Dr MJ Engelbrecht Dept Urology University of Pretoria Fourniers Gangreen Dr MJ Engelbrecht Dept Urology University of Pretoria
Definition Necrotizing faciitis in which the primary etiology remains a mystery It is however widely used to describe a necrotizing infection of the genitalia and perineum in either a male or female Reported mortality of up to 45% Alfred Fournier - 1883
Clinical presentation Local signs and symptoms Pain and edema (100% of patients) Erythema Crepitus Necrosis of the underlying skin Purulent discharge Systemic Fever Septic shock Multi organ failure
Clinical presentation
Clinical presentation
Clinical presentation
Clinical presentation
Pathophysiology Polimicrobial infection caused by colorectal, urogenital and dermatological flora. Infection begins locally with release of inflammatory mediators This leads to local edema and decreased oxygen tension Continued inflammation leads to small vessel thrombosis with local necrosis. Hypoxic tissue provides a environment for synergistic polymicrobial growth Infection spreads rapidly through subcutaneous tissue planes
Pathophysiology Most common co-morbidities DM Alcoholism HIV (Immune compromised patients)
Diagnostic studies CLINICAL DIAGNOSIS!!! AXR Scrotal ultrasound Subcutaneous gas Scrotal ultrasound Intrascrotal gas
Anatomy Colles Fascia involved in most cases Continues up the anterior abdominal wall as Camper’s fascia and Scarpa’s fascia Continues as the dartos fascia on the penis Boundaries Fascia lata – inferior and lateral Urogenital diaphragm – posterior Buck’ fascia – protects the corpora cavernosum Almost never testicular involvement If testicular involvement consider explorative laparotomy for intra abdominal sepsis
Treatment Rescusitation SURGERY!! Fluids Broad spectrum antibiotics Early aggressive surgical debridement of devitalized tissue will improve survival
Surgery
Surgery
Penile Reconstruction Potent Primary closure Thick Split Thickness skin graft Full thickness skin graft Scrotal cutaneous penile flap Impotent Meshed Split thickness skin graft
Scrotal reconstruction Primary closure Superficial testicular thigh pouches Poor cosmesis Decreased sperm production Pain with stretch Meshed STSG Fascio cutaneous and Muscle flaps
Reconstruction