Abstract
Fournier gangrene is a life-threatening surgical emergency caused by multiple infectious organism usually affecting the subcutaneous perineal, genital or perianal region with high incidence in immunocompromised patients.
In very rare situations such our case when it involves the Deep perineal fascia and invading into the corporal body, the necrotizing tissue spread and control becomes more challenging and lead into devastating events with high mortality rate.
Staged timely debridement with highly daily examination to rule out necrosis spread is highly recommended.
Keywords: Fournier, Urethritis, Corporal abscess
Categories: Urology, Infection
1. Introduction
Fournier gangrene is a life-threatening infectious surgical emergency usually caused by multiple organisms of the perineal, genital or peri-anal region. It has an increased incidence in patients with alcoholism and immunocompromised patients especially uncontrolled diabetes. It often begins as a simple abscess or cellulitis with progression to necrotizing soft tissue infection.
Superficial perineal space (inferior fascia of the urogenital diaphragm with colles fascia) limit the extension of the infection to the perineal body and urogenital diaphragm posteriorly and to the pubic rami laterally.
Usually it does not involve the corporal body due to deferent fascial coverage. The deep fascia termed buck's fascia which fuses deep in the dense tunica albuginea deep in the pelvis, spares the corporal body from infection.
We reviewed the literature and found few studies mentioning Fournier gangrene involving the corporal body.1,2,3
2. Case
A 57-year-old male patient who is bed bound with poorly controlled diabetes. Presented to our institute KFSH&RC Riyadh with scrotal swelling and discoloration associated with fever and deterioration of consciousness. He was recently discharged from outside hospital where he was investigated for his recent bilateral lower limp weakness which showed to be due to severely uncontrolled diabetes leading into diabetic neuro/myopathy.
He was discharged with Foley catheter in place for 1 month, with recent history of urethritis. He was having high Fournier gangrene scoring index score (Fig. 1).
Fig. 1.
Scrotal swelling and overdue catheter seen upon presentation.
The patient underwent multiple staged debridement, initially debridement of the scrotum and the penile skin was done, sparing the penile glans. After 3 days the glans started to get blackish with a picture of dry gangrene (Fig. 2). We took him into other sessions of wound exploration and debridement which ended with total penectomy showing puss inside the corpora, with non-viable urethral plate (Fig. 3).
Fig. 2.
Dry gangrene of the glans.
Fig. 3.
Non-viable urethral plate with puss seen inside corporal body.
Which indicate the necrotizing fasciitis entry and starting site to be from the urethra. Perineal uretherostomy was done and the testis was placed into bilateral thigh pouches.
The patient initially was doing fine covered with appropriate antibiotics on Vacuum dressing and Hyperbaric oxygenation chamber. His scrotal wound was clean with good granulation tissue.
After around 10 days he deteriorated clinically and was found to have necrotizing fasciitis of the subcutaneous gluteal area with muscle involvement. The radiological images showed extension from the original necrotizing site of the perineum. The patient eventually died due to multi-organ failure with resistant bacteria.
Literature was reviewed showing 1 study of urethritis causing Fournier gangrene. Also, the patient died eventually after partial penectomy. 4
3. Conclusion
Fournier gangrene due urethritis is lethal, Foley placement should be carefully placed in a sterile technique and exchanged frequently especially in immunocompromised patients. Staged timely debridement is recommended with raising high suspicion into spread of necrotizing tissue into other place, especially in such cases were the starting point involved the deep perineal fascia.
Info
All authors have declared that no financial support was received from any organization for the submitted work.
Financial relationships
All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work.
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All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.
Declaration of competing interest
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References
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