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Background and Objective : The aim of this study was to analyze sex differences in risk factors associated with hospital mortality in patients with Fournier gangrene (FG). Materials and Methods: A retrospective population-based study (2016-2021) included FG hospitalizations in Spain. To identify the risk factors, we used multivariable logistic regression and reported adjusted odds ratios (aORs) with 95% confidence intervals (CIs). Results : There were 3644 admissions for FG during the study period (82.5% men and 17.5% women). The mean hospitalization rate per 1000 admissions/year was 0.23 for men and 0.05 for women, and the mean hospitalization rate per 100,000 inhabitants/year was 2.7 for men and 0.4 in women. The most common comorbidities were hypertension (44.9%) and diabetes mellitus (35.6%). The main complications were sepsis (22.1%), 29.8% were admitted to the intensive care unit and 16.1% died. Mortality was higher in women (aOR 1.32, 95% CI 1.07-1.63). The main independent risk factors for mortality in the entire sample were older age, neoplasms, chronic kidney disease, heart failure, sepsis, acute kidney injury, and admission to the intensive care unit. In women, they were older age, leukemia, sepsis, acute kidney injury, and admission to the intensive care unit. Conclusions: The overall FG mortality rate was slightly higher in women than in men, people aged >64 years, people with chronic kidney disease, sepsis, and acute kidney injury, and admission to the intensive care unit. The independent factors associated with mortality in women were similar in both sexes.

Background: Lack of insurance is associated with poorer outcomes in hospitalized patients. However, few studies have explored this association in hospitalizations for necrotizing soft tissue infections (NSTIs). This study examined the impact of insurance status on the outcome of NSTI admissions. Methods: All adult hospitalizations for necrotizing fasciitis, gas gangrene, and Fournier gangrene between 2016 and 2018 were examined using the Nationwide Inpatient Sample database. Insurance status was categorized as insured (including Medicare, Medicaid, and Private, including Health maintenance organization (HMO) or uninsured (Self-pay). Outcome measures included mortality rates, limb loss, length of hospital stay, prolonged hospital stay, and critical care admissions. Statistical analysis included weighted sample analysis, chi-square tests, multivariate regression analysis, and negative binomial regression modeling. Results: Approximately 29,705 adult hospitalizations for NSTIs were analyzed. Of these, 57.4% (17,065) were due to necrotizing fasciitis, 22% (6,545) to gas gangrene, and 20.5% (6,095) to Fournier gangrene. Approximately 9.7% (2,875) were uninsured, whereas 70% (26,780) had insurance coverage. Among the insured, Medicare covered 39.6% (10,605), Medicaid 29% (7,775), and private insurance 31.4% (8,400). After adjustments, Medicare insurance was associated with greater odds of mortality (adjusted odds ratio [aOR]: 1.81; 95% confidence interval [CI]: 1.33-2.47; p = 0.001). Medicaid insurance was associated with increased odds of amputation (aOR: 1.81; 95% CI: 1.33-2.47; p < 0.001), whereas private insurance was associated with lower odds of amputation (aOR: 0.70; 95% CI: 0.51-0.97; p = 0.030). Medicaid insurance was associated with greater odds of prolonged hospital stay (aOR: 1.34; 95% CI: 1.09-1.64; p < 0.001). No significant association was observed between the lack of insurance or self-pay and the odds of primary or secondary outcomes. Conclusion: Medicare insurance was correlated with greater odds of mortality, whereas Medicaid insurance was associated with increased odds of amputation and longer hospital stay. Uninsured status was not associated with significant differences in NSTI outcomes.

Objectives: To explore the trends in Fournier's gangrene (FG) incidence and mortality rate in Taiwan and to investigate the contributing factors to such changes., Methods: Between 2002 and 2016, hospitalized FG patients who underwent subsequent surgical intervention were included in this retrospective study. Incidence, outcomes, age-adjusted Charlson Comorbidity Index (ACCI), hospitalization cost, surgical timing, and the number of multidisciplinary specialists involved in the first-line management of FG in each year were collected. Simple linear regression and Pearson correlation coefficient (r) were used for the subsequent analysis., Results: The national cohort enrolled 2183 FG patients from 2002 to 2016 in Taiwan. The age-standardized incidence rate of FG was between 0.4 and 0.8 per 100 000 population, and overall mortality was 7.8% in these 15 years. We illustrated the downward trendline of FG mortality with a 0.62 coefficient of determination. The mortality of FG patients who underwent surgery within 24 h and after 24 h were found to be 8.3 ± 3.9% and 14.6 ± 25.2%, respectively (p = 0.02). The numbers of urologists, anesthesiologists, emergency doctors, and physicians per 100 000 population had a strong negative linear correlation with FG mortality (r = 0.8, p < 0.001). ACCI score had a moderate linear relationship with FG mortality (r = 0.57, p = 0.027). The hospitalization cost showed a weak linear correlation with FG mortality (r = -0.03, p = 0.92)., Conclusions: We demonstrated the downward trend of the FG mortality rate in Taiwan from 2002 to 2016. Besides underlying comorbidities and surgical timing, sufficient multidisciplinary specialists are essential for the survival benefit of FG patients in Taiwan experience., (© 2022 The Japanese Urological Association.)

Purpose: The purpose of this paper was to investigate patterns of health care utilization leading up to diagnosis of necrotizing soft tissue infections of the genitalia and to identify risk factors associated with potential diagnostic delay., Materials and Methods: IBM MarketScan Research Databases (2001-2020) were used to identify index cases of necrotizing soft tissue infections of the genitalia. We identified health care visits for symptomatically similar diagnoses (eg, penile swelling, cellulitis) that occurred prior to necrotizing soft tissue infections of the genitalia diagnosis. A change-point analysis identified the window before diagnosis where diagnostic opportunities first appeared. A simulation model estimated the likelihood symptomatically similar diagnosis visits represented a missed opportunity for earlier diagnosis. Patient and provider characteristics were evaluated for their associations with delay., Results: We identified 8,098 patients with necrotizing soft tissue infections of the genitalia, in which 4,032 (50%) had a symptomatically similar diagnosis visit in the 21-day diagnostic window, most commonly for "non-infectious urologic abnormalities" (eg, genital swelling; 64%): 46% received antibiotics; 16% saw a urologist. Models estimated that 5,096 of the symptomatically similar diagnosis visits (63%) represented diagnostic delay (mean duration 6.2 days; mean missed opportunities 1.8). Risk factors for delay included urinary tract infection history (OR 2.1) and morbid obesity (OR 1.6). Visits to more than 1 health care provider/location in a 24-hour period significantly decreased delay risk., Conclusions: Nearly 50% of insured patients who undergo debridement for, or die from, necrotizing soft tissue infections of the genitalia will present to a medical provider with a symptomatically similar diagnosis suggestive of early disease development. Many of these visits likely represent diagnostic delay. Efforts to minimize logistic and cognitive biases in this rare condition may lead to improved outcomes if they lead to earlier interventions.

Fournier's gangrene (FG) is a serious pathology of the soft tissues and fascia of the perineum and genital region with a high morbidity and mortality rate. In recent years, the SGLT-2 inhibitor oral antidiabetic has been related to this entity. According to the new warnings from the main drug agencies, a compilation of cases has been initiated to establish or deny a possible causal relationship. Most of these cases have been reported in men. However, it is important not to underestimate this entity in the gynecological field, since it is extremely serious and requires intense and rapid aggressive treatment based on surgery and empiric antibiotherapy. Later, some cares are needed to involve surgical reconstruction of the defects introduced by debridement. As a result of the low incidence of FG, clinical trials' data may be insufficient to robustly assess this issue because of the limited numbers of participants. Real-world evidence may help to clarify the association between SGLT2i and FG. The aim of this review is to describe and compare the reported cases of GF in diabetic women who received SGLT2 inhibitors as antiglycemic agents.

Objective: This study aims to describe the condition of Fournier's gangrene in Dr. Soetomo General Hospital from January 2014 to December 2020., Material and Methods: This study used a retrospective analytic design, by taking data through medical records at Dr. Soetomo General Hospital from January 2014 to December 2020. This study used total sampling with recorded data: age, gender, length of stay, outcome, location, comorbidities, causes, management, culture results, and Fournier's gangrene severity index (FGSI) score., Result: Of the 135 subjects collected, it was found that 55.56% were individuals over 50 years of age. About 91.11% were male patients, with some sites being in the scrotum 50.37%. Only 25.19% of patients had no comorbids, while the rest had a history of CKD, hypertension, diabetes, or a combination of these diseases. Bacterial cultures obtained were mostly caused by the Enterobacteriaceae bacteria group (32.59%). Of the subjects we studied who experienced mortality, it was found that all were from the group with FGSI >9., Conclusion: From the results of our descriptive study, at a glance, it appears that there is a tendency for the incidence of Fournier's gangrene in the elderly and individuals with comorbidities. And the mortality rate increases with a high FGSI value. So that FGSI could be used as a predictor of mortality in patients with FG.

Fournier's gangrene (FG), a necrotizing fasciitis of the genital and perineal region, is a serious and debilitating multi-infective pathological condition. More commonly seen in adults, its occurrence in neonates is uncommon. We share our experience with neonatal FG (NFG), highlighting potential factors which may predispose neonates to it.Ours is a five year retrospective review of cases of NFG in our service. Data obtained included health facility of birth, mode of delivery, symptoms and duration, investigation results, treatment and outcome. Sixteen neonates were included, comprising 13 males (M:F  =  4.3:1). Fourteen were delivered outside our centre; breech vaginal delivery, hot water massaging and application of native concoctions were common. All were treated with antibiotics and wound debridement, but five (37.5%) died.NFG is not that rare in our service. Early recognition is imperative to reduce mortality. Neonates delivered by breech vaginally may be particularly at risk.

Background: Recent studies of patients with Fournier's gangrene (FG) highlight the importance of early surgical intervention in improving mortality rates. We prospectively determined subgroups of patients with FG at high risk of severe local morbidity., Methods: We prospectively evaluated all patients diagnosed with FG at a tertiary hospital (1 January 2018 to 1 January 2021). Data were collated on demographics, comorbidity, infection source, treatment and clinical outcomes., Results: We identified 14 consecutive male patients with a median (interquartile range) age of 57 (50-64) years. Most common risk factors were diabetes (n = 10, 71%) and obesity (n = 10, 71%). Median (range) HbA1c was 11.20 (7.5-15.3), and body mass index of 41.25 (23.7-70.0). Seven patients had adjacent organ involvement (AOI), involving the corporal bodies (57%) and testes (43%). The most common suspected source was dermatological (50%), followed by genitourinary (29%) and gastrointestinal (GI) (21%). Median (interquartile range) hospital length of stay (LOS) was 32 (8.5-30.75) days. Patients with AOI were more likely to have a suspected GI source, need mechanical ventilation (p = 0.023), a significantly longer LOS (p = 0.015) and time to wound closure (p = 0.04). Patients with suspected dermatological origin of infection, had a significantly lower rate of AOI (p = 0.029), mechanical ventilation (p = 0.029) and a shorter LOS (p = 0.035)., Conclusion: In our prospective series, FG is associated with a high rate of AOI and suspected non-dermatological origin of infection, which confers significant perioperative morbidity including the need for mechanical ventilation, LOS and longer time from initial debridement to wound closure., (© 2021 Royal Australasian College of Surgeons.)

Background: Necrotizing soft-tissue infections (NSTIs) encompass a group of severe, life-threatening diseases with high morbidity and mortality. Evidence suggests advanced age is associated with worse outcomes. To date, no large data sets exist describing outcomes in older individuals, and risk factor identification is lacking., Methods: Retrospective data were obtained from the 2015 Medicare 100% sample. Included in the analysis were those aged ≥65 y with a primary diagnosis of an NSTI (gas gangrene, necrotizing fasciitis, cutaneous gangrene, or Fournier's gangrene). Risk factors for in-hospital mortality and discharge disposition were examined. Continuous variables were assessed using central tendency, t-tests, and Wilcoxon rank-sum tests. Categorical variables were assessed using the chi-squared and Fisher's exact tests. Statistical significance was defined as P < 0.05., Results: 1427 patient records were reviewed. 59% of patients were male, and the overall mean age was 75.4±8.6 y. 1385 (97.0%) patients required emergency surgery for their NSTI diagnosis. The overall mortality was 5.3%. Several underlying comorbidities were associated with higher rates of mortality including cancer (OR: 3.50, P = 0.0009), liver disease (OR: 2.97, P = 0.03), and kidney disease (OR: 2.15, P = 0.01). While associated with high in-hospital mortality, these diagnoses were not associated with a difference in the rate of discharge to home compared with skilled nursing or rehab. Overall, patients discharged to skilled nursing facilities or rehab had higher rates of underlying comorbidities than patients who were discharged home (3 or more comorbid illness 84.3% versus 68.6%, P < 0.0001); however, no individual comorbid illness was associated with discharge location., Conclusions: In our Medicare data set, we identified several medical comorbidities that are associated with increased rates of in-hospital mortality. Patients with underlying cancers had the highest odds of increased mortality. The effect on outcomes of the potentially immunosuppressive cancer treatments in these patients is unknown. These data suggest that patients with underlying illnesses, especially cancer, kidney disease, or liver disease have higher mortalities and are more likely to be discharged to skilled nursing facilities or rehab. It is unclear why these illnesses were associated with these worse outcomes while others including diabetes and heart disease were not. These data suggest that these particular comorbid illnesses may have special prognostic implications, although further analysis is necessary to identify the causative factors., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Methicillin-resistant Staphylococcus aureus USA300, belonging to sequence type (ST) 8, is a rare cause of necrotizing fasciitis in the USA. We herein report a case of monomicrobial Fournier's gangrene caused by an ST8, methicillin-susceptible Staphylococcus aureus (designated ksw1). Whole-genome sequencing and analyses for virulence determinants revealed that, unlike USA300, ksw1 lacked virulence genes, such as Panton-Valentine leukocidin and SCCmec, while harboring the toxic shock syndrome toxin-1 gene. These genomic features correlate with ST8 CA-MRSA/J, which is the major genotype of ST8 in Japan.

Background: To provide better management of Fournier's gangrene, mortality-associated comorbidities and common etiologies were identified., Methods: A systematic search was conducted using 12 databases, followed by meticulous screening to select relevant articles. Meta-analysis and meta-regression (for possible cofounders) were both done for all possible outcomes., Results: Out of 1186 reports screened, 38 studies were finally included in the systematic review and meta-analysis. A higher risk of mortality was detected in patients with diabetes, heart disease, renal failure, and kidney disease, with risk ratios (RR) and 95% confidence intervals (95% CI) of 0.72 (0.59-0.89), 0.39 (0.24-0.62), 0.41 (0.27-0.63), and 0.34 (95% CI 0.16-0.73), respectively. However, there was no association between mortality rates and comorbid hypertension, lung disease, liver disease, or malignant disease (p > 0.05). The highest mortality rates were due to sepsis (76%) and multiple organ failure (66%), followed by respiratory (19.4%), renal (18%), cardiovascular (15.7%), and hepatic (5%) mortality., Conclusions: Modifications to the Fournier's Gangrene Severity Index (FGSI) are recommended, in order to include comorbidities as an important prognostic tool for FG mortality. Close monitoring of the patients, with special interest given to the main causes of mortality, is an essential element of the management process., (Copyright © 2019 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: Is the present study aims to analyze demographic, clinical and surgical data of all patients with FG (Fournier's gangrene) admitted to a tertiary healthcare hospital in the largest city of Turkey., Methods: This study included 35 patients with Fournier's gangrene, who were followed by the General Surgery, Plastic Surgery, and Urology Departments of Istanbul University Cerrahpaşa Faculty of Medicine from January 2010 to January 2015. Demographic and clinical data, including gender, age, length of stay at the hospital, the underlying cause(s), number of debridement, predisposing factors, and surgical reconstructive data over 10 years were assessed and analyzed retrospectively., Results: The mean age of the 35 patients was 58.14±12.71 years. Diabetes mellitus was present in 20 of the 35 (57.1%) patients. Twelve of the patients (34.2%) were hospitalized in the intensive care unit (ICU). Length of stay in the ICU was found to be significantly influenced by age, hematocrit level, FGSI and UFGSI (p=0.013, p=0.030 p=0.025 and p=0.002, respectively)., Conclusion: Fournier's gangrene is a fulminant infection with a high mortality rate. Physical examination and anamnesis are quite important for the diagnosis of FG. DM is the most common comorbidity. Age, hematocrit level, FGSI and UFGSI scores affect the patients' length of stay in the ICU.

Fournier's gangrene (FG) is a rare, life-threatening necrotizing fasciitis of the perineum. The US Food and Drug Administration (FDA) released a Drug Safety Communication regarding the risk of FG associated with sodium-glucose co-transporter-2 inhibitors (SGLT2i), relying on the FDA Adverse Event Reporting System. To verify this association, we performed a meta-analysis of all randomized controlled trials enrolling patients with type 2 diabetes, comparing SGLT2i with placebo or different therapies, collecting cases of FG reported as a serious adverse event. Risk of abscess, cellulitis and erysipela were secondary outcomes. We retrieved 84 trials enrolling 42 415 patients in the SGLT2i group and 27 158 patients in comparator groups. No difference was observed between SGLT2i and comparators in the risk of FG (Mantel-Haenzel odds ratio [MH-OR] 0.41 [0.09, 1.82]), abscess (MH-OR 0.94 [0.54, 1.65]), cellulitis (MH-OR 0.90 [0.71, 1.13] or erysipela (MH-OR 0.89 [0.45, 1.77]). The number of events was small, leading to a wide confidence interval that does not allow ruling out an increase in FG or skin and subcutaneous tissue infections., (© 2019 John Wiley & Sons Ltd.)

Cases of a rare but serious infection called Fournier's gangrene have been reported with sodium-glucose co-transporter-2 inhibitors (SGLT-2i). To evaluate the safety signal in a population of patients with type 2 diabetes, we used administrative claims data from Horizon Blue Cross Blue Shield of New Jersey from 2014 through 2017 to estimate incidence rates of Fournier's gangrene or necrotizing fasciitis of the perineum among patients treated with a second-line antidiabetic drug. We found very low incidence rates of Fournier's gangrene or necrotizing fasciitis. While we found no indication of an increased risk among SGLT-2i users compared with similar patients treated with other second-line antidiabetic medications, the small number of events yielded wide confidence intervals., (© 2019 John Wiley & Sons Ltd.)

Background: Sodium-glucose cotransporter-2 inhibitors (SGLT2i) have been associated with increased occurrence of Fournier's gangrene (FG), a rare but serious form of necrotizing fasciitis, leading to a warning from the Food and Drug Administration. Real-world evidence on FG is needed to validate this warning., Methods: We used data from IBM MarketScan (2013-2017) to compare the incidence of FG among adult patients who initiated either SGLT2i, a dipeptidyl peptidase-4 inhibitor (DPP4i), or any non-SGLT2i antihyperglycemic medication. FG was defined using inpatient International Classification of Diseases, Ninth Edition and Tenth Edition diagnosis codes 608.83 and N49.3, respectively, combined with procedure codes for debridement, surgery, or systemic antibiotics. We estimated crude incidence rates (IRs) using Poisson regression, and crude and adjusted HRs (aHR) and 95% CIs using standardized mortality ratio-weighted Cox proportional hazards models. Sensitivity analyses examined the impact of alternative outcome definitions., Results: We identified 211 671 initiators of SGLT2i (n=93 197) and DPP4i (n=118 474), and 305 329 initiators of SGLT2i (n=32 868) and non-SGLT2i (n=272 461). Crude FG IR ranged from 3.2 to 3.8 cases per 100 000 person-years during a median follow-up of 0.51-0.58 years. Compared with DPP4i, SGLT2i initiation was not associated with increased risk of FG for any outcome definition, with aHR estimates ranging from 0.25 (0.04-1.74) to 1.14 (0.86-1.51). In the non-SGLT2i comparison, we observed an increased risk of FG for SGLT2i initiators when using FG diagnosis codes alone, using all diagnosis settings (aHR 1.80; 0.53-6.11) and inpatient diagnoses only (aHR 4.58; 0.99-21.21)., Conclusions: No evidence of increased risk of FG associated with SGLT2i was observed compared with DPP4i, arguably the most relevant clinical comparison. However, uncertainty remains based on potentially higher risk in the broader comparison with all non-SGLT2i antihyperglycemic agents and the rarity of FG., Trial Registration Number: EUPAS Register Number 30018., Competing Interests: Competing interests: VP: receives salary support from the National Institute on Aging (R01 AG056479), National Institutes of Health (NIH) (R01 HL118255), and the National Center for Advancing Translational Sciences (NCATS, UL1TR002489), NIH. JBB: outside of the submitted work, JBB reports contracted consulting fees and associated travel support paid to his employer from Adocia, AstraZeneca, Dance Biopharm, Dexcom, Eli Lilly, Fractyl, GI Dynamics, Intarcia Therapeutics, Lexicon, MannKind, Metavention, NovaTarg, Novo Nordisk, Orexigen, PhaseBio, Sanofi, Senseonics, vTv Therapeutics, and Zafgen; grants and related travel support from AstraZeneca, Eli Lilly, Intarcia Therapeutics, Johnson & Johnson, Lexicon, Medtronic, Novo Nordisk, Sanofi, Theracos and vTv Therapeutics; personal fees from Cirius Therapeutics, CSL Behring; stock or stock options from Mellitus Health, PhaseBio, Stability Health, and Pendulum Health; grants from the US National Institutes of Health (UL1TR002489, U01DK098246, UC4DK108612, U54DK118612), PCORI and American Diabetes Association. TS: receives investigator-initiated research funding and support as principal investigator (R01 AG056479) from the National Institute on Aging (NIA), and as coinvestigator (R01 CA174453, R01 HL118255, R21-HD080214), National Institutes of Health (NIH). He also receives salary support as Director of Comparative Effectiveness Research (CER), NC TraCS Institute, UNC Clinical and Translational Science Award (UL1TR002489), the Center for Pharmacoepidemiology (current members: GlaxoSmithKline, UCB BioSciences, Merck, Takeda), from pharmaceutical companies (Amgen, AstraZeneca, Novo Nordisk), and from a generous contribution from Dr Nancy A Dreyer to the Department of Epidemiology, University of North Carolina at Chapel Hill. TS does not accept personal compensation of any kind from any pharmaceutical company. He owns stock in Novartis, Roche, BASF, AstraZeneca, and Novo Nordisk., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Fournier gangrene (FG) is a rare, life-threatening infection that can result in significant morbidity and mortality, with many patients requiring emergency department (ED) management for complications and stabilization., Objective: This narrative review provides an evidence-based summary of the current data for the emergency medicine evaluation and management of FG., Discussion: Although originally thought to be an idiopathic process, FG has been shown to have a strong association for male patients with advanced age and comorbidities affecting microvascular circulation and immune system function, most commonly those with diabetes or alcohol use disorder. However, it can also affect patients without risk factors. The initial infectious nidus is usually located in the genitourinary tract, gastrointestinal tract, or perineum. FG is a mixed infection of aerobic and anaerobic bacterial flora. The development and progression of gangrene is often fulminant and can rapidly cause multiple organ failure and death, although patients may present subacutely with findings similar to cellulitis. Laboratory studies, as well as imaging including point-of-care ultrasound, conventional radiography, and computed tomography are important diagnostic adjuncts, though negative results cannot exclude diagnosis. Treatment includes emergent surgical debridement of all necrotic tissue, broad-spectrum antibiotics, and resuscitation with intravenous fluids and vasoactive medications., Conclusions: FG requires a high clinical level of suspicion, combined with knowledge of anatomy, risk factors, and etiology for an accurate diagnosis. Although FG remains a clinical diagnosis, relevant laboratory and radiography investigations can serve as useful adjuncts to expedite surgical management, hemodynamic resuscitation, and antibiotic administration., (Published by Elsevier Inc.)

Introduction: Fournier's gangrene (FG) is a fulminant necrotizing fasciitis of the perineum and genitalia. The objective of this study was to study the etiology and microbiology associated with FG and to study the debridement and reconstructive procedures required in these patients., Methods: This was a prospective follow up study conducted from September 2011 to November 2012 at Coimbatore medical college hospital, Coimbatore, India. Patients presenting to the outpatient department and emergency department with the clinical diagnosis of FG were included in the study., Results: A total of 34 patients were studied in the study period. The mean age of presentation in years was 50±11.13. The male to female ratio was 33:1. The source of the infection was most commonly anorectal. Diabetes mellitus was the most common co morbid factor associated. Most commonly the disease was polymicrobial with escherichia coli being the commonest grown organism. The average number of wound debridement required was 2.9±1.42. Primary closure of the scrotal skin defect was the most common reconstructive procedure performed. Mortality associated with the disease in our series was 11.8%., Conclusion: Although FG is a relatively rare disease, it is still prevalent in Indian population. Incidence of FG in HIV patients is high, even though it is not the commonest of the co morbid condition. The mortality can be kept to minimal with aggressive medical and surgical management. Extensive raw area following the infection and wound debridement can be managed by simple reconstructive procedures with good outcome., Competing Interests: All authors declare no competing interest.

Background: Fournier's gangrene (FG) is a life-threatening infection of the genital, perineal, and perianal regions with a morbidity range between 3 and 67%. Our aim is to report our experience in treatment of FG and to assess whether three different scoring systems can accurately predict mortality and morbidity in FG patients., Methods: All patients that were treated for FG at the Department of Urology of the University Hospital Basel between June 2012 and March 2017 were included and assessed retrospectively by chart review. Furthermore, we calculated Fournier's Gangrene Severity Index (FGSI), the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC), and the neutrophil-lymphocyte ratio (NLR) in every patient and assessed whether those scores correlate with the patients' morbidity and mortality., Results: Twenty patients were included, with a median (IQR) age of 66 (46-73) years. Fifteen of twenty (75%) patients required treatment on an intensive care unit, and three died (mortality rate: 15%). The mean FGSI, LRINEC, and NLR scores were 13.0, 9.3, and 45.3 for non-survivors and 7.7, 6.5, and 26 for survivors, respectively. None of the risk scores correlated significantly with mortality; however, all three significantly correlated with infection- and surgically-induced morbidity., Conclusions: In our series, Fournier's gangrene was associated with a mortality rate of 15% despite maximum multidisciplinary therapy at a specialized center. All risk scores were able to predict the morbidity of the disease in terms of local extent and the required surgical measures., Competing Interests: This retrospective study was approved by the local IRB (EKNZ number 2017-01336).Written informed consent was obtained from the patient’s next of kin for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Necrotizing fasciitis is a severe type of necrotizing soft tissue infection involving the superficial fascia and subcutaneous tissues. Fournier gangrene, a type of necrotizing fasciitis, affects the genitalia or perineum. Although a rare health condition, Fournier gangrene can result in significant morbidity and unnecessary mortality following delay in diagnosis and management. We provide a review of relevant presenting features to aid diagnosis and allow timely surgical management of this serious infectious condition., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Fournier's gangrene is an uncommon but often devastating infection. There are few contemporary data on the risk factors and evolving microbiologic trends including drug-resistant organisms implicated in these life-threatening infections., Methods: A retrospective study of Fournier's gangrene from 2006 to 2015 at a large academic hospital was conducted. Cases were identified using ICD codes (ICD-9: 608.83, V13.89; ICD-10: N49.3, Z87.438), and a review of medical, radiographic, and pathology records was performed to confirm each case. Data collected included socio-demographics, medical conditions, bacterial pathogens and their resistance patterns, treatments, and outcome. Descriptive and univariate statistics were performed., Results: A total of 59 cases were evaluated with an overall incidence of 31.8 cases per 100,000 admissions which remained stable over the study period. Mean age was 56 years (range 18-91), 71% were male, and 44% white. Risk factors included overweight/obesity (61%), diabetes (44%, with a mean A1c of 9.6%), immunocompromised state (34%), and illicit use (20%). A causative organism was identified in all except 2 cases; 12 patients (21%) had a multidrug-resistant organism (MDRO) with MRSA being the most common pathogen (n = 8, 14% of all cases), followed by ESBL E. coli (n = 3) and MDRO Acinetobacter (n = 1). MRSA was the sole pathogen isolated in five (63%) of the eight cases involving this organism. Among those with an aerobic Gram-negative rod (GNR) isolated, 32% were fluoroquinolone-resistant. Overall, 30% of cases had a poor outcome (15% died and an additional 15% had loss of an organ/body part). Those with an MDRO were more likely to experience a poor outcome (42% vs. 28%), although this was not statistically significant (p = 0.48); of note, most (83%) MDRO cases were initially treated with an antibiotic that the organism was susceptible., Conclusions: This report highlights the emergence of MDROs as an important cause of Fournier's gangrene including MRSA and drug-resistant GNRs. Antibiotics should be chosen with broad-spectrum, anti-MDRO activity given the high morbidity and mortality associated with these infections., (Copyright © 2017 The British Infection Association. Published by Elsevier Ltd. All rights reserved.)

Background: Fournier's gangrene is a surgical emergency that progresses rapidly and insidiously and results in high morbidity and mortality rates unless it is immediately diagnosed and managed. Here we analyze the outcomes of patients who were followed up and treated for Fournier's gangrene., Methods: We conducted a retrospective analysis of the medical data of 25 patients operated on for Fournier's gangrene between January 2010 and June 2015. The diagnosis of Fournier's gangrene was made by performing a physical examination. Patients who had genital, perineal, and perianal tenderness; induration; cyanosis; gangrene; and subcutaneous crepitation were considered as having Fournier's gangrene. Following resuscitation, aggressive surgical debridement was performed and vacuum-assisted closure (VAC) was conducted in addition to debridement in select patient. Repeat debridements were performed as requirement., Results: This study included 25 patients. Fourteen patients (56%) were females and 11 (44%) were males. The mean age of the patients was 54.3 years (range: 27-82 years). The mean duration of hospital stay was 21.4 days; the mean number of debridements performed was 2.4. Thirteen patients (52%) had perianal abscesses, and 20 (80%) had diabetes mellitus. All patients underwent extensive debridement; 16 patients (64%) underwent VAC in addition to debridement. Patients undergoing VAC had significantly longer durations of hospital stay and a higher mean number of debridements performed (p=0.004 and p=0.048, respectively). An ostomy was made in one patient, and one patient died., Conclusion: In Fournier's gangrene, early diagnosis, effective resuscitation, aggressive debridement, and VAC application in suitable cases may reduce the morbidity and mortality rates and the need for an ostomy.

Background: This study aimed to evaluate the usefulness of Fournier's gangrene scoring index (FGSI) and Uludag FGSI (UFGSI) for predicting mortality in patients with FG., Methods: Patients who underwent treatment and follow-up in the A division department of general surgery at two education and research hospitals between January 2012 and December 2015 were evaluated for mortality-related factors. The sensitivities of FGSI and UFGSI scoring systems for predicting mortality-related factors and disease prognosis were evaluated. Patients were grouped as survivors (Group I) or non-survivors (Group II)., Results: In total, 29 patients were included in the study. The mean age (±SD) was 51.52±13.36 years. The mortality rate was 20.6% (six patients). Bacterial growth was observed in wound cultures of 17 patients (58.6%). Of the patients with bacterial growth, 11 (47.8%) were in Group I and six (100%) were in Group II. The presence of bacterial growth was significantly associated with mortality (p=0.028). Fourteen patients (48.3%) had comorbid conditions. The number of comorbid conditions was related (p=0.049). FGSI and UFGSI scores were significantly higher in Group II than in Group I (p=0.002 and p=0.001, respectively). Among UFGSI parameters, extent of disease, body temperature, pulse rate, and HCO3 values were significantly higher in Group II than in Group I (p<0.05). The FGSI and UFGSI scoring systems had 100% sensitivity and 78.2% and 73.9% specificity, respectively, for predicting mortality., Conclusion: The FGSI and UFGSI scoring systems are valuable for predicting mortality in patients with FG. The extent of the disease was an important prognostic parameter in this study. Whichever scoring system is used, we suggest the use of the extent of disease score in UFGSI.

Background: Fournier's gangrene (FG) is a life-threatening infection affecting the perineum and genitals. Complex patient management often necessitates transfer to tertiary centers. We aimed to characterize hospital transfer patterns and assess morbidity among patients with FG in Washington State., Study Design: The Washington State Comprehensive Hospital Abstract Reporting System includes claims from all hospital discharges in Washington. We identified patients with FG between 2007 and 2013, based on diagnosis and treatment codes. Analyses were stratified by center volume (low-volume centers [LVCs] or high-volume centers [HVCs]), and transfer status. Variables of interest included number of debridements, septic shock, acute renal failure, acute respiratory failure, length of hospitalization, and death., Results: We identified 165 FG patients. Only 1 HVC treated more than 2 FG patients per year. Overall mortality was 6.7%. Most patients (57%) were treated entirely at LVCs; 87% of patients treated at the HVC were transferred from an LVC. High-volume center-treated patients had similar baseline comorbidities (p = 0.77) and similar mortality (p = 0.87), despite higher rates of septic shock (p < 0.01) and respiratory failure (p = 0.01) compared with LVC patients. Among HVC-transferred patients, immediate compared with delayed transfer was associated with fewer debridements (p < 0.01), lower rates of septic shock (p = 0.05), and acute renal failure (p = 0.04)., Conclusions: Patients treated at the HVC were more acutely ill, yet mortality was similar compared with patients treated solely at LVCs, suggesting a benefit to transfer of high acuity patients. Immediate vs delayed transfer may benefit FG health outcomes; however, this may also reflect greater disease acuity of patients with delayed transfer status., (Copyright © 2016 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Introduction and Hypothesis: Fournier's gangrene is a rare, necrotising fasciitis of the external genitalia, perineal or perianal regions. The disease has a higher incidence in males and risk factors for development include diabetes, HIV, alcoholism and other immune-compromised states. The aggressive disease process is associated with a high mortality rate of 20-30%. In addition, the increasing age and prevalence of diabetes in the population, begs the need for increased clinical awareness of Fournier's gangrene with emphasis on early diagnosis and management. This review aims to highlight the relevant research surrounding Fournier's gangrene, in particular the various prognostic indicators and management strategies., Methods: A search was conducted on the MEDLINE database for all applicable research; clinical reviews, retrospective studies and case reports. In addition to which a search of the European Association of Urology, the British Association for Urological Surgeons and the British Medical Journal was conducted for the most recent recommendations., Results: Immediate broad-spectrum antibiotic therapy and urgent surgical debridement are the core managerial principles of Fournier's gangrene. The use of adjunctive therapies such as hyperbaric oxygen and vacuum assisted closure are supported in some aspects of the literature and disputed in others. The lack of randomized controlled studies limits the use of these potential additional therapies to patients unresponsive to conventional management. The value of unprocessed honey as a topical antimicrobial agent has been highlighted in the literature for small lesions in uncomplicated patients., Conclusion: Fournier's gangrene is a urological emergency with a high mortality rate despite advances in the medical and surgical fields. The aggressive nature of the infection advocates the need for early recognition allowing immediate surgical intervention. The opposing results of available research as well as the lack of high quality evidence surrounding emergent therapies prevents their routine use in the management of Fournier's gangrene. The absence of a specific care pathway may hinder efficient management of Fournier's gangrene, thus based on current guidelines a management pathway is suggested.

Purpose: Case series reported 20-40% mortality rates for patients with Fournier's gangrene with some series as high as 88%. This literature comes almost exclusively from referral centers., Materials and Methods: We identified and analyzed inpatients with Fournier's gangrene who had a surgical debridement or died in the US State Inpatient Databases., Results: One thousand six hundred and forty one males and 39 females with Fournier's gangrene represented <0.02% of hospital admissions. Overall, the incidence was 1.6 cases per 100,000 males and case fatality was 7.5%. Sixty six percent of hospitals cared for no cases per year, 17% cared for 1 case per year, 10% cared for 2 cases per year, 4% cared for 3 cases per year, 1% cared for 4 cases per year, and only 1% cared for ≥5 cases per year. Teaching hospitals had higher mortality (adjusted OR 1.9) due primarily to more acutely ill patients. Hospitals treating more than 1 Fournier's gangrene case per year had an adjusted 42-84% lower mortality (p < 0.0001)., Conclusions: Most hospitals rarely care for Fournier's gangrene patients. The population-based mortality rate (7.5%) was substantially lower than the case series from tertiary care centers. Hospitals that treated more number of Fournier's gangrene patients had lower mortality rates, thereby supporting the rationale that regionalized care worked well for patients with this rare disease., (© 2016 S. Karger AG, Basel.)

Background: Fournier's gangrene (FG) is a rare, rapidly progressive, necrotizing fasciitis of the external genitalia and perineum, leading to soft-tissue necrosis. Despite antibiotics and aggressive debridement, the mortality rate of FG remains high. This study describes our experiences in the management of FG and identifies prognostic factors., Methods: This was a descriptive retrospective study of patients with FG treated at Bugando Medical Centre between November 2006 and April 2014., Results: A total of 84 patients (M:F = 41:1) were studied. The median age was 34 years (range 15-76 years). The most common predisposing factor was diabetes mellitus (16.7%). Nine (11.3%) patients were HIV positive. Bacterial culture results were obtained in only 46 (54.8%) patients. Of these, 38(82.6%) had polymicrobial bacterial growth while 8 (17.4%) had monomicrobial bacterial growth. Escherichia coli (28.3%) were the most frequent bacterial organism isolated. All the microorganisms isolated showed high resistance to commonly used antibiotics except for Meropenem and imipenem, which were 100% sensitive each respectively. All patients were treated with a common approach of resuscitation, broad-spectrum antibiotics, and wide surgical excision. The median length of hospital stay (LOS) was 28 days and mortality rate was 28.6%. Systemic inflammatory response syndrome and diabetes mellitus were significantly associated with prolonged LOS (p < 0.001), whereas advancing age (>60 years), late presentation (>48 h), systemic inflammatory response syndrome on admission, diabetes mellitus, extension of infection to the abdominal wall, FG severity score >9 and HIV infection with CD4 count <200 μl/cells) were independent predictors of mortality (p < 0.001)., Conclusion: Fournier's gangrene remains a very severe disease with high mortality rates. Early recognition of infection associated with invasive and aggressive treatment is essential for attempting to reduce mortality rates associated with this disease in our setting.

Fournier's gangrene (FG) is a rapid progressive bacterial infection that involves the subcutaneous fascia and part of the deep fascia but spares the muscle in the scrotal, perianal and perineal region. The incidence has increased dramatically, while the reported incidence of rectal cancer-induced FG is unknown but is extremely low. Pathophysiology and clinical presentation of rectal cancer-induced FG per se does not differ from the other causes. Only rectal cancer-specific symptoms before presentation can lead to the diagnosis. The diagnosis of rectal cancer-induced FG should be excluded in every patient with blood on digital rectal examination, when urogenital and dermatological causes are excluded and when fever or sepsis of unknown origin is present with perianal symptomatology. Therapeutic options are more complex than for other forms of FG. First, the causative rectal tumor should be removed. The survival of patients with rectal cancer resection is reported as 100%, while with colostomy it is 80%. The preferred method of rectal resection has not been defined. Second, oncological treatment should be administered but the timing should be adjusted to the resolution of the FG and sometimes for the healing of plastic reconstructive procedures that are commonly needed for the reconstruction of large perineal, scrotal and lower abdominal wall defects.

Background: This study was conducted to investigate the bacteriology and associated patterns of antibiotic resistance Fournier gangrene., Methods: Patients with Fournier's gangrene from 2008 to 2012 were identified from the computerized database in a medical center in southern Taiwan. The medical records of all patients with Fournier's gangrene were reviewed retrospectively., Results: There were 61 microorganisms, including 60 bacteria and one Candida spp, isolated from clinical wound specimens from 32 patients. The most common isolates obtained were Streptococcus spp. (n=12), Peptoniphilus spp. (n=8), Staphylococcus aureus (n=7), Escherichia coli (n=7), and Klebsiella pneumoniae (n=7). Among 21 strains of gram-negative bacilli, five (23.8%) were resistant to fluoroquinolones, and three isolates were resistant to ceftriaxone. Two E. coli strains produced extended-spectrum beta-lactamase. Four of the seven S. aureus isolates were methicillin-resistant. Among 15 anaerobic isolates, nine (60%) were resistant to penicillin, and eight (53.3%) were resistant to clindamycin. Four (26.7%) isolates were resistant to metronidazole. The only independent risk factor associated with mortality was inappropriate initial antibiotic treatment (p=0.021)., Conclusion: Antibiotic-resistant bacteria are emerging in the clinical setting of Fournier gangrene. Clinicians should use broad-spectrum antibiotics initially to cover possible antibiotic-resistant bacteria.

Background: Fournier's gangrene is a devastating condition that affects mostly patients whose immunity has been reduced. There is increasing evidence for increasing incidence of the disease in those with HIV disease., Objective: To evaluate the presentation, bacteriology and outcome of Fournier's gangrene in our area in recent times in view of the high prevalence in Nairobi and its environs., Results: One hundred and forty six patients were treated for Fournier's gangrene during the study period; all were male. They had a mean age of 38.6 years (range 2 months - 86 years). HIV infection was the most common associated underlying illness (16.4 %), followed by diabetes mellitus and alcoholism (11%)., Conclusions: HIV infection is emerging as leading predisposing factor and has overtaken diabetes in predisposing for Fournier's gangrene in Kenyatta National Hospital.

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.

Background: Fournier's gangrene (FG) is a devastating and potentially fatal disease requiring prompt and aggressive debridement. In this study, it was aimed to assess the predictors of mortality in a large cohort., Methods: Prospectively maintained data of patients with FG were analyzed. Demographic data, duration of symptoms, Uludag Fournier's Gangrene Severity Index (UFGSI) scores, co-morbidities [particularly diabetes mellitus (DM)], etiologies, number of debridement, stoma requirements, length of intensive care unit and hospital stay, and morbidity and mortality rates were reviewed. Multivariate analysis was performed in order to determine factors affecting mortality., Results: 120 patients (81 males) were included in the study. Median age was 58 (22-85) years. UFGSI score was median 9 (1-30). DM was present in 69 (57.5%) patients. Etiology of FG was perianal in fifty-nine, urogenital in 52, and skin in 9 patients. Median debridement count was 3 (1-12). Thirty-one patients required stoma. Forty-eight patients were admitted to intensive care unit and 25 patients required mechanical ventilation. Overall mortality rate was 20.8%. Multivariate analysis revealed UFGSI as the only predictor of mortality (p=0.001). Mortality rate was 13.64 times higher for patients with a UFGSI score of 9 or higher., Conclusion: Fournier's gangrene is a mortal disease requiring emergency surgery. UFGSI is an efficient predictor of mortality for patients with FG.

Background: The purpose of the present study was to retrospectively analyze the patients' data presented with Fournier's gangrene (FG), to compare obtained data with the literature and to investigate the role of "trauma" in the etiopathogenesis., Methods: A retrospective study was conducted on 126 patients with FG that consulted to our department., Results: There were 76 male and four female patients. The mean age of the patients was 53.5±13.6 years. The most common presentation of patients was swelling (n=74). The scrotum has been shown to be the most commonly affected area in the patients (n=75). Diabetes mellitus was the leading predisposing factor and trauma was the leading responsible cause for FG. Escherichia coli was the most frequently identified microorganism (n=43, 53.75%). Primary closure was the most common technique used for all patients. Three patients exhibited a mortal course due to sepsis and multi-organ failure., Conclusion: FG still has a high mortality rate. Rapid and correct diagnosis of the disease can avoid inappropriate or delayed treatment and even death of the patient. The healthcare professionals should be aware that any trauma in the perineal region could lead to FG.

Background: Fournier's gangrene is a rare necrotizing soft tissue infection of the scrotum and penis. We report, to our knowledge, the first case of Fournier's gangrene caused by Streptococcus dysgalactiae subsp. equisimilis (SDSE), a strain of pyogenic β-hemolytic streptococci that is increasingly being recognized as an important human pathogen., Case Presentation: We describe a healthy 59 year-old Caucasian male who presented to the emergency department with Fournier's gangrene of the penis and scrotum, with extension to the anterior abdominal wall. He underwent urgent surgical debridement of his scrotum, penis, and anterior abdomen. Swabs from the scrotum grew Gram-positive cocci, which were initially identified as Streptococcus anginosus group by matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS). However, polymerase chain reaction (PCR) amplification and sequencing of the 16S rRNA gene identified the isolate as Streptococcus dysgalatiae subspecies equisimilis (SDSE). The incidences of invasive S. anginosus group and SDSE infections at the London Health Sciences Centre, a tertiary-care institution in southwestern Ontario, were determined between August 1, 2011 and August 31, 2012, revealing a slightly lower rate of SDSE (3.2 cases per 100,000 population) than other studies., Conclusions: This case highlights a unique disease manifestation of the emerging human pathogen Streptococcus dysgalatiae subspecies equisimilis that has not been previously reported. This case also underscores the limitations of MALDI-TOF MS in differentiating between closely-related streptococcal species which may have different pathogenic profiles.

Perineoscrotal gangrene is an acute disease, a rare and severe affection of the perineum, whose evolution is unpredictable and rapidly extensive. The diagnosis is clinical. The paraclinical examinations allow early diagnosis and assessment of anatomical and biological repercussions. We conducted a retrospective study of 45 patients spread over six years, involving a multidisciplinary team consisting of three specialists (urologists, visceral, plastic surgeons). The average age was 52 years. The largely male dominated our series. Fournier gangrene was the most common etiology. We noted five cases of death (11%) in the acute phase, secondary to septic shock (four patients) or multiple organ failure (one patient). The evolution was favorable in 40 other patients in the series, requiring an initial management in intensive care unit, and surgical treatment. The average hospital stay was 17 days. After the acute phase, all patients underwent a surgery for skin coverage, ranging from guided healing (two patients) to musculocutaneous flap of the gracilis (six patients) via the secondary suture (four patients), the burying the testes (18 patients) and half thick skin graft, with a functional and aesthetic result was acceptable, and minimal sequelae. In our series, the most predictive prognostic factors would be the delay of care, sepsis on admission and associated diseases., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

Fournier's gangrene is a necrotizing, life-threatening fasciitis of the perineal, genital and perianal region which can spread to the abdominal wall, causing soft-tissue necrosis and sepsis. It is usually a polymicrobial infection. The prevalence of the disease is low, but the mortality rate remains high. Several urogenital and anorectal diseases, as well as diabetes mellitus and conditions associated with the immunosuppressive reaction, may predispose an individual to the development of Fournier's gangrene. A diagnosis of Fournier's gangrene is clinical, but radiological examinations may be helpful in establishing the extent of the necrotic process. The treatment consists mainly of aggressive surgical debridement, broad-spectrum antibiotic combinations and hyperbaric oxygen therapy. The Fournier's gangrene severity index (FGSI) score can be used to evaluate patients. Because of its heterogeneity and aggressiveness, Fournier's gangrene is a very serious and complex medical condition that should be under the care of an interdisciplinary team with access not only to the best surgical and critical care but also to a hyperbaric chamber.

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 37.1.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.

Background and Objectives: Fournier gangrene is a urological emergency associated with a high mortality. It is a necrotizing fasciitis caused by polymicrobial infection originating in the anorectal or genitourinary area. The aim of this study was to analyze the epidemiological and clinical characteristics of Fournier gangrene along with the variables that influence disease course and mortality in patients treated in our department., Material and Methods: We carried out a retrospective study of 37 patients diagnosed with Fournier gangrene between January 2001 and October 2010., Results: All the patients were men, 43.2% had diabetes, and the mean age of the patients was 57.68 years. Statistically significant differences were observed between the age of surviving patients and that of patients who died (55.8 and 69.6 years, respectively). The mean hospital stay was 27.54 days and 32.4% of patients required admission to the intensive care unit. Etiology was unknown in 39.8% of cases. Polymicrobial infection was observed in 59.5% of cases. The mean health care cost associated with a patient diagnosed with Fournier gangrene admitted to intensive care and requiring at least 1 procedure in the operating room was €25,108.67. Mortality was 13.5%. Based on analysis of individual comorbid conditions, only ischemic heart disease displayed a statistically significant association with mortality due to Fournier gangrene; ischemic heart disease was also associated with longer hospital stay., Conclusions: Fournier gangrene is associated with high mortality despite appropriate early treatment. Although the condition is infrequent, the high associated health care costs suggest that primary and secondary prevention measures should be implemented., (Copyright © 2011 Elsevier España, S.L. and AEDV. All rights reserved.)

Introduction: To identify the predisposing factors, etiological and clinical characteristics as well as the Fournier's gangrene (FG) severity index (FGSI) in the outcomes of patients with FG., Materials and Methods: The data from 71 patients diagnosed with FG in a period of 17 years were retrospectively reviewed for the age of the patient, their history, predisposing factors, etiology, prodromal symptoms, FGSI, culture results, hospitalization period, surgical interventions, responses to the therapy and complications., Results: All of the patients were Caucasian males, and the mean age was 61.3 (range 36-92) years. The mean duration from the onset of symptoms to surgery was 7.5 days. The mean hospitalization time was 27.4 days and the most common etiological factor for FG was a perineal abscess. The overall mortality rate was 29.6%. The relationship between the number of predisposing factors and mortality rates in patients with FG was the most statistically significant parameter (p = 0.001)., Conclusions: Multiple predisposing factors predict a poor prognosis and correlate significantly with mortality. Extension of the disease and the FGSI score were not predictive of outcome. The most essential intervention for stopping the rapidly progressing infectious process of FG consists of early recognition of the disease, proper management of the predisposing factors and aggressive surgical debridement. Such an intervention can improve clinical outcomes., (Copyright © 2012 S. Karger AG, Basel.)

Background: Fournier's gangrene (necrotizing fasciitis) is an acute life-threatening disease of the perineal area that requires urgent medical intervention. Once the affected area is surgically debrided and the patient is stabilized, surgical management typically involves 1 or more additional procedures that may include split-thickness skin grafts, flaps, or an elective diverting urostomy and/or colostomy. The professional literature discussing nonsurgical approaches to healing for Fournier's gangrene after surgical debridement is sparse., Case: We present 3 cases of male patients with Fournier's gangrene from our facility who healed uneventfully with negative pressure wound therapy placed after extensive debridement without further surgical intervention. An added benefit was a satisfactory aesthetic effect., Conclusion: Expert wound management including negative pressure wound therapy after surgical debridement of Fournier's gangrene eliminated the need for further operative procedures and prolonged hospitalizations in these cases. We believe that surgical teams should consider using negative pressure wound therapy as part of the initial curative plan of care after debridement, and that plans for restorative plastic surgery should be restricted to patients who do not exhibit adequate improvement with conservative wound management.

Background and Objectives: Fournier gangrene is a urological emergency associated with a high mortality. It is a necrotizing fasciitis caused by polymicrobial infection originating in the anorectal or genitourinary area. The aim of this study was to analyze the epidemiological and clinical characteristics of Fournier gangrene along with the variables that influence disease course and mortality in patients treated in our department., Material and Methods: We carried out a retrospective study of 37 patients diagnosed with Fournier gangrene between January 2001 and October 2010., Results: All of the patients were men, 43.2% had diabetes, and the mean age of the patients was 57.68 years. Statistically significant differences were observed between the age of surviving patients and that of patients who died (55.8 and 69.6 years, respectively). The mean hospital stay was 27.54 days and 32.4% of patients required admission to the intensive care unit. Etiology was unknown in 39.8% of cases. Polymicrobial infection was observed in 59.5% of cases. The mean health care cost associated with a patient diagnosed with Fournier gangrene admitted to intensive care and requiring at least 1 procedure in the operating room was €25,108.67. Mortality was 13.5%. Based on analysis of individual comorbid conditions, only ischemic heart disease displayed a statistically significant association with mortality due to Fournier gangrene; ischemic heart disease was also associated with longer hospital stay., Conclusions: Fournier gangrene is associated with high mortality despite appropriate early treatment. Although the condition is infrequent, the high associated health care costs suggest that primary and secondary prevention measures should be implemented., (Copyright © 2011 Elsevier España, S.L. and AEDV. All rights reserved.)

Study Design: Retrospective chart review., Objectives: The aim of our study was to evaluate the mortality rate and further specific risk factors for Fournier's gangrene in patients with spinal cord injury (SCI)., Setting: Division of Spinal Cord Injury, BG-University Hospital Bergmannsheil Bochum, Ruhr-University Bochum, Germany., Methods: All patients with a SCI and a Fournier's gangrene treated in our hospital were enrolled in this study. Following parameters were taken form patients medical records: age, type of SCI, cause of Fournier's gangrene, number of surgical debridements, length of hospital and intensive care unit stay, co morbidity factors and mortality rate. In addition, laboratory parameter including the laboratory risk indicator for necrotizing fasciitis (LRINEC) score and microbiological findings were analyzed. Clinical diagnosis was made via histological examination., Results: A total of 16 male patients (15 paraplegic and one tetraplegic) were included in the study. In 81% of all cases, the origin of Fournier's gangrene was a pressure sore. The median LRINEC score on admission was 6.5. In the vast majority of cases, a polybacterial infection was found. No patient died during the hospital stay. The mean number of surgical debridements before soft tissue closure was 1.9 and after a mean time interval of 39.1 days wound closure was performed in all patients., Conclusions: Pressure sores significantly increase the risk of developing Fournier's gangrene in patients with SCI. We reported the results of our patients to increase awareness among physicians and training staff working with patients with a SCI in order to expedite the diagnosis.

Fournier gangrene is a necrotizing fasciitis of the genital and perineal region. Diverse factors predispose to Fournier gangrene, such as diabetes mellitus, ethylism, liver dysfunction, haematological disorders, obesity or recent regional instrumentation. Rectal tumours can also predispose to Fournier gangrene; most of the reported cases are perforated or unresectable colorectal tumours, but some cases of anorectal cancer diagnosed after recovery from Fournier gangrene have also been reported. In these cases, the presence of a rectal tumour at the time of, or prior to, diagnosis of Fournier gangrene could not be ruled out. We present three cases of rectal cancer whose first manifestation was as Fournier gangrene.

Aim: This retrospective analysis presents our experience in treating Fournier gangrene (FG) and aims to bring in focus diagnostic and therapeutic problems as well as early and aggressive treatment., Patients and Methods: A total of 16 male patients were included in the study. The gastrointestinal form was seen in 5 and the urogenital form in 11 patients. The subjects ranged in age from 39 to 74 years (average 61) for the urogenital, and from 48 to 72 (average 58) for the gastrointestinal form. Other conditions were seen in 9 patients (diabetes mellitus was most common). Most patients were infected with several bacteria. We performed colostomy in 1 patient, orchidectomy in 2 patients, cystostomy in 2 patients and penis amputation in 1 patient. Ultrasound-guided biopsy or aspiration, and CT was also used. Aggressive surgical necrectomy and aggressive antimicrobial therapy was used., Results: Treatment was successful in 14 of 16 patients (87.5%). The length of hospitalization was 19-58 days (average 48) for the urogenital form and 24-56 days (average 41) for the gastrointestinal form. Mortality was 12.5%. A lethal outcome was recorded in two patients infected with methicillin-resistant Staphylococcus aureus. The average time between onset and hospitalization was 3-11 days (5 on average) for urogenital FG and 4-10 days (average 6) for gastrointestinal FG. Treatment was significantly longer in patients with a comorbidity, such as diabetes or liver cirrhosis due to alcohol abuse., Conclusion: Early diagnosis as well as intensive and aggressive treatment are key to successful treatment of FG. Comorbidity increases length of therapy and lowers the chance for recovery. Disease can be seen again several years after the initial outburst., (Copyright © 2011 S. Karger AG, Basel.)

Objectives: To study the spectrum of presentation and outcome of different treatment modalities in Fournier's gangrene., Methods: It's a prospective analysis of 73 diagnosed patients of Fournier's gangrene admitted and treated in surgical department of a public sector university from June 2000 to June 2008. All patients were admitted through casualty with varying proportions of necrotizing infection of the perineal and genital fascia, with gangrene of the overlying skin. After resuscitation and preliminary investigations, including culture of the necrotic tissue, the patients were treated either conservatively by broad spectrum antibiotics, cardiopulmonary support, nutritional and fluid support or surgically by repeated aggressive wound debridement under anaesthesia. The behaviour of the disease, different modalities of treatment offered, response and outcome of the management were all collected on a proforma for statistical analysis on SPSS version 12., Results: Seventy three patients with a mean age of 57.32 +/- 13.87 years and range of 33-86 years presented with varying degrees of Fournier's gangrene. Of the total population, 67 (91.78%) were males and 6 (8.213%) were females. Fifty nine (80.82%) patients had one or the other co-morbidity with maximum number (n = 44, 60.2%) having diabetes mellitus. State of diabetes control was found to be an important prognostic factor. A source of infection was identified in skin, ano-rectal and perineal regions in 42 (57.53%) patients. Thirteen (17.80%) patients died despite aggressive conservative or surgical treatment., Conclusion: Fournier's gangrene continues to be a lethal disease despite overall improvement in the antibiotic spectrum and surgical techniques. Diabetes remains the most important prognostic factor in the outcome of disease.

Objective: Fournier's gangrene is a necrotizing fasciitis that affects the perineal, genital, or perianal regions. The objective of this study was to highlight this uncommon condition with a particular focus on the disease course in females., Materials and Methods: From 1996 to 2008, we prospectively collected data from 38 patients with Fournier's gangrene (12 women, 26 men) and retrospectively analyzed relevant parameters., Results: The mean age was 60.9 +/- 11.3 years for females (group I) and 56.2 +/- 11.7 years for males (group II). In both groups, the main predisposing factors were diabetes mellitus and obesity (body mass index of 30 or higher). Twelve men (46.2%), but no women, had chronic alcoholism. The most commonly isolated agents were Escherichia coli (n = 22), streptococcal species (n = 18), Pseudomonas aeruginosa (n = 9), and Staphylococcus aureus (n = 7). Mortality was significantly higher among females (50%) than males (7.7%; p = 0.011). Peritonitis was present in seven group I patients (58.3%) and in two group II patients (7.7%). The retroperitoneum was involved in seven female patients (58.3%) and four male patients (15.4%)., Conclusion: The female gender is a risk factor for mortality in patients with Fournier's gangrene and is associated with a higher incidence of inflammation of the retroperitoneal space and abdominal cavity. Differences in male and female genital anatomy may be the reason for the rapid spread of infection to the retroperitoneum and the fatal outcome in women. Fournier's gangrene as a high-risk disease in females should attract exceeding attention.

Background: Fournier's gangrene is a necrotizing fasciitis involving the perineal and genital regions. Even today, this often polymicrobial infection still carries a high mortality rate and continues to be a major challenge to the medical community. The purpose of this study was to report our experience with this condition and to compare it with those reported in published studies. We also introduce our approach to treatment., Methods: We analyzed data from 33 patients with Fournier's gangrene who were managed in our hospital from 1996 to 2007, focusing on patient gender, age, etiology, predisposing conditions, comorbidities, bacteriology, sepsis, blood results, mortality, and spread of gangrene., Results: 18 (54.5%) of the 33 patients had been referred to our department by smaller district hospitals. The patient cohort consisted of 23 men and ten women with a median age of 59 years (range 40-79 years). The median time between the onset of symptoms and progression to gangrene was 6 days (range 2-28 days). An underlying cause was identified in 27 patients (81.8%). The commonest etiological events were perianal and perirectal abscesses (n = 13; 39.4%). Predisposing factors included diabetes mellitus in 12 cases (36.4%), chronic alcoholism in ten cases (30.3%), immunosuppression in six cases (18.2%), and prolonged immobilization in five cases (15.2%). 17 patients (51.5%) had a body mass index (BMI) of 25 or higher, and 13 patients (39.4%) had a BMI of 30 or higher. Positive cultures were obtained in 30 cases (90.9%). In 26 cases (78.8%), multiple microorganisms were recovered, including nine cases (27.3%) with both aerobes and anaerobes. Sepsis was present in 26 patients (78.8%). The mortality rate was 18.2%., Conclusion: Fournier's gangrene remains a major challenge with a high mortality. Our results suggest that women are more commonly affected than has generally been assumed. Contrary to published reports, we found that anorectal sources appear to account for more cases of Fournier's gangrene than urological sources.

Background: Although there is much consensus, certain controversies still exist regarding the pathology of Fournier's gangrene. The purpose of this study was to determine the prevalence of the disease in the catchment area of the three teaching hospitals, to identify the systemic predisposing factors and local aetiological factors, and to assess the recommended role of aggressive surgical debridement as a part of treatment., Materials and Methods: This prospective study was conducted in the surgical departments of three tertiary care hospitals of the Khyber Medical University, Peshawar, Pakistan, from 1 January 2002 to 30 June 2007. Detailed history and examination of all patients were carried out to reach the diagnosis of Fournier's gangrene. After initial resuscitation, patients were treated aggressively, including surgical debridement., Results: Sixty patients were studied in the study period. The male to female ratio was 5:1. The age range was 20-75 years with mean 47+17.4 (SD) years. The socioeconomic status of patients was poor (the average income was less than $50 per week) in 36 (60%) and 24 (40%) were middle class (the average income being $50-100 per week). Thirty-nine patients (65%) presented in the hot humid months of the year. Extent of the disease was scrotum in 18 patients (30%), perineum in 30 (50%) and abdominal wall in 12 (20%). Systemic predisposing factors identified in our study were diabetes mellitus in 20 (33.33%) patients, chronic alcohol abuse in two (3.33%) and long-standing steroid therapy in four (6.67%) while in 34 patients (56.67%) no cause was identified. The local aetiological origin of Fournier's gangrene was urogenital in 14 (23.33%) patients, anorectal in 10 (16.67%) and cutaneous in 8 (13.33%) and no local pathologies could be identified in 28 (46.67%) patients. The mean time interval between first symptom and initial treatment was 2.5 days with a range of 1-7 days. Number of debridement sessions per patient was 2-6 (mean, 3.15). Mean hospital stay was 31+7 (SD) with a range of 10-50 days. Morbidity was 80%. Four patients (6.67%) died. Three of these patients presented to hospital 5-6 days too late., Conclusion: Fournier's gangrene is not an uncommon disease in South Asia. Systemic predisposition such as diabetes mellitus, long-standing steroid therapy, chronic alcoholism and even the hot humid season can contribute to this dreadful disease. Local causes in the form of urogenital, anorectal and cutaneous disorders may trigger this disease in some patients. Early recognition of disease and aggressive surgical debridement are the main treatments.

Purpose: Case series have shown a Fournier's gangrene mortality rate of 20% to 40% with an incidence of as high as 88% in some studies. Because to our knowledge there are no population based data, we used a national database to investigate the epidemiology of Fournier's gangrene., Materials and Methods: We used the State Inpatient Databases, the largest hospital based database available in the United States, which includes 100% of hospital discharges from participating states. Inpatients diagnosed with Fournier's gangrene (ICD-9 CM 608.83) who underwent genital/perineal débridement or died in the hospital were identified from 13 participating states in 2001 and from 21 in 2004. Population based incidence, regional trends and case fatality rates were estimated., Results: We identified 1,641 males and 39 females with Fournier's gangrene. Cases represented less than 0.02% of hospital admissions. The overall incidence was 1.6/100,000 males, which peaked in males who were 50 to 79 years old (3.3/100,000) with the highest rate in the South (1.9/100,000). The overall case fatality rate was 7.5%. Patients with Fournier's gangrene were rarely treated at hospitals (mean +/- SD 0.6 +/- 1.2 per year, median 0, range 0 to 23). Overall 0 to 4 and 5 or greater cases were treated at 66%, 17%, 10%, 4%, 1% and 1% of hospitals, respectively., Conclusions: Patients with Fournier's gangrene are rarely treated at most hospitals. The population based mortality rate of 7.5% was substantially lower than that reported in case series from tertiary care centers.