DOI: 10.1148/rg.282075048
RadioGraphics 2008;28:519-528
© RSNA, 2008
Fournier Gangrene: Role of Imaging1
Robin B. Levenson, MD,
Ajay K. Singh, MD, and
Robert A. Novelline, MD
1 From the Department of Radiology, University of Massachusetts Memorial Medical Center, 55 Lake Avenue N, Worcester, MA 01655 (R.B.L., A.K.S.); and Division of Emergency Radiology, Massachusetts General Hospital, Boston, Mass (A.K.S., R.A.N.). Presented as an education exhibit at the 2006 RSNA Annual Meeting. Received March 19, 2007; revision requested June 18 and received November 2; accepted December 10. All authors have no financial relationships to disclose.
Address correspondence to R.B.L. (e-mail: RBL500{at}yahoo.com).
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Abstract
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Fournier gangrene is a rapidly progressing necrotizing fasciitis involving the perineal, perianal, or genital regions and constitutes a true surgical emergency with a potentially high mortality rate. Although the diagnosis of Fournier gangrene is often made clinically, emergency computed tomography (CT) can lead to early diagnosis with accurate assessment of disease extent. CT not only helps evaluate the perineal structures that can become involved by Fournier gangrene, but also helps assess the retroperitoneum, to which the disease can spread. Findings at CT include asymmetric fascial thickening, subcutaneous emphysema, fluid collections, and abscess formation. Subcutaneous emphysema is the hallmark of Fournier gangrene but is not seen in all cases. Compared with radiography and ultrasonography, CT provides a higher specificity for the diagnosis of Fournier gangrene and superior evaluation of disease extent; however, diagnosis and evaluation can also be performed with these other modalities. The administration of broad-spectrum antibiotics and aggressive surgical débridement of the nonviable tissue are both essential for successful treatment. An awareness of the CT features of Fournier gangrene is imperative for prompt diagnosis and effective treatment planning.
© RSNA, 2008
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LEARNING OBJECTIVES
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After reading this article and taking the test, the reader will be able to:
- Describe the manifestations and treatment of Fournier gangrene.
- Recognize the imaging features of Fournier gangrene at CT, US, and radiography and the limitations of these modalities in this setting.
- Discuss the role of imaging in the early diagnosis of Fournier gangrene and the evaluation of disease extent.
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Introduction
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Fournier gangrene represents a urologic emergency with a potentially high mortality rate. It is a rapidly progressing, polymicrobial necrotizing fasciitis of the perineal, perianal, and genital regions, with a mortality rate ranging from 15% to 50% (1–4). Inflammation and edema from infection result in an impaired local blood supply, leading to vascular thrombosis in the cutaneous and subcutaneous tissues. Perifascial dissection with subsequent spread of bacteria and progression to gangrene of the overlying tissues ensues. The rate of fascial necrosis has been noted to be as high as 2–3 cm per hour, making early diagnosis crucial (5,6).
Early diagnosis is important because immediate surgical débridement and aggressive antibiotic treatment are indicated. Although the diagnosis of Fournier gangrene is often made clinically, radiologic imaging—particularly computed tomography (CT)—can help confirm the diagnosis in clinically ambiguous or questionable cases. Radiography or ultrasonography (US) can also demonstrate some of the findings of Fournier gangrene, but CT has greater specificity for the diagnosis and for demonstration of disease extent (1,7). It is important that radiologists be aware of the imaging features of Fournier gangrene to permit accurate diagnosis and immediate surgical treatment.
In this article, we discuss and illustrate Fournier gangrene in terms of history; predisposing factors; clinical manifestations; routes of spread; imaging characteristics at CT, radiography, and US; and treatment and outcome.
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History
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Fournier gangrene was first described by Jean Alfred Fournier, a French venereologist, in 1883. At that time, it was described as abrupt in onset with rapid progression to gangrene, but without a clear etiology (8). The disease was noted to occur most commonly in young males. Today, Fournier gangrene is most commonly found in middle-aged men (mean age, 50–60 years) (3–5,9,10) and, to a much lesser extent, in women and children. Males are 10 times more likely to develop Fournier gangrene than are females (2,9,11), perhaps due to easier drainage of the female perineum via the vaginal route, which may hinder development of the disease (2,12). In addition, it is thought that the diagnosis of Fournier gangrene in females is underreported (12).
Nowadays, the cause of Fournier gangrene is usually identified, with only 10% of cases being idiopathic (5). The disease is most often due to a local infection adjacent to a point of entry, including abscesses (particularly in the perianal, perirectal, and ischiorectal regions), anal fissures, and colonic perforations. Fournier gangrene has also been reported secondary to rectal carcinoma and diverticulitis (13). The urologic sources of Fournier gangrene include urethral strictures, chronic urinary tract infection, neurogenic bladder, recent instrumentation, and epididymitis (1). In women, additional causes of Fournier gangrene have included septic abortion, Bartholin gland or vulvar abscess, episiotomy, and hysterectomy (9). Insect bites, burns, trauma, and circumcision have been reported as causes of pediatric Fournier gangrene, which is rarely seen (1). Although the actual incidence of Fournier gangrene is unknown, the disease is relatively uncommon.
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Predisposing Factors
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The most common predisposing factors for Fournier gangrene are diabetes mellitus and alcohol abuse (5,9). Coexisting diabetes mellitus has been found in up to 40%–60% of patients with Fournier gangrene (11,14). Other important predisposing factors include indwelling catheters, localized trauma, surgical procedure, malignancy, steroids, chemotherapy, radiation therapy, prolonged hospitalization, and human immunodeficiency virus.
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Clinical Manifestations
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The most common presenting symptoms of Fournier gangrene include scrotal swelling, pain, hyperemia, pruritus, crepitus, and fever (9,13). A foul-smelling discharge may also be present. The onset of symptoms tends to occur over a 2–7-day period (7,10). Soft-tissue gas may be present prior to the detection of clinical crepitus. Crepitus is identified at physical examination in 19%–64% of patients (15). Air in the soft tissues represents insoluble gas produced by anaerobic bacteria and consists primarily of nitrogen, hydrogen, nitrous oxide, and hydrogen sulfide (7,15). Systemic findings in Fournier gangrene may include leukocytosis, dehydration, tachycardia, thrombocytopenia, anemia, hypocalcemia, and hyperglycemia (7,8,16). Fournier gangrene tends to be polymicrobial in nature, with synergy of aerobic and anaerobic bacteria. An average of more than three organisms is cultured per patient (15,17). The most commonly found bacteria are Escherichia coli (aerobe) followed by Bacteroides (anaerobe) and streptococcal species (aerobe) (9). Other bacteria involved in Fournier gangrene include Staphylococcus, Enterococcus, Clostridium, Pseudomonas, Klebsiella, and Proteus species. The organisms that tend to be found in Fournier gangrene are species that normally exist below the pelvic diaphragm, in the perineum and genitalia (2).
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Routes of Spread
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Familiarity with the perineal anatomy and its fascial planes is important in understanding the potential pathways of disease spread. The perineum consists of two triangles: the anal triangle and the urogenital triangle (Fig 1). The anal triangle is posterior to an imaginary line between the ischial tuberosities, whereas the urogenital triangle is anterior to this line (7). The posterior and lateral borders of the anal triangle are the coccyx and sacrotuberous ligaments, respectively. The urogenital triangle is bordered laterally by the ischial rami and anteriorly by the pubis.
Infection in Fournier gangrene tends to spread along the fascial planes (Figs 2, 3). Infection arising from the anal triangle can spread along the Colles fascia (superficial perineal fascia) and progress anteriorly along the Dartos fascia to involve the scrotum and penis. It can also pass superiorly along the Scarpa fascia to involve the anterior abdominal wall. The Colles fascia is attached laterally to the pubic rami and fascia lata and posteriorly to the urogenital diaphragm, thereby limiting the spread of infection in these directions. If the Colles fascia is interrupted, the infection can spread to the ischiorectal fossa and subsequently to the buttocks and thighs (Fig 3). Infection originating from the urogenital triangle, urethra, or periurethral glands can involve the Buck fascia, which initially limits infection to the ventral aspect of the penis. If infection is not initially treated and the Buck fascia is penetrated, the infection may progress along the Colles and Dartos fasciae as described earlier (1,7).
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Figure 3. Drawing of the perineum (axial view) demonstrates routes of fascial spread (arrows). Infection can spread along the Colles fascia and progress anteriorly along the Dartos fascia to involve the scrotum and penis. If the Colles fascia is interrupted, infection can spread to the ischiorectal fossa and then to the buttocks and thighs.
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Imaging Characteristics
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Although the diagnosis of Fournier gangrene is most commonly made clinically, CT can be valuable in patients in whom the diagnosis is unclear or the extent of disease is difficult to discern (18). CT has greater specificity for evaluating disease extent than does radiography, US, or physical examination (7). With the widespread use of CT in the emergency setting, Fournier gangrene has been increasingly studied with this imaging technique. CT plays an important role in the diagnosis as well as the evaluation of disease extent for appropriate surgical treatment (13). The etiology of the gangrene, anatomic pathways of spread, and presence of any fluid collection or abscess are best assessed with CT. Furthermore, subcutaneous emphysema and its extent, including retroperitoneal extension, are well evaluated at CT. The imaging finding of soft-tissue air may be present before clinical crepitus is detected (19). However, the absence of subcutaneous air in the scrotum or perineum does not exclude the diagnosis of Fournier gangrene. Up to 90% of patients with Fournier gangrene have been reported to have subcutaneous emphysema, so that at least 10% do not demonstrate this finding (19). CT can help evaluate both the superficial and the deep fascia. In many cases, physical examination does not accurately help predict the degree of necrosis found at surgery (7). CT is also important in differentiating Fournier gangrene from other less aggressive entities such as soft-tissue edema or cellulitis, which may appear similar to Fournier gangrene at physical examination. In addition, CT is beneficial in the posttreatment follow-up of therapeutic response.
Computed Tomography
The CT features of Fournier gangrene include soft-tissue thickening and inflammation. CT can demonstrate asymmetric fascial thickening, any coexisting fluid collection or abscess, fat stranding around the involved structures, and subcutaneous emphysema secondary to gas-forming bacteria (Figs 4–6) (7,19). The subcutaneous emphysema in Fournier gangrene dissects along fascial planes and can extend from the scrotum and perineum to the inguinal regions, thighs, abdominal wall, and retroperitoneum (Fig 7) (7,19). The underlying cause of the Fournier gangrene, such as a perianal abscess, a fistulous tract, or an intraabdominal or retroperitoneal infectious process, may also be demonstrated at CT (7). In cases caused by colonic perforation, not only does CT demonstrate extraluminal foci of air, but extravasation of enteric contrast material may also be seen (13). The extent of fascial thickening and fat stranding seen at CT has been found to correlate well with the affected tissue at surgery (11,12,19). In early Fournier gangrene, CT can depict progressive soft-tissue infiltration, possibly with no evidence of subcutaneous emphysema. Because the infection progresses rapidly, the early stage with lack of subcutaneous emphysema is brief and is rarely seen at CT (19). Posttreatment follow-up CT is valuable in assessing for improvement or worsening of disease to determine if additional therapy or surgery is needed (Fig 8).
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Figure 4a. Fournier gangrene in an 84-year-old man. (a) Contrast material–enhanced CT scan shows an abscess (arrow) containing fluid and gas in the right posterior pararenal space. Thickening of the perirenal fascia, extending anteriorly, is also noted. (b) Contrast-enhanced CT scan shows the extension of fluid, inflammation, and air (arrow) along the right inguinal canal and into the scrotal sac. (c) CT scan shows extensive inflammatory changes and gas pockets (arrows) in the scrotum. (d) Postoperative CT scan shows interval débridement (arrows) of necrotic tissues in the right anterior abdominal wall. Mild ascites and diffuse soft-tissue edema are also noted. (e, f) Postoperative CT scans (e obtained at a more cephalic level than f) obtained after débridement show that tissue has been removed from the right side of the scrotum (arrows).
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Figure 4b. Fournier gangrene in an 84-year-old man. (a) Contrast material–enhanced CT scan shows an abscess (arrow) containing fluid and gas in the right posterior pararenal space. Thickening of the perirenal fascia, extending anteriorly, is also noted. (b) Contrast-enhanced CT scan shows the extension of fluid, inflammation, and air (arrow) along the right inguinal canal and into the scrotal sac. (c) CT scan shows extensive inflammatory changes and gas pockets (arrows) in the scrotum. (d) Postoperative CT scan shows interval débridement (arrows) of necrotic tissues in the right anterior abdominal wall. Mild ascites and diffuse soft-tissue edema are also noted. (e, f) Postoperative CT scans (e obtained at a more cephalic level than f) obtained after débridement show that tissue has been removed from the right side of the scrotum (arrows).
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Figure 4c. Fournier gangrene in an 84-year-old man. (a) Contrast material–enhanced CT scan shows an abscess (arrow) containing fluid and gas in the right posterior pararenal space. Thickening of the perirenal fascia, extending anteriorly, is also noted. (b) Contrast-enhanced CT scan shows the extension of fluid, inflammation, and air (arrow) along the right inguinal canal and into the scrotal sac. (c) CT scan shows extensive inflammatory changes and gas pockets (arrows) in the scrotum. (d) Postoperative CT scan shows interval débridement (arrows) of necrotic tissues in the right anterior abdominal wall. Mild ascites and diffuse soft-tissue edema are also noted. (e, f) Postoperative CT scans (e obtained at a more cephalic level than f) obtained after débridement show that tissue has been removed from the right side of the scrotum (arrows).
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Figure 4d. Fournier gangrene in an 84-year-old man. (a) Contrast material–enhanced CT scan shows an abscess (arrow) containing fluid and gas in the right posterior pararenal space. Thickening of the perirenal fascia, extending anteriorly, is also noted. (b) Contrast-enhanced CT scan shows the extension of fluid, inflammation, and air (arrow) along the right inguinal canal and into the scrotal sac. (c) CT scan shows extensive inflammatory changes and gas pockets (arrows) in the scrotum. (d) Postoperative CT scan shows interval débridement (arrows) of necrotic tissues in the right anterior abdominal wall. Mild ascites and diffuse soft-tissue edema are also noted. (e, f) Postoperative CT scans (e obtained at a more cephalic level than f) obtained after débridement show that tissue has been removed from the right side of the scrotum (arrows).
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Figure 4e. Fournier gangrene in an 84-year-old man. (a) Contrast material–enhanced CT scan shows an abscess (arrow) containing fluid and gas in the right posterior pararenal space. Thickening of the perirenal fascia, extending anteriorly, is also noted. (b) Contrast-enhanced CT scan shows the extension of fluid, inflammation, and air (arrow) along the right inguinal canal and into the scrotal sac. (c) CT scan shows extensive inflammatory changes and gas pockets (arrows) in the scrotum. (d) Postoperative CT scan shows interval débridement (arrows) of necrotic tissues in the right anterior abdominal wall. Mild ascites and diffuse soft-tissue edema are also noted. (e, f) Postoperative CT scans (e obtained at a more cephalic level than f) obtained after débridement show that tissue has been removed from the right side of the scrotum (arrows).
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Figure 4f. Fournier gangrene in an 84-year-old man. (a) Contrast material–enhanced CT scan shows an abscess (arrow) containing fluid and gas in the right posterior pararenal space. Thickening of the perirenal fascia, extending anteriorly, is also noted. (b) Contrast-enhanced CT scan shows the extension of fluid, inflammation, and air (arrow) along the right inguinal canal and into the scrotal sac. (c) CT scan shows extensive inflammatory changes and gas pockets (arrows) in the scrotum. (d) Postoperative CT scan shows interval débridement (arrows) of necrotic tissues in the right anterior abdominal wall. Mild ascites and diffuse soft-tissue edema are also noted. (e, f) Postoperative CT scans (e obtained at a more cephalic level than f) obtained after débridement show that tissue has been removed from the right side of the scrotum (arrows).
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Figure 5a. Fournier gangrene in a 61-year-old man with scrotal swelling, pain, and redness, along with abdominal pain. Contrast-enhanced CT scans show a markedly enlarged scrotal sac containing foci of gas (arrows in a) (more on the right side than on the left) that extend cranially to the perineum and subcutaneous tissues of the right medial gluteal region via the Colles fascia (arrows in b).
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Figure 5b. Fournier gangrene in a 61-year-old man with scrotal swelling, pain, and redness, along with abdominal pain. Contrast-enhanced CT scans show a markedly enlarged scrotal sac containing foci of gas (arrows in a) (more on the right side than on the left) that extend cranially to the perineum and subcutaneous tissues of the right medial gluteal region via the Colles fascia (arrows in b).
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Figure 6. Fournier gangrene of the penile shaft in a 60-year-old man. Contrast-enhanced CT scan shows fluid and tiny air pockets (arrows) tracking in the two corpora cavernosa. The patient had an uneventful recovery after undergoing surgery, which included perineal débridement, incision and drainage with suprapubic tube placement, and cystoscopy.
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Figure 7a. Fournier gangrene in a 65-year-old man. CT scans show extensive foci of gas in the scrotum (arrows in a), with cranial extension into the left inguinal canal (arrows in b) and left posterior pararenal space (arrows in c).
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Figure 7b. Fournier gangrene in a 65-year-old man. CT scans show extensive foci of gas in the scrotum (arrows in a), with cranial extension into the left inguinal canal (arrows in b) and left posterior pararenal space (arrows in c).
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Figure 7c. Fournier gangrene in a 65-year-old man. CT scans show extensive foci of gas in the scrotum (arrows in a), with cranial extension into the left inguinal canal (arrows in b) and left posterior pararenal space (arrows in c).
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Figure 8a. Fournier gangrene in a 49-year-old man. (a, b) CT scans show inflammation and air in the scrotum (arrows in a) and left inguinal canal (arrows in b). (c) CT scan obtained 17 days after débridement shows marked improvement in the inflammation in the perineal and left superficial inguinal tissues, as well as around the base of the penis. The linear attenuation in the soft tissues (arrows) represents the site of surgical incision. A minimal focus of gas in the region of the surgical site is also noted.
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Figure 8b. Fournier gangrene in a 49-year-old man. (a, b) CT scans show inflammation and air in the scrotum (arrows in a) and left inguinal canal (arrows in b). (c) CT scan obtained 17 days after débridement shows marked improvement in the inflammation in the perineal and left superficial inguinal tissues, as well as around the base of the penis. The linear attenuation in the soft tissues (arrows) represents the site of surgical incision. A minimal focus of gas in the region of the surgical site is also noted.
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Figure 8c. Fournier gangrene in a 49-year-old man. (a, b) CT scans show inflammation and air in the scrotum (arrows in a) and left inguinal canal (arrows in b). (c) CT scan obtained 17 days after débridement shows marked improvement in the inflammation in the perineal and left superficial inguinal tissues, as well as around the base of the penis. The linear attenuation in the soft tissues (arrows) represents the site of surgical incision. A minimal focus of gas in the region of the surgical site is also noted.
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Radiography
At radiography, hyperlucencies representing soft-tissue gas may be seen in the region overlying the scrotum or perineum (Fig 9). Subcutaneous emphysema may be seen extending from the scrotum and perineum to the inguinal regions, anterior abdominal wall, and thighs. Radiographic evidence of soft-tissue air may be present before clinical crepitus is detected, and its absence at physical examination should not exclude the diagnosis of Fournier gangrene (19). Radiography may also demonstrate significant swelling of scrotal soft tissue. Deep fascial gas is rarely seen at radiography, which represents a significant weakness of this modality in the diagnosis and evaluation of Fournier gangrene (20).
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Figure 9a. Fournier gangrene in a 32-year-old man with a history of testicular pain and skin infection. (a) Anteroposterior scout radiograph shows numerous radiolucent pockets (arrows) in the soft tissues overlying the region of the scrotum and perineum, findings that represent extensive subcutaneous emphysema. (b) Axial CT scan of the scrotum and perineum shows extensive inflammation and air in the subcutaneous tissues of the scrotum and extending into the perineum (arrows). (c) Coronal CT scan of the scrotum and perineum shows extensive fat stranding, inflammation (arrowheads), and air (white arrows) in the subcutaneous tissues of the scrotum and extending into the perineum and left inguinal canal. Right inguinal lymphadenopathy (black arrow) is also noted.
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Figure 9b. Fournier gangrene in a 32-year-old man with a history of testicular pain and skin infection. (a) Anteroposterior scout radiograph shows numerous radiolucent pockets (arrows) in the soft tissues overlying the region of the scrotum and perineum, findings that represent extensive subcutaneous emphysema. (b) Axial CT scan of the scrotum and perineum shows extensive inflammation and air in the subcutaneous tissues of the scrotum and extending into the perineum (arrows). (c) Coronal CT scan of the scrotum and perineum shows extensive fat stranding, inflammation (arrowheads), and air (white arrows) in the subcutaneous tissues of the scrotum and extending into the perineum and left inguinal canal. Right inguinal lymphadenopathy (black arrow) is also noted.
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Figure 9c. Fournier gangrene in a 32-year-old man with a history of testicular pain and skin infection. (a) Anteroposterior scout radiograph shows numerous radiolucent pockets (arrows) in the soft tissues overlying the region of the scrotum and perineum, findings that represent extensive subcutaneous emphysema. (b) Axial CT scan of the scrotum and perineum shows extensive inflammation and air in the subcutaneous tissues of the scrotum and extending into the perineum (arrows). (c) Coronal CT scan of the scrotum and perineum shows extensive fat stranding, inflammation (arrowheads), and air (white arrows) in the subcutaneous tissues of the scrotum and extending into the perineum and left inguinal canal. Right inguinal lymphadenopathy (black arrow) is also noted.
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Ultrasonography
A US finding in Fournier gangrene is a thickened, edematous scrotal wall. The thickened scrotal wall contains hyperechoic foci that demonstrate reverberation artifacts, causing "dirty" shadowing that represents gas within the scrotal wall (Fig 10) (6,7,15,16,20). Evidence of gas within the scrotal wall may be seen prior to clinical crepitus. Reactive unilateral or bilateral hydroceles may also be present. The testes and epididymides are often normal in size and echotexture due to their separate blood supply (7). Testicular vascularity is most often preserved because the blood supply to the scrotum is different from that to the testicles: The scrotal blood supply is from pudendal arterial branches of the femoral artery, whereas the testicular blood supply is from testicular branches of the aorta. If testicular involvement occurs, there is likely an intraabdominal or retroperitoneal source of infection (2).
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Figure 10. Suspected Fournier gangrene in a 71-year-old man with fever. US image shows echogenic areas (curved arrows) with dirty shadowing representing air in the right scrotal wall and perineum. There is also a localized fluid collection (straight arrow) in the subcutaneous tissue.
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US is also useful in differentiating Fournier gangrene from inguinoscrotal incarcerated hernia; in the latter condition, gas is observed in the obstructed bowel lumen, away from the scrotal wall (7). US is superior to radiography in this context, since the scrotal contents can be examined along with Doppler blood flow. Soft-tissue air is also more obvious at US than at radiography. Again, CT is superior to both US and radiography in demonstrating Fournier gangrene, its extent, and its underlying causes.
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Treatment and Outcome
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Treatment of Fournier gangrene includes hemodynamic stabilization and the intravenous administration of broad-spectrum antibiotics using multiple antimicrobial agents. The patient must also undergo immediate and complete surgical débridement of the necrotic tissue for full recovery (17). Multiple débridements may be necessary to remove all nonviable tissue (11,14). Patients with incomplete drainage and débridement or who undergo treatment with antibiotics alone have a poor prognosis (21). Hyperbaric oxygen has also been used as adjuvant treatment and may benefit patients who remain ill despite undergoing multiple or extensive débridements, although its role remains controversial. However, it can increase tissue oxygen tension to a point that inhibits and kills anaerobic bacteria. In addition, hyperbaric oxygen improves leukocyte phagocytosis and reduces edema, thereby facilitating the transportation of antibiotics (22). Early diagnosis and complete surgical débridement of all necrotic tissue have been found to be the most important factors in improving survival (12). The causes of death in patients with Fournier gangrene include severe sepsis, multiple organ failure, coagulopathy, acute kidney failure, and diabetic ketoacidosis (4,9,12).
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Conclusions
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Fournier gangrene is a rapidly spreading disease that represents a urologic emergency with a potentially high mortality rate. CT plays an important role in diagnosis and in the evaluation of disease extent for planning appropriate surgical treatment. Although the diagnosis of Fournier gangrene is most often made clinically, CT can be performed in cases in which the diagnosis or the extent of disease is difficult to discern. CT is superior to radiography, US, or physical examination in evaluating the extent of Fournier gangrene. If the diagnosis is unclear and there is concern for testicular torsion, US may be performed prior to CT. An awareness of the CT features of Fournier gangrene is imperative for appropriate diagnosis and subsequent emergent treatment.
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Abstract
LEARNING OBJECTIVES
