Perineoscrotal gangrene: two-staged therapeutic approach.

With approximately 350 reported instances of Fournier's disease (fulminating gangrene of the scrotum) since its description in 1883, individual experience is largely anecdotal and treatment remains controversial. Clarification is specially indicated as to how extensive diagnostic evaluation should be, whether, surgical incision and drainage is justified as initial therapeutic therapy, and that the priorities should be in patients having both severe systemic disease and rapidly advancing gangrene. Of four patients with Fournier's disease, three survived; the fourth died postoperatively in septic shock, diabetic ketoacidosis, and coma. A thorough diagnostic search is necessary to detect and treat all predisposing causes, especially when colorectal lesions are suspected. Simple incision and drainage did not arrest progression of disease even when combined with intensive antibiotic therapy. Critically ill patients with rapidly progressing gangrene present a therapeutic dilemma of priorities because neither immediate operation in unprepared patients nor extensive delay to treat the systemic illness first has proved to be adequate. The role of hyperbaric oxygen therapy in preoperative preparation should be explored further.