FOURNIER’S GANGRENE IN COTONOU, BENIN REPUBLIC

Abstract

Background

Gangrene of the male genitalia called Fournier’s gangrene is not an uncommon surgical condition in the urological service at Cotonou, Benin Republic; it is associated with high mortality and morbidity.

Patients & Methods

This is a retrospective, descriptive study conducted at the Teaching Clinic of Urology and Andrology at the National and Hospitable Center CNHU- Hubert Koutoukou MAGA in Cotonou, Benin Republic. The study is on patients managed for Fournier’s gangrene from January 2002 to December 2012. The demographics, clinical presentation, management and outcome were recorded in a proforma and the data obtained were analyzed using SPSS 10.0 software.

Results

Fournier’s gangrene represented 1.8% of hospitalizations with an annual average of 5 cases. The mean age was 52 years with range of 21 - 85 years. 77.7% of patients were 40 - 59 years and; while 22.3% were 60 years and above. About 28% had a predisposing factor (diabetis, HIV, leukaemia, high blood pressure). Etiological factors were urogenital (42.5%), anorectal (22.5%), and cutaneous (17.5%). In 17.5% of cases, no etiologic factor was found. The diagnosis was clinically obvious because of late presentation, 95% of patients were admitted in the acute phase.

CONCLUSION

Fournier’s gangrene mostly affects young males and the diagnosis was clinical. It is a disease with high morbidity and mortality in Benin Republic.

Introduction

Fournier’s gangrene is an infectious gangrene of the male external genitalia with variable frequency in different regions. Though rare in developed countries, it is still present in developing countries1,2 and it is associated with high mortality since its first description in 1983 by Jean Alfred Fournier. Aetiological factors could be identified even in most of the cases1 Predisposing factors cause a peripheral micro-angiopathy, immuno-suppression or both. Fournier’s gangrene is both a medical and surgical emergency. Its management should be multidisciplinary, and aggressive. We report our experience in the management of this condition over 10 years.

Reports

Patients & Methods

This is a retrospective descriptive study of all consecutive patients with Fourniers’ gangrene managed at the National and Hospitable Center CNHU- Hubert Koutoukou MAGA in Cotonou, Benin Republic from January 2002 to December 2012. The demographics, clinical presentation, management and outcome were recorded in a proforam. The diagnosis was essentially clinical. After clinical assessment, patients had the following investigations; haemogramm, blood biochemistry, urine culture and culture of exudate/pus. Emergency treatment consisted of broad spectrum antibiotics, immediately followed, by generous excision of all devitalized or suspicious tissues until bleeding was encountered. Abdominal or lumbar incisions drainage was done when appropriate. Wound grafting was done when clean granulation tissues were achieved; while open wounds were dressed daily. Tetanus prophylaxis was routinely given to all patients. No patient received hyperbaric oxygen therapy as the facility was not available at this centre. Data obtained were analyzed using SPSS 10.0 software.

RESULTS

A total of 72 consecutive patients were managed during the study period. Fournier’s gangrene represented 1.8% of hospitalizations with an annual average of 5 cases per year. The mean-age was 52 +/- 8ans with a range of 21 - 85 years. The distribution of patients according to age groups is shown in Table I.

Table 1 Distribution according to age group

Ages (years)	Number (n)	Percentage (%)
20-29	4	5.6
30-39	12	16.7
40-49	17	23.6
50-59	15	20.8
60-69	13	18
>70	11	15.3
Total	72	100

Associated morbidities were Diabetes mellitus in 10 (28%) patients, hypertension 6 (%), HIV/AIDS 2 (%) and leukaemia 2 (%).

The average time before presentation was 8 days with a range of 3 to 15 days.

The various reasons for consultation are summarized in Figure 1 but mainly as a result of paining the scrotum and lower urinary tract symptoms.

Figure 1:

Reasons for consultation

After the clinical examination 95% of patients were admitted at the acute phase; clinical infectious syndrome was present in all cases associated with a poor general state condition.

The location of the gangrene was variable as shown in Fig2.

Figure 2:

Location of the gangrene

4 patients presented strangulated inguinal scrotal hernia with enterocutaneous fistula

The blood film in 88% showed leucocytosis with neutrophilia. Serum electrolytes in 75% of patients showed hyperkalaemia or hyponatremia. The blood urea and creatinine in 72.5% of patients were elevated in 10 patients. To search for causative organisms we realized urine culture (25%) and culture of exudate/pus (12,5%). Isolated organisms are shown in the Table 2.

TABLE 2: Distribution of micro-organisms in the patients

	Number	Percentage
Escherichia Coli	18	36
Staphylocoque aureus	11	22
Pseudomonas aeruginosa	9	18
Klebsiella pneumoniae	5	10
streptococcus of group A	4	8
Providencia stuartii	3	6
Total	50	100

The treatment consisted of resuscitation and debridement. The latter was followed daily with Dakin® (n = 62) and sucrose (n = 10) dressings with continuous urinary drainage. Colostomy was performed in 4 patients who had entero-cutaneous fistula to protect the wound. The other associated surgical procedures include unilateral Orchiectomy for suppurative orchitis in 5(6, 9 %) patients; intestinal resection + hernia repair in 4(5,6%) patients because they had strangulated hernia and resection of the tunica vaginalis due to infected vaginal hydrocele (n = 3).

The hospital stay ranged from 2 to 130 days with an average of 72 days. The mortality rate was 10% mainly from septic shock in7 patients. Secondary wound closure was performed in 90% of patients, and one patient had scrotal reconstruction.

Discussion

The incidence of gangrene of the external genitalia in males is variable over time and across regions. This is often an opportunistic infectious disease in selected chronic health conditions. Improving living conditions would result in considerable reduction in the incidence of this condition. It is the same for chronic conditions that are better controlled. This would explain the low incidence of this disease in developed countries3 where the standard of living is high in contrast to the frequency of the disease in developing countries, including Africa1. The annual incidence in our study was five cases per year but lower series have been reported in the sub-region3,4, 5. Higher incidence had been reported reaching up to 97 cases per year1.

The average age of patients was 52 years in our study. It is similar to the finding of Abessan et al5 in Morocco, which was 58 years. Gangrene of the male genitalia is commoner in the young adult age with associated co-morbidities especially diabetes and high blood pressure predominate. These conditions facilitate the development of gangrene by immunodeficiency or micro-angiopathy. The same observation was made by Kane et al in Senegal4. High sexual activity, with repeated urogenital infections is common in the age group commonly affected. Diabetes is the main predisposing factor found in the literature5,6, however, other factors such as alcoholism, smoking, obesity, HIV, and blood diseases such as leukaemia. Sometimes, the insidious onset of the disease1, attempts to manage the disease traditionally or by unqualified care personnel are often the cause of delayed presentation. This causes delayed presentation with most patients discovered at an advanced stage of the disease known for its rapid expansion. Fascial destruction rate of 2 to 3 cm per hour has been described1. In our study 95% of our patients presented in the acute state phase with septicaemia. This would explain the frequency of penile-scrotal forms and perineo-peno-scrotal which are indices of delayed presentation . The most commonly found causes were urogenital; colorectal and skin pathologies while in some cases no cause was identified. The same observation was made in our series. The identification of the causative agent(s) allows proper management of the disease with targeted and effective antibiotic therapy However, some micro-organisms are known for their synergy in the development of gangrene of the external genitalia. These are both aerobic and anaerobic organisms4. The most common organism was E. coli in our series and in the work of other authors3,5. Imaging techniques may help to better assess the extent of the gangrene, but should not delay the treatment. In our study no patient had imaging evaluation before treatment.

Therapeutically, the combination of antibiotics used in our study was the same as those used by most authors3,5. It would enable effective action on the micro-organisms commonly found in this condition. This therapy is effective only if it is accompanied by early resuscitation and debridement to limit further spread to other fascial planes. This debridement should be followed by daily dressing to further remove necrotic tissue. Orchiectomy is rarely required unless the origin is a suppurative orchitis1. Wound dressing is effective with honey 7 or in combining the sitz bath permanganate4.

The most commonly used dressing agent in our department was Dakin® and sometimes sucrose. Hyperbaric oxygen therapy has not been used in our study owing to unavailability; even then the results are still controversial8. The procedures may be performed when necessary: colostomy (if there is colorectal extension) and suprapubic urinary diversion (if the urethra is involved). This is a general approach which aims to protect the wound for better healing. Another challenge in the management of gangrene is skin cover for extensive skin loss, which sometimes requires a skin flap. In our study, no patient required a skin flap, but secondary suture and controlled healing were sufficient. This accounted for the long duration of treatment in our study (72 days). Bah et al3 reported a significantly higher duration of up to 90 days. Lower durations of hospitalization have been reported by other authors5,9,10. The high mortality explains all the attention paid to this condition. It is estimated to be between 30% and 50% or even 60% according to some authors 3, 11. In our study it was 10%. It is less than that found in an earlier study which was 21.8%12. But it is close to the work of Bah et al3. A better understanding of the disease and a more aggressive care would bring the mortality rate even lower. The latter is recognized by other workers5,11 as beneficial to the patient because it helps break the extension chain.

Conclusions

Fournier’s gangrene is a urological emergency with high mortality and morbidity that requires early presentation, and effective management in order to achieve a good outcome.

Figure 3 .

Penoscrotal gangrene

Figure 4 .

Penoscrotal gangrene after debridement