|Year : 2014 | Volume
| Issue : 4 | Page : 174-178
Clinical characteristics and outcome of management of Fournier's gangrene at the Lagos State University Teaching Hospital, Ikeja, Lagos, Nigeria
Olufunmilade A Omisanjo, MJ Bioku, SO Ikuerowo, GA Sule, JO Esho
Department of Surgery, Urology Division, Lagos State University Teaching Hospital, Ikeja, Lagos, Nigeria
|Date of Web Publication||7-Oct-2014|
Olufunmilade A Omisanjo
Department of Surgery, Lagos State University College of Medicine and Teaching Hospital, 1 5 Oba Akinjobi Road, Ikeja, Lagos
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Fournier's gangrene (FG) though a rare condition can be associated with significant mortality. There are few reports in our environment documenting the outcome of management of the condition. The aim of the following study was to describe the clinical characteristics and outcome of management of patients with FG in a tertiary hospital in Southwest Nigeria.
Patients and Methods: The clinical records of patients who presented with FG at a tertriary hospital over a 5 year period were reviewed.
Results: A total of 11 cases were reviewed and all patients were male. The scrotum alone was the most common site of involvement (54.5%). Late presentation was common with 9.6 days (range 1-21 days) being the average duration between the onset of symptoms and presentation at the hospital. Most of the patients (63.6%) did not have any identifiable systemic predisposing factor. There was no mortality or testicular loss recorded.
Conclusion: Patients with FG still present late in our environment. However, appropriate aggressive treatment can help ameliorate the associated mortality and morbidity even in a resource poor setting.
| Abstract in French|| |
Contexte: Gangrθne de Fournier (FG) bien qu'une maladie rare peut κtre associιe ΰ une mortalitι significative. Il y a peu de rapports dans notre environnement de documenter les rιsultats de la gestion de l'Ιtat. Le but de cette ιtude ιtait de dιcrire les caractιristiques cliniques et les rιsultats de la gestion des patients avec FG dans un hτpital tertiaire au sud-ouest du Nigeria.
Patients et mιthodes: Les dossiers cliniques des patients qui ont prιsentι avec FG ΰ un hτpital tertiaire sur une pιriode de 5 ans ont ιtι revus.
Rιsultats: Un total de 11 cas ont ιtι examinιs et tous les patients ιtaient de sexe masculins. Le scrotum seul fut le site plus courant d'implication (54,5 %). Prιsentation tardive ιtait commune avec 9,6 jours (gamme 1-21) ιtant la durιe moyenne entre l'apparition des symptτmes et de la prιsentation ΰ l'hτpital. La plupart des patients (63,6 %) n'avaient pas de n'importe quel facteur prιdisposant systιmique identifiable. Il n'y n'avait aucune perte testiculaire ou mortalitι enregistrιs.
Conclusion: Patients avec FG encore prιsentent vers la fin de notre environnement. Toutefois, un traitement agressif appropriι peut aider ΰ amιliorer la mortalitι et la morbiditι mκme dans un mauvais paramθtre de ressource.
Mots-clιs: La gangrθne de Fournier, mortalitι
Keywords: Fournier′s gangrene, mortality, morbidity
|How to cite this article:|
Omisanjo OA, Bioku M J, Ikuerowo S O, Sule G A, Esho J O. Clinical characteristics and outcome of management of Fournier's gangrene at the Lagos State University Teaching Hospital, Ikeja, Lagos, Nigeria. Ann Afr Med 2014;13:174-8
|How to cite this URL:|
Omisanjo OA, Bioku M J, Ikuerowo S O, Sule G A, Esho J O. Clinical characteristics and outcome of management of Fournier's gangrene at the Lagos State University Teaching Hospital, Ikeja, Lagos, Nigeria. Ann Afr Med [serial online] 2014 [cited 2020 Feb 19];13:174-8. Available from: http://www.annalsafrmed.org/text.asp?2014/13/4/174/142287
| Introduction|| |
Fournier's gangrene (FG) was first described in 1883 by French Venereologist Jean-Alfred Fournier. Over the years, improved knowledge of the etiopathogenesis of the condition has simplified its principle of management. It is a potentially life threatening progressive infection characterized by polymicrobial necrotizing fascitis of the perineal, perianal or genital areas. It is regarded as an emergency because prompt adequate treatment is needed to prevent a rapid progression with attendant mortality.
FG is rare as only 1726 cases were reported world-wide over a 50 year period (1950-1999) with only 502 African patients. 
Although both males and females are affected as found by Unalp et al.,  reports on women remain scanty.
Though the diagnosis of FG is largely made on clinical grounds, imaging and histopathological investigations may help to define the extent of the disease and monitor response to therapy.
Various treatment modalities have been described with varying outcomes. The treatment may demand a multimodal approach including aggressive hemodynamic stabilization in patients who present acutely, parenteral antimicrobial agents and surgical debridement.
Curiously, the mortality rates of infection have been found to be lowest in Africa and highest in North America  despite the various technological advancements.
FG has been discussed in several reports. However, there are few accounts from Nigeria. In this study, we present the clinical characteristics and outcome of management of cases of FG seen at the Lagos State University Teaching Hospital, Ikeja, Nigeria.
| Patients and Methods|| |
The surgical emergency unit, urological wards and operative theatre registers of patients that presented with FG in our hospital over a 5 year period between April 2008 and March 2013 were retrospectively reviewed. Eleven out of 14 consecutive cases with complete clinical records were suitable for inclusion in the study. Data obtained were the patients' age, site of gangrene, predisposing factors, duration of symptoms, clinical features, microbiology, treatment modalities and presence of testicular loss, Fournier's Gangrene Severity Index (FGSI) score and mortality.
The data analysis was performed using the Statistical Package for Social Sciences version 15.0 for window USA.
| Results|| |
Of the 14 patients treated during the study period, 11 (78.6%) cases were suitable for analysis.
All the patients were males with an average age of 51.9 years (range 24-71 years). The site most commonly affected by the gangrene was scrotum alone (n = 6, 54.5%). The other sites involved were penoscrotal (n = 2, 18.2%), scrotoperineal (n = 2, 18.2%) and penile (n = 1, 9.1%). One of patients with scrotoperineal gangrene also had extensive abdominal involvement.
We found the average time from the onset of symptoms to presentation was 9.6 days (range 1-21 days). The majority of the patients (n = 6, 54.5%) presented after 7 days while only 2 patients (18.2%) reported within 2 days of the onset of the symptom.
Most of the patients did not have any identifiable systemic predisposing factor (n = 7, 63.6%). Two of the patients (18.2%) were diabetic, 1 patient (9.1%) had severe malnutrition while 1 (9.1%) had human immunodeficiency virus (HIV) infection. Similarly, no local predisposing factor was found in 7 of the cases (63.6%). Of the patients who presented with local foci of entry, 2 (18.2%) had scrotal carbuncle while ischio-rectal abscess and scrotal laceration accounted for 1 case (9.1%) each.
The review of microbiological spectrum of wound biopsy culture revealed mixed growth of Klebsiella species, Escherichia More Details coli and Pseudomonas aeruginosa in 10 patients (90.9%) while there was no growth in 1 patient (9.1%). There was considerable variability in the antibiotic sensitivity of the bacterial isolate. This ranged from gentamycin, amikacin, amoxiclav, levofloxacin to ceftriaxone and meropenem.
For patients with acute presentation and signs of toxicity (n = 7, 63.6%), treatment comprised of hemodynamic stabilization and empiric parenteral broad spectrum antimicrobial therapy. Culture sensitive antibiotics were administered upon availability of culture results. All of them had serial wound debridement followed by regular Sitz bath. The stable patients not in need of hemodynamic stabilization (n = 4, 36.4%) were treated with antibiotics, wound debridement and Sitz bath.
The severely malnourished patient had some supplementary parenteral nutrition. All the patients had initial urethral catheterization. The patient with extensive scrotoperineal and abdominal involvement had temporary sigmoid loop colostomy for fecal diversion.
None of the patient had hyperbaric oxygen. Only 4 patients (36.4%) had scrotoplasty (with secondary closure) while the remaining 7 patients (63.6%) had their wounds healed by secondary intention.
Majority of the patients (n = 10, 90.9%) presented with FGSI score of less than 9. Only 1 patient (9.1%) had FGSI score more than 9. We recorded no mortality or testicular loss. The average duration of hospital stay was 22.7 days (range 9-48 days).
| Discussion|| |
There has been a significant boom in the body of knowledge regarding the anatomy, etiopathogenesis and management of Fournier's disease since its initial description by Jean-Alfred Fournier in 1883.  The disease is not limited to the young or males only and a cause is now usually discernable. In our study, all the patients were males, with a mean age of 51.9 years (range 24-76 years). This tallied with the findings in earlier studies in Ibadan  and Southeastern Nigeria.  The relatively younger age of patients in Nigerian studies contrasts reports from Europe and North America where preponderance of the patients were in the seventh and ninth decades of life. ,,, The disparity has been adduced to the difference in life expectancy, which is relatively low in Nigeria.  None of our patients was a female. It is probable that the female cases were managed by the Gynecologists and general practitioners.
The most common site of gangrene was the scrotum alone, in keeping with the findings in other series. ,, Other areas (penile, penoscrotal, scrotoperineal and abdominoscrotal) had less predilection for the infection. The delayed presentation we found has also been previously reported. ,, The reasons for the delay may not be unconnected with prior presentation to our "first on-call" alternative health practitioners such as patent medicine dealers, herbalists or clerics as is common practice in our environment. Furthermore, feeling of embarrassment due to the sensitive nature of the external genitalia has been advanced as a probable contributing factor. 
Clinically, we noticed variable presentations. However, generalized malaise, fever and painful scrotal swelling were common to all the patients in keeping with earlier reports. ,
Some studies found the most common source of gangrene to be perianal. , However, in our study, only 4 (36.4%) had any identifiable focus of entry. The preponderance of our patients did not have any traceable focus of infection. It is possible that more extensive investigations may have been helpful in identifying the portal of entry in these other patients.
Several works have documented an association between FG and diabetes mellitus (DM). ,, Indeed one study reported FG as the presenting feature of DM.  Like HIV and malnutrition, DM has immune suppressant effects. 18% and 9.1% of our patients had DM and HIV respectively. However, the majority of the cases (63.6%) were otherwise healthy. Though the diagnosis was made clinically, hematological and biochemical panels were obtained for the purpose of severity index scoring.
With respect to microbiological investigations, we discovered a polymicrobial pattern. A mixed growth of E. coli, Klebsiella species, P. aeruginosa and Staphylococcus aureus was the commonest picture, as documented by other studies. , The treatment of FG often requires a multimodal approach. Our patients who presented acutely (63.6%) had aggressive hemodynamic stabilization. Parenteral broad spectrum antibiotics and tetanus prophylaxis were administered to all patients. Serial debridement of the wound was critical to all cases treated. This involved excision of all non-viable and necrotic tissues until well perfused viable tissue was reached. We routinely prescribed regular warm Sitz bath after debridement. Patients were instructed to sit in a tub with salt containing lukewarm water at 40-45°C for 10 min. The regime has been suggested to have anti-inflammatory and analgesic effects. It may also reduce bacterial load through its hygroscopic property.
Urinary and fecal diversion as adjuncts to the care of FG patients have been described in the literature. ,, All our patients had successful urethral catheterization as shown by the patient in [Figure 1],[Figure 2] and [Figure 3]. None of them had a stricture. This might be due to the relatively older patients we had. One patient had temporary sigmoid loop colostomy done to reduce fecal contamination of the wound.
|Figure 1: Fournier's gangrene involving virtually the whole of the scrotum. The testes are exposed but viable|
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|Figure 2: Same patient as in Figure 1, showing extension beyond the perineum|
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|Figure 3: Same patient as above after 4 weeks of serial debridement, Sitz bath and regular wound dressing|
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We used neither honey nor hyperbaric oxygen therapy although their benefits have been previously documented. , Pure honey has a low PH of 3.6 and contains enzymes which digest necrotic tissue. It has also been found to stimulate growth and multiplication of epithelial cells at wound edges thus accelerating wound healing. ,
Overall, only 36.3% of the cases required some form of scrotoplasty after achieving healthy wound granulation. The remaining 63.6% had their wounds healed by secondary intention. None of the patient needed an orchidectomy. This is not surprising given that in most cases of FG, the testes are usually spared due to their independent arterial supply and venous drainage.
Among the prognostic indicators of FG described are acute physiology and chronic health evaluation and FGSI score. Some authors have incorporated dissemination score as well as age score  to the FGSI in order to improve its predictive value. However, at present, there is no consensus on which clinical variables adequately predict a poor outcome in FG. In our series, 90.9% of patients had FGSI score of less than 9 while only 9.1% of patients had a score more than 9. We did not record any mortality contrary to earlier Nigerian and Turkish studies. ,,
| Conclusion|| |
FG remains a rare urologic emergency though late presentation is still the norm in our environment. The predisposing factors, local or systemic, should always be diligently searched for and this factored into the treatment plans.
We found prompt diagnosis, aggressive hemodynamic stabilization, combination antimicrobial therapy and adequate wound management to be the cornerstone of the management of patients with FG and these were instrumental in avoiding mortality in patients.
| References|| |
|1.||Eke N. Fournier's gangrene: A review of 1726 cases. Br J Surg 2000;87:718-28. |
|2.||Unalp HR, Kamer E, Derici H, Atahan K, Balci U, Demirdoven C, et al. Fournier's gangrene: Evaluation of 68 patients and analysis of prognostic variables. J Postgrad Med 2008;54:102-5. |
|3.||Eke N. Fournier's gangrene, still an enigma. J Postgrad Med 2008;54:83-4. |
|4.||Fournier JA. Gangrene foudroyante de la verge. Semaine Medicale 1883;3:345-8. |
|5.||Okeke LI. Fournier's gangrene in Ibadan. Afr J Med Med Sci 2000;29:323-4. |
|6.||Ugwumba FO, Nnabugwu II, Ozoemena OF. Fournier's gangrene - Analysis of management and outcome in south-eastern Nigeria. S Afr J Surg 2012;50:16-9. |
|7.||Hejase MJ, Simonin JE, Bihrle R, Coogan CL. Genital Fournier's gangrene: Experience with 38 patients. Urology 1996;47:734-9. |
|8.||Benizri E, Fabiani P, Migliori G, Chevallier D, Peyrottes A, Raucoules M, et al. Gangrene of the perineum. Urology 1996;47:935-9. |
|9.||Safioleas M, Stamatakos M, Mouzopoulos G, Diab A, Kontzoglou K, Papachristodoulou A. Fournier's gangrene: Exists and it is still lethal. Int Urol Nephrol 2006;38:653-7. |
|10.||Ayan F, Sunamak O, Paksoy SM, Polat SS, As A, Sakoglu N, et al. Fournier's gangrene: A retrospective clinical study on forty-one patients. ANZ J Surg 2005;75:1055-8. |
|11.||United Nations Development Programme. International Human Development Indicators: Nigeria. Available from: http://www.hdrstats.undp.org/en/countries/profiles/NGA.html. [Last accessed on 2010 Jan 06]. |
|12.||Morua AG, Lopez JA, Garcia JD, Montelongo RM, Guerra LS. Fournier's gangrene: Our experience in 5 years, bibliographic review and assessment of the Fournier's gangrene severity index. Arch Esp Urol 2009;62:532-40. |
|13.||Ong HS, Ho YH. Genitoperineal gangrene: Experience in Singapore. Aust N Z J Surg 1996;66:291-3. |
|14.||Rajbhandari SM, Wilson RM. Unusual infections in diabetes. Diabetes Res Clin Pract 1998;39:123-8. |
|15.||Smith GL, Bunker CB, Dinneen MD. Fournier's gangrene. Br J Urol 1998;81:532-3. |
|16.||Villanueva-Sáenz E, Martínez Hernández-Magro P, Valdés Ovalle M, Montes Vega J, Alvarez-Tostado F JF. Experience in management of Fournier's gangrene. Tech Coloproctol 2002;6:5-10. |
|17.||Slater DN, Smith GT, Mundy K. Diabetes mellitus with ketoacidosis presenting as Fournier's gangrene. J R Soc Med 1982;75:530-2. |
|18.||Bahlmann JC, Fourie IJ, Arndt TC. Fournier's gangrene: Necrotising fasciitis of the male genitalia. Br J Urol 1983;55:85-8. |
|19.||Baskin LS, Carroll PR, Cattolica EV, McAninch JW. Necrotising soft tissue infections of the perineum and genitalia. Bacteriology, treatment and risk assessment. Br J Urol 1990;65:524-9. |
|20.||Paty R, Smith AD. Gangrene and Fournier's gangrene. Urol Clin North Am 1992;19:149-62. |
|21.||Efem SE. Recent advances in the management of Fournier's gangrene: Preliminary observations. Surgery 1993;113:200-4. |
|22.||Yilmazlar T, Ozturk E, Ozguc H, Ercan I, Vuruskan H, Oktay B. Fournier's gangrene: An analysis of 80 patients and a novel scoring system. Tech Coloproctol 2010;14:217-23. |
|23.||Eke N, Echem RC, Elenwo SN. Fournier's gangrene in Nigeria: A review of 21 consecutive patients. Int Surg 2000;85:77-81. |
[Figure 1], [Figure 2], [Figure 3]