Perineal necrotizing fasciitis--surgical approaches

Perineal necrotising fasciitis is a fast advancing necrotic inflammation in the soft tissue of the perineal and perianal spaces and in the genital area sometimes involving even the abdominal wall and the two hips.

To analyse and investigate the clinical symptoms and surgical approaches in the treatment of perineal necrotizing fasciitis so that clinical results can be optimised and improved.

We conducted a retrospective analysis of the material using the analysis of variance, the alternative, non-parametric and graphic analyses at a level of significance for the null hypothesis P = 0.05. We registered data about the gender, age, onset of disease, infection entry site, time since onset of the disease, clinical course, microbiologic data, treatment (surgical and therapeutic), duration of hospital stay, and outcome of the treatment. Eleven patients with perineal necrotizing fasciitis were treated in the clinic over a period of 12 years. The patients included in this study were 10 men and 1 woman, middle aged, mean age 53.55 +/- 2.55 years; baseline location of the disease in the perianal region, then the inflammation extended to the scrotum, the external genitalia and the adjacent areas. The inflammation was diffuse; in three patients (27.27 +/- 13.43%) we found production of gas in the inflamed subcutaneous tissues, with crepitations and fast progressing skin necrosis. The general condition of all patients was dominated by the clinical manifestation of sepsis.

Treatment of the perineal necrotizing fasciitis is combined--surgery and therapeutic management. Surgery should be performed at first within the first 24 hours as an emergency including a lot of incisions, necrectomy and effective drainage. All patients had to undergo more than four surgical interventions. In two patients (18.18 +/- 11.63%) we conducted unilateral orchiectomy. 24 to 48 hours after the initial surgical intervention, after accurate evaluation of the local status, it is important to decide when to repeat surgery since if delayed the condition could become fulminant. The therapeutic treatment included broad-spectrum antibiotics as well as complex therapy to manage the septic condition. Two patients (18.18 +/- 11.63%) died because of multiorgan failure.

To achieve optimal treatment of perineal necrotizing fasciitis it is necessary to diagnose the condition as early as possible, to administer comprehensive, combined therapy, the surgical treatment being always adequate, timely and effective. The favourable outcome depends also on the rational antibiotic treatment and the intensive resuscitation