What is Fournier ‘s Gangrene and Treatment Methods
A rather rare but dangerous disease of the male reproductive system is Fournier ‘s gangrene (ICD-10 code – A.48.0, N49.2). This is an infectious pathology characterized by a very rapid spread of bacteria in the external organs of the reproductive system, atrophy and necrosis of the scrotal tissues.
For the first time, the description of the disease was carried out by the French venereologist J.A. Fournier in 1883, describing the symptoms of the disease, in which healthy young men encountered progressive gangrene without visible prerequisites.
Today, this pathology has received a scientific name – polymicrobial necrotizing fasciitis , developing in the perineum, anus or scrotum.
Reasons for development
Fourier ‘s gangrene in women is a rare phenomenon, but isolated cases have also been recorded. The main reason for the development of pathology is considered to be a weakening of the immune system, which contributes to an increase in susceptibility to bacteria that provoke it. The penetration of pathogenic microorganisms most often occurs as a result of traumatic lesions of the external genital organs.
The development of gangrene of the scrotum in 95% of cases is of an infectious nature. Bacteria can penetrate not only after injury, but also through the urethra, rectum. This is facilitated by:
- abscesses present on the skin around the anus, in the anus, mucous membranes of the rectum;
- anal fissures;
- perforation (rupture) of the rectum.
Perforation of the rectum can be provoked by instrumental examinations, surgical interventions on nearby organs, malignant tumors and long-term inflammatory bowel processes.
Fournier ‘s urogenital gangrene has the following causes: inflammation and trauma of the urethra, testicle or its appendages, infectious pathologies of the genitourinary system. The dermatological type of pathology occurs when penetrating wounds of the genitals or non-compliance with the rules of personal hygiene. Among the secondary provoking factors, the following are distinguished:
- deep scratches, wounds of the skin of the genitals;
- piercing and tattoo in the intimate area;
- injections of narcotic substances into the penis;
- installation of genital implants;
- bowel cleansing with an enema, the composition of which includes steroid drugs (a necessary procedure in the treatment of radiation proctitis);
- the presence of a foreign object in the anus.
In women , Fournier gangrene can be provoked by complications after termination of pregnancy (abscess), purulent inflammation of the Bartholin glands, removal of the uterus, dissection of the perineum during childbirth (performed to facilitate the birth process, reduce the risk of ruptures in a woman in labor). Anal sexual contact several times increases the chances of developing pathology in both sexes.
Children also face this serious disease. In babies, circumcision of the foreskin, which is carried out among many Muslim peoples, infringement of an inguinal hernia, inflammation after bites of some insects, traumatic injuries of the genital organs, and chronic infectious diseases of the genitourinary system, become provoking factors. Also, the disease can develop as a complication of omphalitis – infection of the umbilical wound, abdominal tissues in newborns of the first days of life, as well as abscesses of the anus.
Gangrenous syndrome is caused by representatives of pathogenic microflora that contribute to the development of other dangerous infectious pathologies. So, in clinical studies of purulent contents, Proteus, Staphylococcus, Enterococcus, Streptococcus, Klebsiella, Pseudomonas , Clostridia are found .
If factors that suppress the body’s defenses are present, the risk of developing gangrene will increase. People with autoimmune diseases, pathologies of the endocrine system, and obesity can face the symptoms of necrotizing fasciitis . Alcohol abuse and diseases resulting from alcoholism (cirrhosis of the liver, hepatitis, etc.) can also bring necrosis of the intimate zone closer.
Circulatory disorders in the pelvis, which are usually characteristic of elderly people, malignant pathologies of the urinary and reproductive organs, chronic lupus erythematosus, Crohn’s disease for the presence of HIV infection – all this also contributes to the active spread of infection in the inguinal zone.
Another factor is malnutrition, which causes a deficiency of useful micro and macro elements, which means suppression of the human immune system.
Manifestations of the disease
The main symptoms of the pathology are acute pain and increased sensitivity of the intimate zone. The general clinical picture of the disease includes:
- manifestations of fever (fever, weakness, drowsiness, chills) present from two to seven days;
- increasing pain, provoked by swelling of the skin over the site of the abscess, itching;
- rapid damage to nearby tissues;
- change in skin color: red, cyanotic, purple, black;
- discharge of pus from an existing wound or breakthroughs of the epidermis from the inside, accompanied by purulent discharge.
Many patients notice that every day the pain syndrome decreases, and they take this as the result of an improvement in well-being. But the reason for this phenomenon is different: the disease progresses, affects all new tissues and nerve fibers, and this reduces the sensitivity of the affected area, reducing pain.
Necrotic lesions range from sensitization of the intimate area to the development of septic shock. That is, the larger the area of dead tissue, the worse the general health of the patient.
Physical examination plays an important role in the diagnosis and establishment of a preliminary diagnosis. By palpation of the affected area, the doctor must correctly assess the presence of symptoms of pathology. If an examination of the scrotum, anus or perineum reveals increased softness, increased sensitivity, or the presence of injuries, it is imperative to examine the patient for the presence of Fournier ‘s gangrene in order to exclude or confirm a dangerous ailment and immediately begin its treatment.
The condition of the skin over gangrenous manifestations can be:
- with a bluish, purple, copper tint;
- contain blisters;
- with clear signs of necrosis;
The latter condition often plays against the doctor and the patient: the absence of visible signs of gangrene does not allow timely recognition of the disease, which means that the chances of a successful recovery are reduced. The presence of an unpleasant, repulsive odor is not always diagnosed: some pathogenic microorganisms do not emit fetid gases, so there is no clear smell of decay. Often patients complain of the standard manifestations of viral diseases: manifestations of fever, heart rhythm disturbances, increased blood pressure.
Fournier ‘s gangrene includes both standard clinical tests and specific examination methods. Therapy is prescribed only according to the results of all diagnostics performed.
IMPORTANT! Significant assistance in establishing an accurate diagnosis is provided by an incisional biopsy: the study of a part of a pathological formation or a directly affected organ.
The main research methods include:
- a clinical blood test, in which a complete count of the cells of the bloodstream is carried out : erythrocytes, platelets, leukocytes;
- study of the level of gases in arterial blood;
- clinical study of urine;
- study of the level of disseminated intravascular coagulation (RVS – syndrome);
- bacterial culture of the separated contents.
The gas composition of the blood allows you to determine the state of the patient’s respiratory function and assess the level of acid-base balance of the body. Deviations from the norm may indicate that the blood does not properly absorb oxygen, that is, necrosis processes are observed.
Examination of RVS syndrome will show if there is a blood clotting disorder, i.e. whether the number of platelets, the main satellites of gangrene, is increased. Bakposev reveals pathogens of pathology and establishes their sensitivity. This will allow you to choose the most effective antibiotic drugs that can block the reproduction of bacteria and slow down the spread of infection.
Imaging studies in Fournier ‘s gangrene are of little diagnostic value, since the final diagnosis is established by the results of laboratory tests. But x-rays and computed tomography are also indicated, as they help to determine the degree of damage to internal organs, to establish the presence of subcutaneous air, because gases and oxygen are released during necrotic processes.
The appointment of other studies is at the discretion of the attending physician: studies for infections, HIV status, glucose tolerance, cardiogram, etc. may be required.
Treatment of the disease
The therapy of Fournier ‘s gangrene is complex, carried out in several stages. An obligatory element of treatment is surgical intervention: only when access to internal tissues is obtained, it will be possible to establish a final diagnosis, as well as excise tissues that have undergone necrosis.
If the patient’s condition is aggravated by manifestations of intoxication (this often happens with insufficient blood supply to the affected organ), resuscitation procedures will be required to restore blood flow and provide tissues with nutrients contained in the bloodstream. Treatment of patients is necessarily carried out in a hospital: before the operation, the infected person is in the intensive care unit, after – in the surgical department.
In addition to surgery, the use of broad-spectrum antibiotics, usually in the form of injections or droppers, is indicated. If gangrene has developed as a result of an injury, tetanus vaccination is indicated.
In the case of a chronic disease (diabetes mellitus, HIV infection, genitourinary infection, etc.), monitoring of the indicators of these ailments is mandatory. As medical practice shows, it is precisely such chronic ailments that take precedence among the provoking factors. Another danger of such diseases is the frequent complications and aggravation of the course of gangrene.
The final diagnosis is established by dissection of the affected organ, and if it is confirmed, the excision of all dead tissues is mandatory. To reduce bleeding, as well as to carry out the operation faster, the use of electrocoagulation allows.
Surgeons try to save all the reproductive organs of the patient, if the clinical picture of the disease allows it, otherwise they are also removed. After the operation, a second surgical intervention may be required, already with the participation of plastic surgeons, who will help restore the anatomical appearance of the genital organs.
The prognosis for complete recovery depends on the stage at which the referral to a specialist occurred and therapy was started. Only at an early stage can doctors give a firm guarantee that the infected person will remain alive and even be capable of procreation.
The scrotum area is characterized by a high ability to regenerate, and therefore its tissues are restored very quickly, as soon as the pathogenic microflora is eliminated from the body.
The negative consequences of the transferred gangrene and the operation performed are painful and uncomfortable manifestations during erection, which are provoked by scars left by the scalpel.
A negative prognosis is typical for men and women of advanced age who suffer from a gangrenous symptom in the anus or in those whose illness has affected large areas of the body. Aggravate the course of gangrene and are aggravating factors of shock, the development of sepsis, dysfunction of the kidneys and liver. These are the ones that most often lead to death.
It is possible to prevent the development of the disease. Since it is caused by bacterial microflora, every measure should be taken to prevent its entry into the body. First of all, you should observe the rules of personal hygiene, have personal toiletries.
The purity of intimate relationships is also important: when having sex with an unfamiliar partner, barrier contraceptives should always be used. If an injury to the inguinal zone occurs, it is necessary to treat it with an antiseptic solution, contact surgeons for its treatment.
It is also recommended to undergo treatment with antibiotic drugs to prevent viral infections.
It is very important to strengthen the body’s defenses: play sports, lead an active lifestyle, eat right, get rid of bad habits. Vitamin-mineral complexes, immunomodulatory drugs, special biologically active additives provide good help to the immune system.
Any medicines, including dietary supplements and vitamins, should be used only after consulting a doctor.
It is necessary to regularly undergo preventive examinations that will help identify the presence of any infections in the early stages of development. Their complete therapy will guarantee the absence of complications, which include Fournier ‘s disease .