Fournier's gangrene--analysis of management and outcome in south-eastern Nigeria.
Abstract: Background. Fournier's gangrene is a necrotising fasciitis of the genitalia and perineum, with associated polymicrobial infection and risk of organ failure or death. The purpose of this study was to determine the presentation, systemic and local predisposing factors, management challenges and outcome in south-eastern Nigeria.

Patients and methods. We studied 28 out of 34 consecutive male patients with complete case notes seen in two centres (the University of Nigeria Teaching Hospital and St Mary's Hospital) between January 1995 and December 2008. Operating theatre registers and urology ward admission registers were used to identify patients.

Results. The mean patient age was 48.3 years (range 28-66 years), with a peak age incidence of 50-59 years. The majority of patients were farmers, manual labourers and artisans. The site of gangrene was scrotal in 22 patients (78.6%), penoscrotal in 3 (10.7%), abdominoscrotal in 2 (7.1%) and scroto-perianal in 1 (3.6%). The mean interval between onset of symptoms and presentation was 7.2 days (range 3-14 days). Systemic predisposing factors identified were diabetes mellitus in 6 patients (21.4%), filariasis in 2 (7.2%), congestive cardiac failure in 1 (3.6%) and HIV infection in 1 (3.6%). In 18 patients (64.3%) no systemic factor was identified Local predisposing factors identified were chronic scrotal skin itching in 16 patients (57.1%), scrotal thorn injury in 2 (7.1%) and urethral catheterisation in 2 (7.1%). Scrotal carbuncle and scrotal surgery each accounted for 2 patients (7.1%), and zipper injury and ischiorectal abscess occurred in 1 patient each (3.6%). No local predisposing factor was identified in 1 patient (3.6%). The common clinical features were fever, scrotal swelling/pain, and later a malodorous painless wound. Treatment involved fluid administration, correction of electrolyte imbalance, antibiotics, debridement and daily wound inspection/ dressing with hydrogen peroxide soaks and sodium hypochlorite. The mean duration of hospital stay was 37.l.days (range 21-84 days). One patient died (3.6%).

Conclusion. Fournier's gangrene is a challenging surgical problem, with significant morbidity. Diabetes mellitus is a significant systemic risk factor. In the majority of our cases, no systemic predisposing factor was identified Local risk factors, especially chronic scrotal itching, were contributory. With proper management, mortality is low.
Article Type: Report
Subject: Gangrene (Care and treatment)
Gangrene (Patient outcomes)
Gangrene (Research)
Infection (Complications and side effects)
Infection (Research)
Authors: Ugwumba, F.O.
Nnabugwu, I.I.
Ozoemena, O.F.N.
Pub Date: 02/01/2012
Publication: Name: South African Journal of Surgery Publisher: South African Medical Association Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2012 South African Medical Association ISSN: 0038-2361
Issue: Date: Feb, 2012 Source Volume: 50 Source Issue: 1
Topic: Event Code: 310 Science & research
Geographic: Geographic Scope: Nigeria Geographic Code: 6NIGR Nigeria
Accession Number: 281375516
Full Text: According to Ong and Ho, (1) Fournier's gangrene was originally described by Baurienne in 1764, but named by Jean Alfred Fournier (1832-1914) in 1883 when he described the occurrence of a condition characterised by sudden onset in previously healthy young men, rapid progression to gangrene and absence of a definite cause, as quoted by Stephens et al. (2) and Laor et al. (3) The Persian physician Avicenna (980-1037) had earlier described the same condition in his book The Canon of Medicine, as quoted by Nathan. (4)

It is now known that Fournier's gangrene is caused by acute infection of the tissues of the perineum, evolving in a sudden and unpredictable manner to necrotising cellulitis due to anaerobic bacteria, Gram-negative bacteria, or both (Fig. 1). (5) Although the condition is rare in absolute terms, over 1 726 cases have been reported in the English literature, with a male/female ratio of 10:1. There have been 502 cases from Africa, which ranks second to the USA/Canada. (6)

Controversy exists regarding the difference between primary and secondary Fournier's gangrene, and the condition has several other names: necrotising fasciitis, peri-urethral phlegmon, phagedena and necrotising cellulitis. However, there appears to be no significant differences between the definitions offered. (6) Necrotising fasciitis in the region of the perineum and genitalia should be termed Fournier's gangrene, regardless of the aetiology or the presence of infection, because the prognosis and treatment are the same. (7)

Fournier's gangrene is no longer considered idiopathic, because the pathological features are well defined and the portals of entry of causative organisms well known. (8) The disease is an obliterative endarteritis caused by the spread of organisms. (8) The relentless necrotising cellulitis may be localised to the perineum, genitalia and groin. (9) Causative factors are known to arise in the local skin, colorectal region and urinary tract. (10-12) Systemic illnesses such as diabetes mellitus and alcoholism are also implicated. (1,5,13,14)

[FIGURE 1 OMITTED]

This study examines the presentation, management and outcome of Fournier's gangrene in south-eastern Nigeria.

Patients and methods

The University of Nigeria Teaching Hospital and St Mary's Hospital are major urological referral centres in south-eastern Nigeria, which has a total population of over 20 million people. Between January 1995 and December 2008, 28 out of 34 patients treated for Fournier's gangrene who had complete records were assessed Research ethics committee approval was obtained for this study. Operating theatre registers and urology ward admission registers were used to identify patients.

Data collected were the patients' age at presentation, clinical features, investigations, treatment given, problems with management and outcome. The data were analysed using SPSS statistical package version 16.

The diagnosis of Fournier's gangrene was made on clinical grounds after a detailed history and physical examination. Baseline evaluation consisted of packed cell volume, full blood count, serum electrolytes, urea and creatinine, fasting or random blood sugar estimation and culture of a wound swab. Routine testing for syphilis and HIV was not done. Radiographs were taken and abdominal ultrasonography done in patients with abdominal involvement to assess the presence and extent of gas in the abdominal wall and the condition of the intra-abdominal viscera.

The successful passage of an average-sized Foley catheter (18G) and no prior history of lower urinary tract symptoms served to rule out any significant urethral stricture in the acute period.

Antibiotics (ceftriaxone 1 g daily, gentamicin 80 mg 8-hourly and metronidazole 500 mg 8-hourly) were commenced pending culture and sensitivity results. Resuscitation with intravenous crystalloids was carried out, after which debridement was done to remove all non-viable tissue.

Dressings were with hydrogen peroxide and sodium hypochlorite. Secondary closure or reconstruction was done when the wounds were clean and granulating.

Results

Twenty-eight male patients (mean age 48.3 years, range 28-66 years) were seen during the study period. Only 25% of patients were in the second and third decades of life, the majority (28.6%) being 50-59 years old.

Evaluation of patients' occupations showed that the majority (64.2%) were low-income earners, mostly subsistence farmers, and 35.8% were middle-income earners.

According to their histories, all patients experienced fever, malaise, scrotal pain and swelling, and at presentation all had painless and malodorous wounds; 21 (75%) were febrile.

The site most commonly involved was the scrotum only (22 patients, 78.6%) followed by the penis and scrotum (3 patients, 10.7%). Two patients (7.1%) had abdominoscrotal and 1 patient (3.6%) scrotal and perianal involvement. A diabetic patient with scrotal and extensive perianal involvement and septicaemia had organ failure.

Systemic predisposing factors identified were diabetes mellitus in 6 patients (21.4%) and others as shown in Fig. 2.

Chronic scrotal itching was the most common local factor identified (16 patients, 57.1%). Scrotal surgery, scrotal carbuncle, scrotal thorn prick and urethral catheterisation accounted for 28.4% (2 patients each), and ischio-rectal abscess, scrotal zipper injury and urethral stricture for 10.8% (1 patient each). No local factor was identified in 1 patient.

In this series, the mean interval between onset of symptoms and presentation was 7.5 days (range 3-14 days). Three patients (10.7%) presented within 3 days, and 8 (28.6%) within 4- 6 days. The majority of the patients (60.7%) presented after 7 days.

Nine patients (32.1%) had received oral and topical herbs from traditional medicine practitioners, while 10 patients (35.7%) had received antibiotics from patent medicine dealers; 5 patients (17.8%) had patronised both groups.

At baseline assessment of haematological indices, 11 patients (39.2%) were anaemic (haemoglobin concentration <10 g/dl), the mean haemoglobin concentration being 7.75 g/dl. The anaemic patients received whole blood transfusions to attain a haemoglobin concentration of 10 g/dl. Mild leucocytosis (neutrophilia) was noted in 21 patients (75%), 1 (3.6%) had renal failure, and 23 (82.1%) had evidence of dehydration as evidenced by slight elevations in urea levels but normal creatinine levels.

Wound swab culture results were available in 22 patients and showed mixed growth of Escherichia coli and Pseudomonas in 4 patients and E. coli and Proteus in 3. The remaining 15 patients had single-organism isolates, mainly E. coli. Isolates were sensitive to cephalosporins and/or gentamicin.

Treatment consisted of antibiotic therapy using a combination of ceftriaxone, gentamicin and metronidazole, fluid resuscitation, urine output monitoring and tetanus prophylaxis. Antibiotic therapy was modified when culture results were received. Debridement was carried out to remove all necrotic tissue and the wound was cleaned with hydrogen peroxide and dressed with gauze soaked in sodium hypochlorite. Daily wound inspection was carried out and repeat debridement was performed if indicated. Wounds were allowed to granulate and subsequently closed or reconstructed.

All patients were catheterised per urethra except for one patient in whom suprapubic cystostomy was done for an impassable stricture. A temporary sigmoid colostomy to avoid wound contamination was done in one patient with perianal involvement.

Most patients were fed enterally. When this was impossible, patients were maintained on intravenous dextrose-containing solutions until they could eat, which was usually within 48-72 hours.

In the early period of this study (1995-2002) there was a mean delay before debridement of 23.6 hours (range 5-50 hours), the delay in the later period (2003-2008) falling to 4.5 hours (range 4-8 hours).

The mean time to reconstruction was 22.9 days (range 8-63 days). Twenty-two patients had direct scrotal skin apposition, while 8 had a combination of scrotal skin suture apposition and split-skin grafting. The mean duration of hospital stay was 37.1 days (range 21-84 days). One patient (3.6%) died.

Discussion

Fournier's gangrene is considered rare in terms of absolute numbers, with about 1 700 cases reported in the English literature up to 2000. (6) Factors arising in the perianal and perineal regions are often reported as the commonest causes of this ailment. (1,15) However, in our series, 57.1% of patients had had scrotal itching for a mean duration of 26 days (range 15-46 days), and ensuing microtrauma might have led to a local skin infection that was made unidentifiable by the ensuing gangrene. (5,15) This is in agreement with the findings of other workers. (10) It is postulated that poor hygiene may increase the risk of scrotal skin infection and subsequent gangrene, or that the scrotal itching is an early symptom of dermatitis of unidentified aetiology. It is also noteworthy that we did not encounter any female patients in our series; this may be due to the small number of cases, or female patients may have been managed by gynaecologists without our knowledge.

The average age of the patients in our series was 48.3 years (range 28-66 years). This may be due to the relatively low life expectancy in Nigeria, (16) as series from Europe and North America, where life expectancy is longer, included much older patients in the 7th to 9th decades of life. (5,8,15,17)

An intriguing finding was the long interval between onset of symptoms and presentation to hospital (mean 7.5 days, range 3 - 14 days). This was consistent with the reports of Beniziri et al., (5) Ayan et al. (5) and Safioleas et al., (17) but much longer than the findings of Nisbet et al. (18) and Dahm et al. (19) Reasons for delay included poor access to health care facilities and prior presentation to unorthodox practitioners such as herbalists, traditional medicine practitioners and patent medicine dealers. (20) Embarrassment owing to the private nature of the external genitalia was probably also a contributory factor. (6)

Delay in presentation did not seem affect outcome negatively, and the patient who died presented early; this suggests that the biological characteristics of each infection are distinct.

Most of our patients had also been seen by traditional medicine practitioners and patent medicine dealers, who treated them with applications of herbs and suboptimal doses of antibiotics. The free availability of counterfeit drugs (21) is a near-endemic problem in Nigeria. These dealers operate outside the official health care system and do not get their supplies from accredited pharmaceutical representatives. Furthermore, antibiotic therapy alone, even in adequate doses, is inadequate treatment for established Fournier's gangrene, which is basically a surgical infection. (13)

With regard to the clinical features, the prevalence of fever, malaise, scrotal swelling and pain was similar to the findings of earlier workers. (5)

The leading isolate was E. coli, which is in agreement with the findings of others. (5,15)

Our patients were treated with intravenous fluid resuscitation, blood transfusion where necessary and urine output monitoring, with emphasis on the more ill patients in full realisation of the lethal complications of these physiological upsets. Tetanus prophylaxis was given to all patients, and hyperimmune tetanus globulin was administered when available to prevent possible tetanus infection due to faecal contamination. Debridement of necrotic tissue was done once these measures were in place, after an interval of 5-40 hours in the early period of the study due to lack of anaesthetic support and inability of the patients to procure drugs and consumable'. (Patients are required to obtain drugs and consumables on a cash and carry basis if they are not enrolled in the National Health Insurance Scheme (NHIS). As this scheme caters largely for public sector and organised private sector workers, the majority of these patients were not beneficiaries.) In the latter part of the study, the delay was reduced to 2-8 hours, and local anaesthesia was used in some cases. These delays did not appear to affect outcome negatively, although it cannot be denied that our response time needs to improve further.

The use of colostomy has been described by earlier workers (8,11) and a sigmoid colostomy was performed on one of our patients to divert faeces and reduce further wound contamination.

The association between diabetes mellitus and Fournier's gangrene is well known. (14,22,23) Two of our patients were known diabetics with poor or no control and 4 were newly diagnosed during the admission (21.45%). It is well known that patients with diabetes have immune suppression and poor cellular immune response.

Various dressings have been used for Fournier's gangrene. We used hydrogen peroxide soaks as an oxygen donor to increase oxygen tension in the wound and counter the growth of anaerobes. This was followed by sodium hypochlorite solution. We did not use honey, though its salutary effect in malodorous wounds has been reported. (8,9) Also, no patient in our series received hyperbaric oxygen therapy as this facility was not available to us, though we noted the reported salutary effects (5) and equivocal results in some series. (24) Orchidectomy was not done in our series.

The average duration of hospital stay (37 days) is similar to the figures reported by Ayan et al. (15) and Safioleas et al., (17) but much longer than that reported by Dahm et al. (19) A long hospital stay, financed by patients from their meagre resources, often means that they are unable to pay their bill on discharge, resulting in the further negative outcome of a yet longer stay after they should have been discharged, while they try to raise money to offset the debt. There was no health insurance scheme in place for most of the study period and our patients had to finance their treatment personally, usually with difficulty as most were in the low socioeconomic groups.

The one patient in our series who died (mortality rate 3.6%) was a diabetic who presented with severe septicaemia and multiple organ failure. Mortality rates ranging from 3% to 45% have been reported, (6) and causes include severe sepsis, coagulopathy, acute renal failure and diabetic ketoacidosis.

Regarding predictors of outcome, alkaline phosphatase, lactate dehydrogenase and serum albumin were not routinely requested, although the single patient who died had renal failure and severe leucocytosis.

Our mortality rate is similar to that found in an earlier study in Nigeria. (10) This low mortality rate appears to suggest that Fournier's gangrene here has a less aggressive course than in other climes. It is possible, however, that there was a selection bias due to the retrospective nature of this study, i.e. records of patients managed by other units might not have been accessed.

Conclusion

Fournier's gangrene remains a challenging problem for the surgeon and has a significant association with diabetes mellitus. The managing physician is required to deal with fluid and electrolyte management, antibiotic use, wound care and sepsis to achieve overall treatment of this condition.

We emphasise that the diagnosis is a clinical one, and that the purpose of investigations is to assess patients' baseline values, determine the degree of physiological imbalance, and identify predisposing and aetiological factors.

In a developing country such as Nigeria, there is a paucity of resources, and laboratory results are often delayed owing to power failures, lack of reagents, etc. Prudent and selective use of these investigations may hasten decision making and reduce cost. Awareness of diabetes mellitus needs to be increased via public education programmes, as this was found to be a significant risk factor for Fournier's gangrene and appeared to increase the risk of death.

The maintenance of good scrotal hygiene may possibly reduce the incidence of the condition, although there is no real evidence that this is so.

Improved access to qualified doctors and hospitals, with healthcare subsidies for poor patients, will be of great value. Thorough assessment, correction of fluid/electrolyte deficits, debridement and regular wound inspection, combination antibiotic therapy, tetanus prophylaxis, wound dressing and well-timed closure remain the bedrock of the management of Fournier's gangrene.

Acknowledgement. We are grateful to house officers Dr Ohakanu Istiphanus and Dr Nwaiwu Obioma and medical student Ekpenisi Ijeoma, who participated in data collection.

Conflict of interest. None.

Funding. Nil.

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F. O. Ugwumba, M.B. B.S., F.W.A.C.S., F.I.C.S.

Urology Unit, Department of Surgery, University of Nigeria Teaching Hospital, Enugu, Enugu State, Nigeria

I. I. Nnabugwu, B. B.S., F.W.A.C.S.

Urology Unit, Federal Medical Centre, Asaba, Delta State, Nigeria

O. F. N. Ozoemena, M.B. B.S., F.W.A.C.S., F.I.C.S.

Urology Unit, Department of Surgery, University of Nigeria Teaching Hospital
Fig. 2. Pie chart showing systemic predisposing factors.

Systemic predisposing factors

NI       = 64%
DIABETES = 21%
HIV      =  4%
FILARIA  =  7%
CCF      =  4%

Note: Table made from pie chart.
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