Necrotizing soft-tissue infections of the genitalia (NSTIG), historically (and still) referred to as Fournier’s gangrene, are universally hailed as the least favorite on-call consult by urologists in the US.¹ They always seem to present to the emergency room at night, just after you’ve fallen asleep. They must also be treated emergently with surgery (ie, no “let the hospitalist deal with it until the AM”) since antibiotics can’t get to tissues that lack a blood supply. The resections leave the patients with wounds that are difficult to manage, and closure often requires a (generally reluctant) plastic surgeon. Mortality remains stuck at around 5%.²

In 1000 words, 4 photos, and 1 video, we are going to try to convince the readers that while NSTIG (Fournier’s) remains an emergency that, yes, often presents at night, recent advances in its management may change how urologists feel about the disease. The takeaway should be this– urologists know how to manage this disease best and should own the disease for the sake of our patients.

Presentation of Disease, Diagnosis and Early Management

Unfortunately, there is nothing we can do about the emergent nature of NSTIG. You will still have to take your cases to the operating room–probably at 2 AM–and early resection will always be associated with better outcomes.³ But our recent work suggests that we’re probably missing a lot of these patients early in the disease process. The NSTIG prodrome has been described before and is often thought to be about 3 days, but we found that many who ultimately present with NSTIG have been suffering symptoms for up to 2 weeks.⁴ The symptom that should elicit the most concern? New onset of pain in the genitalia (likely early ischemia). Obese patients were more likely to have a delay in their diagnosis for unknown reasons, but we hypothesize that they may be more difficult to examine (we’ve all had the morbidly obese, nursing home NSTIG patient that wasn’t examined for days before presentation). Key point–if you’re alerted by a colleague about a patient with new genital pain with comorbidities–obesity, diabetes, immunocompromised–make sure they do a good physical exam. Early reports also suggest that thermal imaging may aid in making earlier diagnoses (Figure 1), but further work will be required before this becomes the standard of care⁵.

Surgical Excision

We try to take the Goldilocks approach to the surgical excision of NSTIG (not too little, not too much), keeping in mind that we will also be the team ultimately closing the wound. We’ve found the best approach is to start with a deep incision through the duskiest portion of the disease (sometimes aided by thermal imaging), then work laterally as needed until the skin starts to bleed. Because the infection travels along the deep fascial planes and not the skin, this means that some of the skin lateral to this incision can sometimes be preserved even if the underlying fascia and soft tissue has been compromised and removed, as the blood supply is different.⁶

During the initial resection, it is important to develop the deep planes bluntly–wherever this may take you–before removing tissue sharply. Early abscess drainage and assessment of the totality of the infection is key. Notably, large incisions are not always synonymous with large excisions. Large incisions are easy to close–large resections aren’t.

Our threshold to include general surgery in the case is abdominal wall involvement beyond the suprapubic region and concern for rectal involvement (especially if thought to be the infectious source, which is not always clear at the onset of the case). It is rare to have non-contiguous areas involved with necrotizing infection so once the initial incision is made, aggressive manual dissection to open the extent of the disease is crucial. Remember–we’re the urologists (ie there isn’t much you can hurt down there that you can’t fix later, but you’d ideally like to stop the spread of the disease after a single operation)

Once the resection margins have been reached, excision can commence with the goal of preserving any viable skin that could be used for later reconstruction. Post resection, we initially pack the incision with wet-dry Kerlix and then being 72 hours of monitoring. An immediate spike in white blood cell count is not unusual but should begin to drop by 12 hours, along with the fevers. If the patient is not improving clinically, repeat imaging. We continue broad spectrum antibiotics (started preoperatively) with vancomycin, piperacillin/tazobactam, and now fluconazole based on data suggesting a high rate of fungal infections in these wounds.⁷

Surgical Reconstruction (Video)

While reconstruction has traditionally been delayed for many weeks to months, we have begun (along with many others) to close these wounds during the initial hospital stay.⁸ There are many advantages with this approach. First, they are in house already; thus, arrangement of operating room time is generally easier. Second, management of these wounds as an outpatient can be a logistical nightmare. Wound vacs can work, but we have found them difficult to keep on suction, especially when the perineum and suprapubic tube regions are involved, and wound care is not always predictable or reliable. Third, prolonged catheterization in a penile urethra not covered by skin tends to lead to urethral erosion. Fourth, primary closure is much easier if significant granulation tissue has not settled in.

We will attempt closure at a minimum of 72 hours after the white blood cell count has normalized, and the patient is afebrile and medically optimized (blood sugars controlled, TPN instituted as needed, etc). Notably, even in the setting of a rectal source of NSTIG (eg, rectal injury, abcess, fistula), the scrotum and penis can be reconstructed even if the rectal defect is not deemed to be closeable by the general surgeon.

The first step in closure is the liberal use of the Versajet, which precisely debrides the granulation tissue, and any remaining nonviable tissue, using saline jets. Notably, Versajet irrigation has been shown to decrease infection rates, decrease the inadvertent removal of viable tissue, and speed surgical time.⁹ We then attempt primary closure in all of these wounds using a separation of components methodology. In general, this means all tissue lateral to, and within, the resection bed is widely mobilized along with its vascular supply. Importantly, in the setting of a preserved hemiscrotum, this strategy requires the intentional disruption the scrotal septum to allow for increased mobilization of the contralateral scrotal tissue for coverage. The testicles and spermatic should be freely mobile bilaterally up to the external ring. Any nonessential fatty tissue can be excised unless required for coverage of sensitive areas (eg, rectal wall, urethra), especially if the bulkiness is inhibiting closure. When necessary, mobilization into the medial thigh or abdominal wall can be performed, staying anterior to the fascia. Wounds are closed over a closed-suction drain using 2-0 polyglycolic acid sutures deep and 2-0 nylons in a horizontal mattress fashion on the skin. Both thighs are prepped in before surgery to allow for a ready source of split-thickness skin grafting (4 in, 0.018-in depth; unmeshed on penis, meshed 1:1 or 2:1 on scrotum; grafting of the perineum is not recommended). Drains are removed when output is < 40 mL/d. Sutures remain in place for 10-14 days. Minor wound separation can occur but can generally be managed with local wound care and closure by secondary intention.

Published data on primary closure strongly suggests a decrease in convalescence time without an increase in wound infection when guidelines above are followed.⁸ The mobility and redundancy of the genital skin allow for the primary closure +/- minor skin grafting in well over 90% of cases (Figures 2-4).