Fournier’s gangrene (FG) is a necrotizing, life-threatening fasciitis of the perineal area, external genitalia and the anus, which may extend towards the abdominal cavity and result in soft tissue necrosis and the development of sepsis. As early as more than 200 years ago, in 1764, Baurienne described rapid inflammation of the perineum. In 1883 Jean Alfred Fournier, a French dermatologist and venereologist, described a gangrene in five young men without diagnosed etiologic factors (1, 2). The infection is usually caused by a mixed microbial flora. The prevalence of the disease is low; however, mortality still remains high. Certain diseases of the genitourinary and anorectal areas as well as diabetes and conditions associated with immunosuppression are conducive to the development of FG. The diagnosis of FG is made based on clinical symptoms with diagnostic imaging being useful for the evaluation of advancement of necrosis. Therapeutic management primarily involves aggressive surgical excision of necrotic tissues, the use of broad-spectrum antibiotics, anti-shock treatment and supporting therapy. The Fournier’s Gangrene Severity Index Score may be used to assess the condition of the patients (tab. 1). Due to its diversity and aggressive course FG is a very serious and complex medical problem that requires a multi-disciplinary therapeutic approach.

The etiologic factor for FG is successfully established in over 90% of cases. It should be sought since the treatment and prognosis are dependent on it (3). In some cases the etiologic factor cannot be determined due to necrotic lesions. Every process during which pathogens enter the subcutaneous tissue of the anorectal area may be the starting point for a severe infection. The infection may spread to the genitourinary organs, in the anal and rectal region, to the skin in these areas and in the retroperitoneal space. The area of the genitourinary organs is the most common location for the development of the etiologic factor, diseases of the urethra being the primary one. The knowledge of the anatomy of these regions is necessary to understand the etiology and pathogenesis of fulminant infections. The causes of FG are listed in table 2. Each of the listed areas may be the source of infection with a spread through interfascial spaces causing proliferative fasciitis (4-8). Although FG is found primarily in older men, it may occur at any age and only 10% of cases are found in women (7, 9). The FG causes specific for women include pudendal nerve block, episiotomy for a natural childbirth, septic miscarriage, hysterectomy, Bartholin’s gland abscess and vulvar abscess. In the vast majority of cases patients with FG have comorbidities that cause a compromised blood flow or immunity impairment, which increases their susceptibility to infection with a mixed flora (tab. 3). FG is often the result of a primary condition such as diabetes, genitourinary tuberculosis, syphilis and HIV infection. Diabetes is the most common comorbidity and is found in approximately 60% of patients with FG. Patients with diabetes suffer from urinary tract infections more frequently due to cystopathy and urinary stasis (4). Hyperglycaemia decreases cell immunity by reducing phagocytic activity. It compromises leukocyte chemotaxis to inflammation sites as well as reducing neutrophil adhesion and intracellular processes of pathogen destruction by oxygen. Wound healing is also impaired as a result of compromised epithelialisation and deposition of collagen (10-12). Apart from hyperglycaemia, diabetic patients also have impaired microcirculation, which contributes to a significant extent to the pathogenesis of PG. It is also noteworthy that diabetes increases the risk of PG, but does not increase its mortality (4, 13). Factors which increase the risk of FG include chronic alcoholism, malnutrition, cirrhosis and poor personal hygiene (tab. 3). Other factors which compromise immunity and may predispose individuals to the development of FG are chronic steroid therapy, organ transplant, chemotherapy for cancer such as leukaemia and HIV infection (14). The rising incidence of HIV is accompanied by an increase in the incidence of FG, especially in Africa. FG may be the first symptom of HIV infection (14, 15). Risk factors include CD4 count below 400, chemotherapy for Kaposi sarcoma and the placement of a femoral venous line for intravenous drug administration. Patients with HIV and FG are younger and have a broader spectrum of pathogenic bacterial flora.