Fournier's gangrene: a review of 1726 cases

Background: Although there is much consensus, certain controversies exist regarding the management of Fournier's gangrene. Method: Publications in English on Fournier's gangrene from January 1950 to September 1999 were obtained through the Medline database and relevant reference lists in publications. It was possible to identify 1726 cases for study. Data extracted for review included country of reported cases, number of patients in each report and relevant clinical features. Results: Fournier's gangrene occurs worldwide. However, its definition has generated considerable controversy as efforts are made to refine the original description in the light of increasingly understood aetiological factors. Attempts to classify the disease into primary and secondary forms have not been successful. The basic pathological process, necrotizing fasciitis, has been identified in the perineum of women and children, although the disease afflicts the male more often than the female. Most reported cases have occurred in the USA and Canada. The major sources of sepsis are the local skin, colon, anus and rectum, and the lower urinary tract. Colonic, anal and rectal sources carry the worst prognosis. Diabetes mellitus is important in aetiological terms. Rare causes include vasectomy and circumcision. Investigations are essential to define the cause of an episode but not for the diagnosis of the disease. Early aggressive treatment of Fournier's gangrene and underlying conditions is essential. Hyperbaric oxygen and honey are treatment modalities yet to be universally adopted. Risk of death, 16 per cent overall in this series, is related to the patient's condition at presentation. Conclusion: Controversies over the definition of Fournier's gangrene persist but these do not affect the treatment options. The diagnosis is made on clinical grounds. The occurrence of the disease in women is under-reported and may go unrecognized by some clinicians. Some treatment options, such as hyperbaric oxygenation and radical excision, remain controversial.