Necrotizing infections of the perineum

During a 6-year period, 10 patients were treated for severe necrotizing infections of the perineum (Fournier's gangrene) at the Edward Hines Veterans Administration Hospital (Hines, Ill). All were male, and their average age was 60 years. When known, duration of symptoms was 2 to 5 days. Prodromal signs such as edema, erythema, and pain frequently developed into rapidly spreading, full-thickness cutaneous gangrene in less than 24 hours. All patients had significant concomitant disease; 60% were diabetic. All patients had expedient and aggressive initial debridement, usually within 24 hours of presentation to the surgical service. Each patient had a "second-look" debridement within 1 or 2 days. Debridement was done an average of 2.6 times per patient. The cause of the infection was noted in seven patients--five with perirectal abscess and two with urethral trauma. Suprapubic catheters were placed in both patients with urethral trauma. Diverting colostomy was done on two patients who had perirectal abscess as a nidus; eight patients were treated without colostomy. Polymicrobial bacteriologic flora were found in all patients, with a predominance of Escherichia coli, Bacteroides sp, and staphylococci. Broad spectrum antibiotics and early nutritional supplementation were given. Hospital stay averaged 4 weeks (range, 3 to 12 weeks). One patient died (mortality of 10%). Successful management of these patients requires expedient diagnosis, aggressive nutritional supplementation, and early and repeated debridement as clinically indicated. We have not found diverting colostomy to be a necessary part of the management of these patients even when the nidus is perirectal.