Fournier's gangrene: evolving understanding and modern management of a necrotising surgical emergency

Fournier's gangrene (FG) is a rapidly progressive, life-threatening necrotising soft tissue infection of the perineum and external genitalia that remains a surgical emergency with a high mortality despite advances in critical care. Once considered idiopathic, contemporary evidence demonstrates that FG most often arises from identifiable anorectal, urogenital, or cutaneous sources in patients with significant comorbidities, particularly diabetes mellitus and other states of immunocompromise. Mortality remains substantial, typically in the range of 20-30% and is strongly influenced by delays in diagnosis and definitive surgical intervention. This review updates and expands the previous 1998 review (Smith et al.) synthesising recent literature on the epidemiology, pathophysiology, microbiology, clinical presentation, diagnostic principles, management strategies, and outcomes of FG. Emphasis is placed on FG as a primarily clinical diagnosis requiring a high index of suspicion in patients presenting with rapidly progressive perineal pain and infection disproportionate to the physical findings. Prompt and aggressive surgical debridement remains the cornerstone of management, supported by broad-spectrum antimicrobial therapy, intensive supportive care, and a multidisciplinary approach, while the role of adjunctive therapies such as hyperbaric oxygen therapy and negative pressure wound therapy is critically appraised. Despite improvements in recognition and treatment, FG continues to carry significant morbidity and mortality, underscoring the importance of early diagnosis, immediate pathogen control, and coordinated multidisciplinary care to optimise patient outcomes.