06-Fournier Gangrene

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					 Original Article

Fournier Gangrene Following Iatrogenic Urethral Trauma
Abdul Mannan, Muhammad Farooq, Riaz Ahmed Tasneem

Objectives: To assess outcome of 17 patients with         and multiple sessions of debridement (mean 3.07).
Fournier gangrene due to iatrogenic urethral trauma       Mean hospital stay was 21.3 days and mean time
after aggressive treatment.                               taken for rehabilitation of urethra and skin cover
Materials and Methods: Record of patients with            was 16.5 weeks. Optical urethrotomy was required
Fournier gangrene due to iatrogenic urethral trauma       in 11 patients, end to end urethral anastomosis in
was reviewed retrospectively between Jan 2000 to          four and perineal urethrostomy in one patient.
Dec 2007 in Department of Urology Services                Bilateral orchiectomy was done in two and
Hospital, Lahore. Etiology, duration of injury,           penectomy in one patient. Five patients required
extent of involvement, management, hospital stay          skin grafting.
and course of rehabilitation were evaluated.              Conclusion: Urethral trauma due to transurethral
Results: Seventeen patients were identified. Mean         manipulations may lead to Fournier gangrene.
age of the patients was 43.5 years. Mode of urethral      Patients usually present late in our set up.
injury included traumatic catheterization (9 cases),      Multidisciplinary approach towards management
traumatic bougienage (6 cases) and urological             including aggressive repeated sessions of
endoscopy (2 cases). Mean time interval between           debridement can improve survival. Rehabilitation
                                                          takes a long course. Measures should be taken to
injury and presentation in the hospital was 7.14 days
                                                          prevent iatrogenic urethral injury.
(range 1-30 days). All patients were treated with         Key Words: Fournier Gangrene, Iatrogenic urethral
broad spectrum antibiotics, suprapubic cystostomy         trauma, debridement, rehabilitation.

INTRODUCTION                                              MATERIALS AND METHODS
         Fournier gangrene is a devastating condition.             Record of 17 patients with Fournier gangrene
It can rapidly involve penis, scrotum, perineum and       following iatrogenic urethral trauma was reviewed
even abdominal wall. Associated morbidity and             retrospectively during the last seven years at our
                                                          Department. Etiological factors, time of presentation
mortality is significant. Mortality rate may be as high
                                                          and extent of gangrene were assessed. Patients were
as 45% in spite of multi modality treatment [1].          managed with broad spectrum antibiotics, extensive
Sources of infection may be urogenital, anorectal or      debridement, suprapubic urinary diversion and
cutaneous. Urogenital route is responsible for about      antiseptic dressings with sodium hypochlorite. Initial
50% cases of Fournier gangrene [2,3]. Various             hospital stay, ultimate management and time required
urogenital foci include urethral strictures, trauma,      for rehabilitation was also evaluated.
indwelling catheters, urethral calculi and prostatic
biopsy [4]. Itrogenic urethral trauma may result in
                                                                  Mean age of the patients was 43.5 years (range
extravasation of urine which can some times end up in     29-66 years). Etiological factors were traumatic
Fournier gangrene.                                        catheterization, traumatic bougienage, and urological
We have retrospectively reviewed the outcome of the       endoscopy (Fig-1). Mean time interval between
patients with Fournier gangrene following iatrogenic      urethral injury and presentation in the hospital was
urethral trauma. To our knowledge this is the first       7.14 days (range 1-30 days).          Extent of the
series of this kind.                                      involvement of Fournier gangrene was variable (Fig-2).
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Most of the patients presented with dribbling of urine.      urinary diversion and urgent surgical debridement.
Seven patients had associated fever. Details of              Extensive debridement of devitalized tissue remains
causative organisms are given in (Fig-3). All patients       the mainstay of management [1,4]. Many patients
required urinary diversion by suprapubic route.              require multiple sessions till all dead and infected
Multiple sessions of debridement were carried out            tissue is excised. Mean number of debridement
under general or spinal anesthesia.         Number of        sessions in our study was 3.07. Post operatively local
debridement sessions ranged from 1 to 7 (mean 3.07).         application of sodium hypochlorite or hydrogen per
Mean initial hospital stay of patients was 21.3 days.        oxide is effective. Application of unprocessed honey
Rehabilitation of the patients took a long time. Mean        has also been found effective. It can digest dead and
time of rehabilitation of urethra and skin cover was         necrotic tissue and accelerate healing [8]. Hyperbaric
16.5 weeks (range 8.5-38.6 weeks). Details of urethral       oxygen therapy if available, may prove beneficial [9].
and skin rehabilitation are given in Table 1 & 2.            We did not have the facility of hyperbaric oxygen.
                                                             Testes are rarely infected in Fournier gangrene because
DISCUSSION                                                   of their abundant blood supply. Incidence of patients
         Urethral      injury      following      urethral   requiring orchidectomy for non viable testes is upto
catheterization by untrained staff is not uncommon in        21% [3,8]. In our series two (11.7%) patients
our setup. Inflation of balloon in urethra leads to          underwent bilateral orchidectomy and one of them
urethral injury in most of the cases. In our series nine     required penectomy as well. Seven patients required
patients developed Fournier gangrene following this          transposition of testes in thigh pouches after
type of injury. Conventional bougienage is still being       debridement.
practiced by old fashioned urologists and surgeons in
peripheral hospitals which can prove disastrous. It has
hardly any place in modern urology. Urethral
dilatation with rubber catheter rather than metallic
                                                                Numbe r of
bougies has proved safer. Urological endoscopy by                Patie nts
untrained urology residents may also result in injury to
urethra leading to devastating complications. Injury                         0
may result from forceful introduction of instrument or
overzealous attempts to cut urethral stricture.
Ever since Fournier gangrene was first described by                     Fig. 1: Mode of Urethral Injury
Jean Alfred Fournier in 1883 the epidemiology and              Traumatic catheterization
clinical features of the disease have changed. Now it is       Traumatic bougienage
defined as infective necrotizing fascitis of the perineal,     Urological Endoscopy
genital, or periurethral region[4]. In modern setup it is
not truly idiopathic. Etiology may be identified in                   Some centers have recommended use of
approximately 95% of cases[5]. Infection is usually          Fournier gangrene severity index (FGSI) which
polymicrobial.       Bacterial      enzymes       activate   includes clinical and biochemical parameters. It has
intravascular clotting and vascular thrombosis which         proved to be useful prognostic indicator [3,10]. In
lead to dermal gangrene. Synergistic action of these         earlier studies very high mortality rates have been
bacteria can lead to extensive tissue destruction[6].        reported [11]. Cause of death is sepsis and multi organ
Diagnosis of Fournier gangrene is made primarily on          failure. With better understanding of disease and
clinical grounds. However radiological evaluation can        aggressive management, mortality has come down
be helpful in doubtful cases. Plain film and ultrasound      significantly [12]. In spite of late presentation there
may reveal air in the soft tissues. C.T can more clearly     was no mortality in our series. It was probably due to
depict the extent of soft tissue gas along with fascial      aggressive surgical debridement. Moreover, Fournier
thickening and fat stranding [7].                            Gangrene of urogenital origin is generally associated
         Management of this life threatening condition       with lesser morbidity and mortality than Fournier
has always been a challenge. Principles of                   Gangrene of anorectal origin [13].
management         are      aggressive     hemodynamic                In our Country, patients usually present late
stabilization, parenteral broad spectrum antibiotics,        when gangrene has already caused extensive
A.P.M.C Vol: 2 No.2 July-December 2008                                                                           88
destruction (Fig.2). Late presentation has also been        Table-1
reported in some other Asian studies as well [3,6].         Urethral Rehabilitation
Reasons behind late presentation are inaccessibility to      Optical urethrotomy                11(64.7%)
medical care in rural areas, illiteracy, poverty and fear    Urethroplasty                      04(23.5%)
of surgery.                                                  No further treatment               01(05.88%)
         Iatrogenic urethral trauma can sometimes lead       Perineal Urethrostomy              01(05.88%)
to life threatening Fournier gangrene. Patients usually
report late in our setup. Diagnosis is usually clinical.    Table-2
The mainstay of the management is radical                   Skin Rehabilitation
debridement along with repeated dressings, broad             Healed by secondary intention            09 (52.9%)
spectrum antibiotics and urinary diversion. In spite of      Secondary suturing                       03 (17.6%)
multi modality treatment patients require multiple           Skin grafting                            05 (29.4%)
hospitalizations and surgical procedures. Total
rehabilitation may take more than a year.                   REFERENCES
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A.P.M.C Vol: 2 No.2 July-December 2008                                                                         89
12. Verit A and Verit F.F. Fournier’s Gangrene. The    AUTHORS
    development of a classical pathology. BJU Int.       • Dr. Abdul Mannan
    2007; 100:1218-20.                                     Associate Professor
13. Laor E, Palmer LS, Tolia BM, Reid RE, Winter HI,       Department of Urology
    et al. Outcome prediction in patients with             Services Institute of Medical Sciences
    Fournier’s gangrene. J Urol 1995; 154: 89-92.          Lahore-Pakistan
                                                         • Dr. Muhammad Farooq
                                                           Senior Registrar
                                                           Department of Urology
                                                           Services Hospital,
                                                         • Prof. Dr. Riaz Ahmed Tasneem
                                                           Professor of Urology
                                                           Department of Urology
                                                           Services Institute of Medical Sciences

A.P.M.C Vol: 2 No.2 July-December 2008                                                              90

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