Diagnosis and Management of Fournier Gangrene

Clinical Characteristics

The presence of systemic toxicity signs, tissue necrosis, crepitation, and disproportionate pain to physical examination indicates Fournier gangrene and requires emergency surgical intervention, as recommended by the World Journal of Emergency Surgery 1, 2
Rapid progression (hours to days) with accelerated clinical deterioration is a characteristic of Fournier gangrene 1, 2
Subcutaneous crepitation is present in approximately 50% of Fournier gangrene cases 2, 3

Initial laboratory evaluation should include a complete blood count, markers of inflammation (such as C-reactive protein and procalcitonin) 1, and lactate levels 2
The LRINEC score can aid in the early diagnosis of necrotizing infections 1, 3
Elevated lactate levels indicate tissue hypoperfusion 1
Coagulopathy is a suggestive laboratory finding of Fournier gangrene 3

Ultrasonography is the preferred initial imaging modality when available, especially in unstable patients, and can detect subcutaneous gas with a specificity of 94% for necrotizing infection 2, 3
Computed tomography (CT) with contrast can be considered in hemodynamically stable patients with equivocal clinical findings, with a sensitivity of 90% and specificity of 93.3% for necrotizing infections 1, 2, 3

Never delay surgical intervention to obtain imaging when there is high clinical suspicion of Fournier gangrene, as recommended by the World Journal of Emergency Surgery 1, 2, 3
Strong recommendation (1B): imaging should not delay surgery 2, 3
In patients with persistent hemodynamic instability after adequate resuscitation, proceed directly to surgery without imaging 1, 2

Patient with scrotal pain/edema + systemic toxicity + any sign of necrosis/crepitation → High suspicion of Fournier → Immediate emergency surgery without waiting for imaging 1, 2
Unstable patient → Resuscitation + immediate emergency surgery without imaging 1, 2

Fournier's gangrene is a necrotizing fasciitis of the scrotum, penis, and perineum with mortality rates approaching 20-50% in affected patients, according to the European Urology guidelines 4, 5
The disease is an aggressive, polymicrobial soft-tissue infection involving the external genitalia, perineum, and perianal region, as defined by European Urology 5, 6, 7
The infection typically presents with painful swelling of the scrotum or perineum accompanied by sepsis, though up to 40% of cases have a more insidious onset with undiagnosed pain that delays treatment, as reported by European Urology 5, 6

Diabetes mellitus is the single most important risk factor for Fournier's gangrene, according to European Urology 5, 6, 8
Immunocompromised status from malnutrition or other causes is a critical predisposing factor, as stated by European Urology 5, 6
High body mass index/obesity is a significant risk factor, as reported by European Urology 5, 6, 8

Scrotal or perineal erythema, edema, and tenderness are common clinical presentation features, according to the World Journal of Emergency Surgery 4
Subcutaneous crepitations (gas in tissues), patches of gangrene or necrosis, and foul-smelling purulent discharge are also characteristic features, as described by the World Journal of Emergency Surgery 4
A high index of suspicion is essential, particularly in obese patients where examination is limited, as emphasized by European Urology 5, 6

The infection extends along fascial planes, allowing cranial extension to the abdominal wall and caudal spread to the thighs, as explained by the World Journal of Emergency Surgery 4, 8
Testicular involvement is rare due to the separate blood supply from the spermatic vessels, according to the World Journal of Emergency Surgery 4