Necrotizing Infection of the Perineum

Hospital Physician January 2008 39 S pontaneous gangrene of the scrotum was described for the first time in 1753 by Boerhaave,1 who reported on a 40-year-old man with urinary retention. Since that time, several authors have reported similar cases of spontaneous gangrene of the scrotum and penis with associated diseases such as systemic infections, diabetes, urinary extravasations and infiltration, trauma to the perineal area, and inflammatory processes involving the genitalia. In 1883–84, Fournier reported 1 similar case and discussed 4 others from his own experience, all of whom did not have any known risk factor or associated diseases.2–4 In his landmark paper,2 he then established the 3 criteria of what became known as Fournier’s gangrene:1 abrupt onset of penile or scrotal gangrene in previously healthy young male patients;2 rapid progression to fulminating gangrene; and absence of identifiable causes.3 The first and third criteria were quickly dropped among authors reporting such cases, and the second criterion, namely the rapid progression to fulminating gangrene, became a landmark diagnostic clue. Gangrene starts anywhere in the perineum but progresses to involve the scrotum and penis. The concept of male predilection was broken in 1927 when Narducci5 reported on a female patient with fulminating gangrene involving the external genitalia. This diversion from Fournier’s main definition created confusion in the literature about the name, diagnosis, and treatment of this disease. This article reviews the diagnosis and treatment of Fournier’s gangrene in the context of a representative case that illustrates clinical aspects of the disease process.