treatment

Last reviewed 10/2020

The treatment of Fourniere's Gangrene is both medical and surgical.

Medical treatment entails:

• fluid resuscitation is septic
• commencement of broad-spectrum empirical antibiotics:
  • need to cover the common organisms eg staphylococci, streptococci, anaerobes and Enterobacteriaceae
  • consult with local microbiology departments
  • if initial stains reveal fungi from biopsies, systemic antifungals will need to be added
• hyperbaric oxygen:
  • only as an adjunctive procedure
  • should not delay formal debridement of necrotic soft tissues
• treat any underlying pathologies eg:
  • diabetes sliding scale of insulin
  • transfusion for anaemia
  • alcohol withdrawal treatment

Rapid surgical treatment is imperative if there is a strong suspicion of Fourniere's Gangrene. In a relatively well patient early in the disease process, there can be a short delay while bedside incisional biopsies are taken to exclude differentials such as severe cellulitis. In the unwell patient, in theatre under general anaesthetic all necrotic tissue is excised. A urinary catheter is placed at the start of this procedure to faciliate toileting during the subsequent management. A key macroscopic criteria for involved fascia is easy separation of subcutaneous tissue from fascia with digital manipulation. Dissection is carried out to healthy, contractile, bleeding muscle and adherent, fibrous fascia. Any skin showing evidence of thrombosed vessels, ecchymosis, bullae or necrosis is excised. Samples are taken for microbiology (gram stain, anaerobic culture, anaerobic culture) and histology. The testicles are usually preserved from infection due to the protective effect of the deeper layers of fascia, but if they are involved, orchidectomy may be necessary and the patient should be warned about this possibility pre-operatively. The testes may need to be buried in subcutaneous pockets created at the superior border of the medial thighs in order to provide some protection.

It is often necessary to undertake serial debridements every 24 to 48 hours dependent on the appearance of the wound, clinical parameters and blood tests such as CRP and white cell count. In the interim, a vacuum dressing may reduce oedema and infection while promoting granulation tissue. It should not be kept in place for prolonged periods of time.

Once the infection has been cleared, the wound is closed with a variety of techniques including direct closure of mobile surrounding skin, split thickness skin grafting or regional flaps. Rarely, muscular flaps such as a pedicled rectus abdominis or gracilis may be necessary to obturate a cavity eg from perianal debridement. Exposed testes and spermatic cord can be directly grafted.