What Is Fournier Gangrene?

Fournier’s gangrene: a life-threatening infection

Fournier’s gangrene is a rapidly progressing bacterial infection of the scrotum, penis, or perineum. Whilst the infection is rare, the potential for fatal consequences prompts a need for awareness of the condition to allow for early identification and subsequent urgent treatment.

Read on to learn more about the condition and the key signs of infection.

What is Fournier's gangrene?

Fournier’s gangrene is an acute bacterial infection of the scrotum, penis, or perineum (the area between the genitals and anus), which develops quickly and rapidly spreads to other parts of the body. Due to the immense risk of profound, permanent damage to the body, Fournier’s gangrene is deemed to be a urological emergency.

Fournier’s gangrene is a concerning condition due to the nature of the damage it can cause to the body's tissues. This infection is a type of necrotizing fasciitis—also known as a flesh-eating bacterial infection that affects the skin and soft tissues of the body, including the fascia (thin layer of connective tissue under your skin that surrounds and supports every structure in your body, such as bone, blood vessels, and muscle). When the causative bacteria penetrate the skin and reach the fascia, they can travel deep beneath the skin's surface, allowing them to be relatively unnoticed at the early stages of the infection. The limited blood supply to the fascia allows the infection to cause extensive necrosis (irreversible tissue death) in deep structures.¹ However, the skin's surface may initially appear normal, only displaying signs of infection as it progresses to a more severe stage. The infection and necrosis can spread extensively, eventually causing multiple organ failure and death.²

What causes Fournier's gangrene?

The main cause of Fournier’s gangrene is bacterial infection. However, no specific bacterial species are associated with this condition, as it is considered polymicrobial, meaning multiple types of bacteria cause the condition. Usually, a mixture of anaerobic and aerobic bacteria is present. The sources of these bacteria are the urinary tract, anus, rectum, or skin.^2,3 Sometimes, bacteria enter through a wound. Thus, it is important to monitor the appearance and temperature of any wound and associated pain, as these can be key indicators of wound infection.

Signs and symptoms of Fournier's gangrene

Fournier’s gangrene can be difficult to detect in its earliest stages because the infection affects tissues much deeper than the skin. Initially, you may experience a prodrome (an early sign), including feeling lethargic, feverish, and tired.²

The first symptoms of Fournier’s gangrene you might complain of are:^4,5

• Severe pain in and around the genitals or anus
• Swelling in the genital area
• Red genitals or perineum

As the infection progresses, the skin may become dusky (darkish in colour) or red, without clear borders or demarcation. The skin may also look somewhat crunchy or feel like there are trapped air bubbles beneath the skin. This phenomenon is called crepitus. It occurs when bacteria beneath the skin release gases that become trapped under the skin's surface.⁴

During the advanced stages of infection, the skin will appear visibly cracked, revealing underlying tissue. Typically, there is a putrid smell and leakage associated with tissue necrosis. This manifestation is gangrene, which is why the condition is called Fournier’s gangrene.²

Management and treatment of Fournier's gangrene

How is Fournier's gangrene treated?

Due to its emergency status, any patient suspected of having Fournier's gangrene is immediately escalated to a surgeon (usually a urologist or general surgeon). The patient receives intravenous (IV) fluids and antibiotics and is prepared for emergency surgery to debride the affected tissue. Surgical debridement is a process of removing all dead and necrotic tissues from the wound to promote healing and prevent the spread of the infection. Because of the deeper nature of Fournier’s gangrene and other necrotizing fasciitis, it is common to repeatedly debride the wound due to its rapid and extensive spread.

Once the patient's condition has stabilised and the infection has resolved, reconstructive surgery might be performed depending on the amount of tissue removed and the size of the remaining wound. This surgery helps to reconstruct the perineum, scrotum, or penis to look like it did before Fournier’s gangrene. Sometimes, the wound can be left to heal by itself, while in other cases, a skin graft or flap may be required.⁵ However, patients with Fournier’s gangrene should expect to have multiple surgeries.

What if surgery is not suitable for the patient?

If surgery is not suitable for the patient or the spread of the infection is extensive, supportive management will be used. This includes pain management, which is of utmost importance to the patient and the healthcare team.

Alternative treatments such as hyperbaric oxygen therapy, negative pressure therapy, and the use of honey have been suggested as potential treatments but have not yet been proven to be effective.^5,6

What complications can arise?

Fournier’s gangrene is a life-threatening condition which can lead to death if left untreated. Despite receiving treatment, some patients may experience loss of sexual or urological function due to the extensive tissue and nerve damage. This can significantly impact their quality of life, potentially leading to substantial genital deformities in some cases.

Fertility may also be affected by Fournier’s gangrene, depending on the extent of tissue damage. For example, while the testes (where sperm is made) might be preserved, damage to the urethra can block the normal passage of sperm. An andrologist (a medical doctor who specialises in the treatment of male health issues) can offer further guidance on the next steps in such cases. Additionally, some patients might endure permanent damage to other organs in the abdomen and pelvis.

FAQs

How do doctors diagnose Fournier's gangrene?

Your doctor will typically diagnose the condition based on the presence of the abovementioned signs and symptoms and skin examination. Additionally, your doctor might order some diagnostic imaging tests and scans, such as:

• Ultrasound
• Computed tomography (CT) scan
• X-ray
• Complete blood count (CBC) 

These tests assist in identifying the severity of the condition or the underlying cause of the infection. However, diagnostic tests can take up valuable time, and given the life-threatening nature of Fournier’s gangrene, it is best for doctors to proceed with the management if there is clinical suspicion. Any delay in treatment increases the risk of further tissue damage or even death.²

How quickly does the infection spread?

While Fournier’s gangrene is usually diagnosed in its later stages due to the lack of early signs, it can actually develop over days or weeks before the skin shows any changes. Thus, it is often described as a sudden infection. 

In fact, the infection destroys tissue at a rate of approximately one inch per hour.⁴

Who does Fournier's gangrene affect?

As an infection of the scrotum, penis, or perineum, the infection mostly occurs in men but has been known to affect women and children to a significantly lesser degree.⁷

Fournier’s gangrene most commonly occurs in men aged between 30 and 60, with one US study stating an average age of 50.9 years in men.⁸

What increases my risk of developing Fournier's gangrene?

If you are immunocompromised, you have a greater risk of developing infections like Fournier’s gangrene.

This includes having any of the following conditions:^4,9

• Diabetes: This is the most common risk factor, in which 20% to 70% of patients with Fournier’s gangrene are diabetic
• HIV/AIDS-positive
• Malnourished
• Undergoing chemotherapy
• Taking immunosuppressive medications

Additionally, vascular conditions such as hypertension (high blood pressure) or peripheral vascular disease, obesity, liver failure, and alcohol dependency increase the risk of developing the condition. IV drug users are also at increased risk of developing Fournier’s gangrene since the needles can introduce bacteria directly into deeper structures of the body.^2,4

In children, the development of Fournier’s gangrene can be attributed to poor hygiene.⁷

How can I reduce my risk of developing Fournier's gangrene?

Following these recommendations can reduce your risk of developing Fournier’s gangrene:

• Maintain good personal hygiene, especially in the genital and perianal areas
• Ensure that any medical conditions such as diabetes and hypertension are under control 
• Seek support from a healthcare professional if you are struggling with alcohol dependency or IV drug use
• Maintain a healthy weight

Is there any support available if I have been affected by Fournier's gangrene?

If you have been affected by Fournier’s gangrene, ask your healthcare provider about support groups. There are many patient support groups available that offer people the chance to share their experiences with others who have been through similar situations.

Summary

Fournier’s gangrene is a serious, life-threatening infection that can be difficult to identify in its early stages. Patients and doctors should be particularly aware of intense pain in the genital or anal region accompanied by any skin changes, especially among those who are immunocompromised, have chronic illnesses, or use IV drugs. Treating Fournier’s gangrene often requires multiple surgeries to remove the affected tissues, and patients may undergo reconstructive surgery after the resolution of the infection. Patients might experience a loss of sexual or urological function, significantly affecting their quality of life. Specialist services or reconstructive urologists can offer support and guidance regarding the long-term effects of Fournier’s gangrene. Early detection and prompt management are crucial in treating the condition.