Diabetes mellitus urological complication.

Diabetes mellitus is a disease characterized by chronic hyperglycaemia due to an absolute or relative lack of insulin. The disease mainly affects the nervous system, and the urological complications themselves develop on the basis of these disorders. Urological patients with diabetes present in ambulance with manifestations of common urological diseases, but also suffer from complications of the urinary system or genital organs that are specific for diabetic patient. Usually, these complications go unrecognized for a long time or manifest only non-specifically. But they are often life-threatening for patients. Treatment does not consist only in urological stabilization, but stabilization of the diabetes itself is also necessary. It can be said that diabetes increases the risk of urological problems, and on the contrary, urological problems (especially inflammation) can lead to decompensation of the patient's diabetes.

Fournier's gangrene with retroperitoneal extension in an immunocompetent patient.

A male patient in his 80s presented with the classic signs of Fournier's gangrene. At his initial debridement, an unusual florid involvement of the right cord was noted requiring a right inguinal orchidectomy in addition to extensive debridement. Although he subsequently stabilised in the intensive care unit, his inflammatory markers were noted to uptrend again requiring a relook procedure which revealed evidence of progressive necrosis in the right inguinal region. After further debridement, a CT scan of the abdomen and pelvis revealed intra-abdominal extension of the disease process with a retroperitoneal collection adjacent to the caecum-a rare complication of Fournier's gangrene. This required open surgical drainage for adequate disease control. He subsequently underwent split skin grafting prior to discharge to a rehabilitation facility.

Effect of Sarcopenia on Mortality and Morbidity in Patients With Fournier's Gangrene.

BACKGROUND: Preoperative sarcopenia is an essential factor that negatively affects postoperative results. The effect of preoperative sarcopenia on postoperative complications and prognosis in patients treated for Fournier's gangrene (FG) is controversial. This retrospective cohort study analyzed the effect of FG to evaluate the effect of preoperative sarcopenia on postoperative complications and prognosis in patients who were operated on. METHOD: The data of patients who were operated on with FG diagnosis in our clinic between 2008 and 2020 were reviewed retrospectively. Demographic data (age and gender), anthropometric measurements, preoperative laboratory values, abdominopelvic CT, location of FG, number of debridements, ostomy, microbiological culture result, wound closure method, length of hospital stay, and overall survival were recorded. In addition, the presence of sarcopenia was determined according to psoas muscular index (PMI) and Hounsfield unit average calculation (HUAC). RESULTS: Of the patients, 57 (30.8%) were female and 128 (69.2%) were male. According to the PMI, sarcopenia was detected in 67 (36.2%) patients and 70 (37.8%), according to the HUAC. At the end of one postoperative year, the mortality rate was higher in the sarcopenia group than in the non-sarcopenia group (P = .002, P = .01). According to the PMI, patients with sarcopenia have an 8.17 times greater risk of exitus than non-sarcopenic patients. According to the HUAC, patients with sarcopenia have a 4.21 times greater risk of exitus than non-sarcopenic patients. CONCLUSION: Based on this large retrospective study, sarcopenia is a strong and independent predictor of postoperative mortality after Fournier's treatment for gangrene.

Management of Necrotizing Soft Tissue Infections (Fournier's Gangrene) and Surgical Reconstruction of Debridement Wound Defects.

In this article, the authors discuss the epidemiology, pathophysiology, and mechanism of spread of necrotizing soft-tissue infections of the genitalia, including classification schemas. The authors then discuss the acute clinical management of the disease, including suggestions for ways to improve surgical debridements (such that eventual reconstructions are simpler), ways to predict disease severity using laboratory, vital sign, and physical examination findings, and suggestions for initial antimicrobial treatments. Finally, reconstructive techniques and algorithms to ensure that the reconstructive goals of coverage, function, and cosmesis are met, are discussed, including the management of postoperative complications.

Orchidopexy and Split-thickness Skin Graft for Scrotal Defects After Necrotizing Fasciitis.

OBJECTIVE: To demonstrate a technique for performing orchidopexy and split-thickness skin graft for patients with deficient scrotal skin after debridement for Fournier's gangrene. This is an alternative strategy to healing by secondary intention, flaps, or testicular thigh pouches. METHODS: Orchidopexy was performed after initial debridement using interrupted Vicryl sutures to bring the testicles and inferior penis together. During this procedure, the testicles and spermatic cord were mobilized, and redundant spermatic cord was coiled under the abdominal wall. Once patients were medically stable with no additional planned debridement, a split-thickness skin graft at a depth of 18/1000 inch and meshed 2:1 was applied to the scrotum. The graft was covered with a bolster dressing that was sutured to the scrotum for 5 to 7 days. An inpatient stay was not required after skin graft and bolster placement. Patients were evaluated for cosmetic appearance, pain, and need for revision. RESULTS: From 2017-2021, 10 patients underwent orchiopexy and split-thickness skin graft to the scrotum. Etiology of Fournier's gangrene included diabetes (5), urethral stricture (2), alcohol abuse (2), unknown (1). Median age was 56 years and median BMI was 30 kg/m2. Median length of stay after orchidopexy and skin graft were 18 and 9 days respectively. At a median follow-up of 8 months, there were no issues with chronic pain, discomfort, or need for further intervention. CONCLUSION: Orchidopexy and split-thickness skin graft to scrotum is a feasible method of scrotal reconstruction that leads to acceptable clinical and cosmetic results, and does not result in prolonged inpatient hospitalization. Future research should focus on long term sexual function and quality of life outcomes.

Fournier's gangrene by perianal abscess / Gangrena de Fournier por abscesso perianal

ABSTRACT Objective: To describe and analyze the cases of Fournier's Gangrene caused by perianal abscess treated in a tertiary hospital in western Paraná, correlating possible factors that influence mortality, with emphasis on late diagnosis and therapy. Methods: A retrospective and descriptive case series was carried out based on the analysis of medical records of patients with Fournier's Gangrene due to perianal abscess from January 2012 to December 2017. Results: Thirty-one patients with Fournier's Gangrene due to perianal abscess were treated in the period: 26 men and 5 women. Mean age was 53.51 ± 14.5 years. The most prevalent comorbidity in this group was type 2 diabetes mellitus, showing a strong correlation with mortality. The mean time from disease progression, from the initial symptom to the admission at the service, was 9.6 ± 6.81 days. All patients were submitted to antibiotic therapy and surgical treatment, with a mean of 3.25 ± 2.89 procedures/patient. Seven (22.58%) patients died and all of them showed signs of sepsis on admission; only 2 patients with sepsis did not die. Conclusion: The presence of sepsis on admission and type 2 diabetes mellitus were strongly correlated with mortality.

RESUMO Objetivo: Descrever e analisar os casos de gangrena de Fournier por abscesso perianal atendidos em hospital terciário do oeste do Paraná, correlacionando possíveis fatores que influenciem a mortalidade, com ênfase ao diagnóstico e terapêuticas tardias. Métodos: Realizou-se um estudo de série de casos, retrospectivo e descritivo baseado na análise de prontuários de pacientes portadores de gangrena de Fournier devido a abscesso perianal no período de Janeiro de 2012 à Dezembro de 2017. Resultados: Foram tratados 31 pacientes com gangrena de Fournier por abscesso perianal no período, sendo 26 homens e 5 mulheres. A média de idade foi de 53,51 ± 14,5 anos. A comorbidade de maior prevalência neste grupo foi diabete melitus tipo 2, demonstrando forte correlação com mortalidade. A média do tempo de evolução da doença, do sintoma inicial até entrada no serviço, foi de 9,6 ± 6,81 dias. Todos os pacientes foram submetidos à antibioticoterapia e tratamento cirúrgico com média de 3,25 ± 2,89 procedimentos/paciente. Sete (22,58%) pacientes evoluíram para óbito e todos estes apresentavam sinais de sepse na admissão; apenas 2 pacientes com sepse não evoluíram a óbito. Conclusão: Presença de sepse a admissão e diabete melitus tipo 2 foram fortemente correlacionadas com mortalidade.

Fatal infections in andrology. Atypical clinical presentation of a Fournier's disease.

BACKGROUND: Fournier disease (FD) is a worrisome infection of genital area caused by a polimicrobial infection and characterized by a rapid progression to necrosis. Scrotum, perineum and lower abdomen represent the primary sites of origin. Clinical presentation and laboratory strongly suggest FD, but if not precociously diagnosed, it may quickly evolve into septic syndrome and patient's death. CASE REPORT: A 62 years old Caucasian male presented for fever and penile gross oedema recently occurred. No history of previous urinary tract infection, hematuria or genital trauma was referred. He did not complain any storage or voiding low urinary tract symptom (LUTS); no foci of infection in genitoperineal area was observed nor urethral discharge. The ultrasound (US) revealed a disomogeneous broad thickening of subcutaneous tissues with increased vascularity on Color-Doppler. When the penis was manipulated in order to reduce oedema, retract foreskin and evaluate the glans, clinical parametres rapidly worsened and the patient developed a septic shock with blood pressure falling down, dyspnoea and tachyarrhythmia, and he was fastly sent to Intensive Care Unit where it has been hemodynamically stabilized and subjected to antibiotic therapy. Considering the clinical absence of gangrene's foci, we opted for a conservative treatment by maintaining bladder catheter and drug therapy.

Dangers of delayed diagnosis of perianal abscess and undrained perianal sepsis in Fournier's gangrene: a case series.

Fournier's gangrene (FG) is a rapidly progressing infective necrotising fasciitis of the perianal, perineal and genital region. It is characterised by its aggressive nature and high mortality rates of between 15% and 50%. While it has been commonly found to primarily develop from urological sources, there have been increasing reports of the role of colorectal sources as the underlying aetiology of FG. Presented is a case series of four FG presentations at a single institution during a 12-month period as a result of underlying untreated perianal disease highlighting its dangers in progressing to a deadly infection, advocating for early and aggressive surgical debridement, and the role of adjunct scoring systems, such as Laboratory Risk Indicator for Necrotising Fasciitis, in guiding clinical diagnosis.

Fournier's gangrene mortality: A 17-year systematic review and meta-analysis.

BACKGROUND: To provide better management of Fournier's gangrene, mortality-associated comorbidities and common etiologies were identified. METHODS: A systematic search was conducted using 12 databases, followed by meticulous screening to select relevant articles. Meta-analysis and meta-regression (for possible cofounders) were both done for all possible outcomes. RESULTS: Out of 1186 reports screened, 38 studies were finally included in the systematic review and meta-analysis. A higher risk of mortality was detected in patients with diabetes, heart disease, renal failure, and kidney disease, with risk ratios (RR) and 95% confidence intervals (95% CI) of 0.72 (0.59-0.89), 0.39 (0.24-0.62), 0.41 (0.27-0.63), and 0.34 (95% CI 0.16-0.73), respectively. However, there was no association between mortality rates and comorbid hypertension, lung disease, liver disease, or malignant disease (p > 0.05). The highest mortality rates were due to sepsis (76%) and multiple organ failure (66%), followed by respiratory (19.4%), renal (18%), cardiovascular (15.7%), and hepatic (5%) mortality. CONCLUSIONS: Modifications to the Fournier's Gangrene Severity Index (FGSI) are recommended, in order to include comorbidities as an important prognostic tool for FG mortality. Close monitoring of the patients, with special interest given to the main causes of mortality, is an essential element of the management process.

Health-Related Quality of Life Is Decreased After Necrotizing Soft-Tissue Infections.

BACKGROUND: A necrotizing soft-tissue infection (NSTI) is a rare but severe infection with a high mortality rate of 12%-20%. Diagnosing is challenging and often delayed. Treatment consists of surgical debridement of all necrotic tissue and administration of antibiotics. Despite adequate treatment, survivors are often left with extensive wounds, resulting in mutilating scars and functional deficits. Both the disease and the subsequent scars can negatively influence the health-related quality of life (HRQoL). The present study was performed to contribute to the knowledge about HRQoL in patients after NSTI. METHODS: We retrospectively identified patients treated for NSTI in a tertiary center in the Netherlands. Patient and treatment characteristics were collected and patients were asked to fill in a Short Form 36 questionnaire. RESULTS: Forty-six patients with a diagnosis of NSTI were identified. Twenty-eight (61%) were male and mean age was 57 y. Thirty-nine patients (80%) survived. Thirty-one (84%) of the survivors returned the questionnaire after a median follow-up of 4.1 y (interquartile range [IQR], 2.4-5.9 y). Statistically significantly decreased scores when compared to the Dutch reference values were observed for the Short Form 36 domains, physical functioning, role-physical functioning, general health, and the combined Physical Component Score. No differences were observed for the other five domains or for the Mental Component Score. CONCLUSIONS: This study confirms that NSTI negatively affects HRQoL as reported by the patient, especially on the physical domains. To learn more about HRQoL in patients after NSTI, studies in larger groups with a more disease-specific questionnaire should be performed. LEVEL OF EVIDENCE: Level 3, prognostic and epidemiological.

The rash that leads to eschar formation.

When confronted with an existent or evolving eschar, the history is often the most important factor used to put the lesion into proper context. Determining whether the patient has a past medical history of significance, such as renal failure or diabetes mellitus, exposure to dead or live wildlife, or underwent a recent surgical procedure, can help differentiate between many etiologies of eschars. Similarly, the patient's overall clinical condition and the presence or absence of fever can allow infectious processes to be differentiated from other causes. This contribution is intended to help dermatologists identify and manage these various dermatologic conditions, as well as provide an algorithm that can be utilized when approaching a patient presenting with an eschar.

Recognizing Fournier's Gangrene in the Emergency Department.

Fournier's gangrene is a rare disease with a significant mortality rate. The potentially fatal disease stems from both aerobic and anaerobic bacteria and primarily occurs in men. The majority of Fournier's gangrene cases are idiopathic or derived from perineal and genital skin infections. Comorbid risk factors include diabetes mellitus, alcohol misuse, and immunosuppression (). The infection initially presents as a cellulitis in the perineum or perianal area. As Fournier's gangrene progresses, the infected tissue becomes swollen, significantly painful, and necrotic. The progression of infection can lead to systemic symptoms, sepsis, and death. Early intervention is a key component in the treatment plan for Fournier's gangrene. The primary intervention is surgical debridement of the necrotic tissue. If an abscess is present, incision and drainage are indicated. In addition to surgical debridement, the administration of broad-spectrum antibiotics and hemodynamic stabilization are required (). Complications after treatment include chronic pain, sexual dysfunction, decreased sensation of the penile skin, and scarring ().

Fournier's Gangrene With Septic Shock and Multiple Organ Dysfunction Syndrome.

Fournier's gangrene is a rare, rapidly progressing, and life-threatening infection associated with necrotizing fasciitis in the perineal, genital, and/or lower abdominal regions. Septic shock and multiple organ dysfunction syndrome due to the condition are even rarer events. We describe the case of a 58-year-old man who visited the emergency department with severely painful swelling in the scrotal, perianal, and lower abdominal regions. Physical examination combined with computed tomography and clinical findings led to the diagnosis of Fournier's gangrene with septic shock and multiple organ dysfunction syndrome. Broad-spectrum antibiotics, fluid resuscitation, sedative administration, and several surgeries that included perineum reconstruction were performed successfully, and the patient fully recovered. Comprehensive, timely treatments are critical for treating Fournier's gangrene.

Outcomes in Fournier's Gangrene Using Skin and Soft Tissue Sparing Flap Preservation Surgery for Wound Closure: An Alternative Approach to Wide Radical Debridement.

INTRODUCTION: Fournier's gangrene (FG) remains a forbidding necrotizing soft tissue infection (NSTI) that necessitates early recognition, prompt surgical excision, and goal-directed antibiotic therapy. Traditionally, surgical management has included wide radical excision for sepsis control, but this management often leaves large, morbid wounds that require complex wound coverage, prolonged hospitalizations, and/or delayed healing. OBJECTIVE: The purpose of this case series is to report the outcomes of FG using a surrogate approach of concurrent debridement of spared skin and soft tissue, negative pressure wound therapy (NPWT), and serial delayed primary closure (DPC). MATERIALS AND METHODS: A retrospective review of 17 consecutive patients with FG treated with concurrent skin and soft tissue sparing surgery, NPWT, and serial DPC at Miami Valley Hospital Regional Adult Burn and Wound Center (Dayton, OH) between 2008 and 2018 was conducted. Patients were included if the following were noted: clinical suspicion of FG based on genital and perineal cellulitis, fever, leukocytosis, and confirmation of tissue necrosis upon surgical exploration. Patients not treated with skin sparing surgical debridement or wounds with an inability to maintain a NPWT dressing seal were excluded. RESULTS: The mean number of total surgeries including simultaneous debridement and reconstruction was 5.5. The average intensive care unit and hospital length of stay was 3.2 and 18.9 days, respectively. The average number of days from initial consult to wound closure was 24.3. The need for colostomy and skin grafts were nearly eliminated with this surrogate approach. Using this reproducible technique, DPC was achieved in 100% of patients. Only 11.8% (2/17) required split-thickness skin grafting as part of wound closure. The majority (9/17; 52.9%) were partially managed as an outpatient during wound closure. During staged DPC, the mean number of outpatient management days was 16.0. There were no mortalities in this series of patients. CONCLUSIONS: To the best of the authors' knowledge, this is the largest case series reported in the literature using skin and soft tissue sparing surgery for wound closure of a FG NSTI.