken from the scrotum)
• Fasciocutaneous pedicle flaps (flaps containing fat and muscle with blood vessels)
• Placement of testicles in a new site (if scrotal involvement is extensive)

There is no single consensus on the best reconstructive approach, as it depends on the extent of tissue loss and patient condition.⁷

Fecal and urinary diversion

In cases where anal or perineal involvement causes wound contamination, a colostomy may be performed to divert stool away from the infected area, facilitating healing. However, as a surgical procedure, it comes with additional risks.

• Flexi-Seal faecal management system: Handles bowel movements, diverting waste away from the wound
• Urinary diversion: May be necessary in cases of urethral swelling or penile complications⁸

Fluid resuscitation and glucose management

Immediate fluid replacement is critical, as electrolyte imbalances are common. Many FG patients with uncontrolled diabetes experience diabetic ketoacidosis, accelerating disease progression.

• Glucose levels must be corrected urgently, as some cases report extremely high glucose levels (≥1020 mg/dL)
• Insulin pumps may be more effective than subcutaneous insulin injections, though evidence remains inconclusive⁹

Hyperbaric oxygen therapy (HBOT)

HBOT has been shown to improve outcomes in FG treatment by:

• Enhancing oxygen delivery to affected tissues
• Slowing bacterial growth, particularly in areas where blocked blood vessels limit oxygen supply
• Being especially useful for anaerobic bacterial infections

Alongside early debridement, HBOT may be beneficial for patients who do not respond to standard treatments such as sterile honey and maggot therapy.¹⁰

Honey

Recent studies highlight honey’s antimicrobial properties, which promote wound healing in FG patients.

• High osmotic pressure: Dehydrates bacterial cells
• Low pH (3.6): Inhibits bacterial growth
• Enzymatic activity: Aids in breaking down necrotic tissue and stimulating new cell growth¹¹

Summary

• Fournier’s gangrene is a severe infection of the perineum, primarily affecting AMAB individuals
• Immediate intervention is essential, involving:
  • Antibiotic therapy
  • Surgical debridement
  • Advanced wound care (VAC therapy, HBOT, honey therapy)
• Fluid and glucose management is vital, particularly in diabetic patients
• Surgical reconstruction may be required to restore function and aesthetics