Fournier’s gangrene (FG) is a necrotizing soft tissue infection of the perineal, genital or anorectal region. This infection most commonly affects males in their fifth to sixth decade, and associated comorbidities include diabetes mellitus, hypertension, renal failure, heart failure, alcohol abuse and immunosuppression.¹ Females are not spared, and clinical presentation can vary considerably.² Despite modern surgical and antimicrobial management, mortality has been reported to be 7.5% in the United States.³ Delays in diagnosis likely contribute to this degree of mortality. Drobish et al reported that patients diagnosed with FG presented with symptomatically similar diagnoses on average 12 days prior to formal diagnosis, representing an opportunity for an earlier diagnosis. These patients most commonly presented with cutaneous infections, urinary tract infections and constitutional symptoms.⁴ Warner et al found that patients on average presented 1.8 times prior to formal FG diagnosis for symptomatically similar diagnoses and estimated a delay in diagnosis of 5.1 days.⁵

Figure 1. FG on presentation.

Figure 2. FG after initial debridement and wound VAC placement. Pictures are from same date.

Figure 3. Four months after initial debridement, healing by secondary intention.

Figure 4. Eight months after initial presentation, now status post-excision of penile granulation tissue and release from scar contracture with skin graft. He did unfortunately go on to develop recurrent FG of left scrotum, which is packed.

Early diagnosis followed by surgical management and antimicrobial coverage are key for optimal outcomes in this population. Empiric broad spectrum antimicrobial therapy should be initiated upon diagnosis. FG is most commonly polymicrobial, and fungal growth was reported in 1 series in 22% of patients.⁶ Broad antibiotic and antifungal agents such as vancomycin, piperacillin-tazobactam and caspofungin should be considered for initial empiric therapy, though local antibiograms may help guide initial treatment as well. Blood, urine and wound cultures can be helpful in narrowing therapy further. Urgent debridement of nonviable tissue is critical followed by daily wound monitoring.⁷ Most patients will likely require 2 or more debridements as the extent of tissue involvement becomes clearer in the days following presentation.²

Tissue loss varies considerably among patients. In those requiring wide excision, reconstruction after the infection is treated may be necessary. Healing by secondary intention with or without wound VAC (vacuum-assisted closure) can be an option for those with smaller surgical defects. While healing by secondary intention for larger wounds is an option, employing reconstructive techniques and wound closure can expedite healing and may be required to prevent or treat scar contracture. For example, the patient featured in figures healed primarily by secondary intention but eventually went on to require reconstruction in the form of penile release from scar contracture, granulation tissue excision and skin grafting (figs. 1–4). Classically wound closure has been delayed weeks or months after initial debridement. However, Sandberg et al reported comparable outcomes between early and late wound closure groups with median delay of 5 days in the early group.⁸ Reconstructive methods vary based on defect location, size and surgeon preference. Methods described include local flap, split thickness skin grafting and component separation with primary closure.⁹ There is paucity of quality data on long-term quality of life as well as urinary and sexual function of affected individuals.

FG requires decisive surgical management, careful antimicrobial coverage and often reconstruction to support patients through this challenging infection. Delays in diagnosis are common, and a thorough physical exam is necessary to reduce these delays when patients present with related complaints. Currently, there are no formal guidelines by the AUA for the management of this condition, and development of these guidelines may be helpful for consistent urological management in the future. Further research is needed to determine how best to support these patients in the long term, past the acute necrotizing infection. By employing the strategies discussed here, we can help patients return to a high quality of life.