Healing of Fournier's gangrene of the scrotum in a haemodialysis patient after conservative therapy alone
Yoshio Horita,
Masanobu Miyazaki,
Mitsuru Noguchi1,
Masato Tadokoro2,
Kouichi Taura2,
Yoshiyuki Ozono and
Shigeru Kohno
Second Department of Internal Medicine, Nagasaki University School of Medicine, Nagasaki,
1 The Departments of Urology and
2 Internal Medicine, Nagasaki Municipal Medical Center, Nagasaki, Japan
Correspondence and offprint requests to:
Yoshio Horita, M.D., 2nd Department of Internal Medicine, Nagasaki University School of Medicine, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
Keywords: chronic renal failure; medical treatment; Fournier's gangrene; dialysis
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Introduction
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Since Fournier first described a patient with unexplained gangrene of the male genitalia in 1883 [1], this condition has been referred to as Fournier's gangrene. The condition is characterized by a synergistic polymicrobial necrotizing fascitis usually associated with predisposing factors, particularly immunocompromised states such as malignancies, diabetes mellitus, alcoholism, liver or acute renal failure [2] and acquired immunodeficiency syndrome [3]. It can also arise as a secondary infection resulting from extant pathological conditions of the colo-rectal area, the lower urogenital tract and the perineum [2]. Because the mortality rate associated with Fournier's gangrene is high, therapy must be aggressive. A three pronged treatment strategy consisting of antibiotic coverage for aerobes and anaerobes, general supportive measures and surgical debridement is usually applied [4]. Recently, superoxidized water has proven to be a powerful bactericidal disinfectant against a variety of aerobic Gram-positive and Gram-negative rods [5]. In addition, superoxidized water is highly effective in treating infectious skin conditions and refractory ulcers associated with diabetes mellitus or peripheral circulatory insufficiency [6]. For an immunologically compromised patient a multifaceted therapeutical approach may be most appropriate.
The present report describes a patient with chronic renal failure on haemodialysis in whom Fournier's gangrene was the presenting sign in the very early stages of this disease. We propose that superoxidized water may help to avert or at least reduce this type of focal gangrene.
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Case
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A 73-year-old man was admitted to the Nagasaki Municipal Medical Center with acute progression of chronic renal failure due to nephrosclerosis. He had a 15-year history of hypertension, but no sign of diabetes mellitus. His serum creatinine level was 5.6 mg/dl, blood urea nitrogen was 141 mg/dl and he was disoriented due to uraemia. Haemodialysis was immediately started. A urinary catheter revealed clear urine and urine cytology and culture were negative upon admission.
Chills and sweats appeared with the increasing pain and swelling of the scrotum skin 1 month later. Physical examination showed an enlarged tender scrotum with white discoloration and some necrosis (Figure 1
). The penis shaft and foreskin were intact. His body temperature was 38.5°C and blood pressure was 160/74 mmHg. Electrocardiography revealed a regular pulse rate of 98 beats/min (sinus rhythm). The white blood count was 11.5x103/ml and the erythrocyte sedimentation rate was 131 mm. Fournier's gangrene of sudden onset and precipitous focal progression was clinically diagnosed. Intravenous cefpirome and oral lomefloxacin was immediately administered. Simultaneously, the entire area was irrigated with copious amounts of superoxidized water and packed with gauze soaked with zinc peroxide and hydrogen peroxide. Tissue culture of the scrotum lesion before antibiotic administration revealed numerous aerobic Gram-positive and Gram-negative rods, which were identified as methicillin resistant Staphylococcus aureus and Pseudomonas aeruginosa. Urine and sputum cultures contained the same organisms, but blood cultures were negative and anaerobes were absent.

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Fig. 1. Scrotum skin shows white discoloration and partial necrosis. The penis was intact. These changes were of sudden onset.
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One month later, the wound had healed. Thus the need for surgical drainage and debridement could be avoided (Figure 2
). The patient underwent haemodialysis treatment without any particular incident during the entire course of this serious complication.

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Fig. 2. Wound completely healed 1 month after antibiotic administration and irrigation with superoxidized water.
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Discussion
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Many patients with Fournier's gangrene have predisposing factors such as diabetes mellitus, which has been understood since the original report by Fournier et al. [1]. However, this condition has recently tended to appear in older patients, particularly among those with poor general health [2]. The important conditions associated with Fournier's gangrene include urinary bladder catheterization [4]. Karim et al. [7] described Fournier's gangrene of the scrotum secondary to necrosis of the urethra caused by a balloon catheter, and Hajase et al. [4] have described scrotal and urethral trauma in a patient with long-term bladder catheterization who frequently removed the catheter by himself. In addition to long-term insertion of a bladder catheter, the chronic renal failure and advanced age of our patient also seemed to be important predisposing factors in the development Fournier's syndrome.
Several species of aerobic and anaerobic organisms are typically isolated from patients not only with Fournier's syndrome but also with other forms of necrotizing fascitis, particularly in immunocompromised hosts. When more than two bacterial pathogens are involved, interaction may occur among them. The most prevalent organisms are Staphylococcus aureus, Staphylococci (Beta-haemolytic and anaerobic or microaerophilic), Escherichia coli, Bacteroides species, Pseudomonas, Proteus and Clostridia [4]. Most of these bacteria are also associated with other forms of necrotizing fascitis. Meleny et al. [8] were the first to describe the association between these bacteria and necrosis of the skin and subcutaneous tissues. Urine and sputum cultures from our patient revealed MRSA and Pseudomonas aeruginosa, but no anaerobes. We therefore considered this patient an immunocompromised host. In this respect, early recognition of a pre-gangrenous state and application of optimal antibiotic therapy is critical. In general, combined broad-spectrum antibiotics, prompt surgical drainage and debridement are advised based upon an assumption of mixed infection [9]. Hyperbaric oxygen may help reduce mortality and the spread of gangrene, especially if applied during the early stage of the disease [10]. However, we simply administered antibiotics and irrigated the scrotal skin with superoxidized water, and found that this strategy was sufficient to effectively treat Fournier's gangrene. Superoxidized water is a powerful bactericidal disinfectant against a variety of aerobic Gram-positive and Gram-negative rods [5], and it is effective in treating infectious skin defects or the refractory ulcers associated with diabetes mellitus or peripheral circulatory insufficiency [6]. Superoxidized water can be considered one reason for the improvement of Fournier's gangrene without surgical drainage and debridement. In addition, we recognized this condition in our patient early, which all allowed immediate application of the treatment strategy using superoxidized water and broad-spectrum antibiotics.
We describe here the conservative treatment of Fournier's gangrene of the scrotum in an elderly patient with chronic renal failure on intermittent haemodialysis. The condition was successfully treated, without the need for surgical intervention. We recommend superoxidized water as an adjunct measure since this therapy appeared to be very successful in our patient.
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References
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Received for publication: 6. 9.99
Accepted in revised form: 21.10.99