21.37 Selected Case Reports and Personal Experience The Lord of the Rings – Fournier’s Gangrene as a Consequence of Strangulating Testicular Rings N. Zantl, R. Hartung Fournier’s gangrene is a rare but life-threatening, spe- cial form of dermal necrosis located in the genitouri- nary region. Mortality rates range from 4 % to 43 % in actual series (Dahm et al. 2000; Mindrup et al. 2005; Ye- niyol et al. 2004; Korkut et al. 2003; Burdal et al. 2003; Chawla et al. 2003; Asci et al. 1998; Nisbet and Tompson 2002; Corman et al. 1999; Korhonen et al. 1998; Holla- baugh et al. 1998; Benizri et al. 1996; Palmer et al. 1995). The main treatment principle is an immediate, exten- sive debridement of the entire necrotic tissue under concurrent broad-spectrum antibiotic therapy. Recon- struction can be performed only when the wound is free from infection. In this chapter, we report a case of Fournier’s gangrene caused by the deterioration of the blood supply caused by scrotal rings and discuss etiolo- gy, symptoms, and treatment of Fournier’s gangrene. Fig. 21.37.1. Three scrotal rings were put around the scrotal base over 2 years. The third ring had deteriorated the blood supply to such an extent that necrosis of the scrotal skin result- ed. Typical for Fournier’s gangrene is the overlapping of the Report of the Case gangrene to healthy tissue, not affected by the ischemia. Note also the penile piercings A 42-year-old man was admitted to our department in a highly compromised condition. The temperature was during the usage of the angle grinder. Figure 21.37.2b 39.8 °C, the heart rate was 120 bpm, and his blood pres- shows the remnants of the three rings; Fig. 21.37.3 sure was 100/60 mm Hg. He presented a leukocytosis of shows the patients genitalia freed of the metal rings. 19.60×109 cells/l (normal, 4.0 – 9.0), fibrinogen of We then proceeded with the debridement of the en- 624 µg/l (normal, < 192), C-reactive protein of 7.4 mg/ tire necrotic skin, including a resection of approxi- dl (normal, 0.5) (74 mg/l; normal, 5). Figure 21.37.1 mately 0.5 cm in macroscopically healthy tissue. The shows the initial condition of his genital region. Over right testicle was also necrotic, resulting in the indica- the previous 2 years he had put three metal rings tion of right-sided orchiectomy. Figure 21.37.4 shows around the base of his scrotum, the last ring obviously the extent of the resection 1 week later. The spermatic intensely deteriorating the blood supply and thus re- cord is elongated due to the chronic overexpansion sulting in necrosis of the scrotal skin. Interestingly, the caused by the scrotal rings. We provided daily changes gangrenous delineation exceeded the proximal border of the wound dressings, including wound cleaning and of the most proximal ring, which is a typical property flushing, and performed two additional wound de- of Fournier’s gangrene. bridements during the course of treatment. After initial assessment of physical and medical After 16 days, the denuded tissue showed no more findings, after clinical stabilization, fluid resuscitation signs of inflammation and appeared clean. Only then and application of broad-spectrum antibiotics, we im- was plastic coverage performed in the lithotomy posi- mediately brought the patient into the operating room tion with a Foley catheter inserted. Granulation tissue where we removed the foreign bodies with the help of was completely removed. The dorsal part of the perine- the fire department, using their heavy equipment (the al wound was directly sutured. The penile skin defect metal rings were fixed with some kind of “super glue,” was covered with a split-thickness skin graft without which made it impossible to disassemble them). Fig- meshing in order to give it as much resistibility for po- ure 21.37.2a shows this procedure. Note the ice cooling tential mechanical exposure in the future, whereas all The Lord of the Rings – Fournier’s Gangrene as a Consequence of Strangulating Testicular Rings 579 a Fig. 21.37.3. The genitalia freed from the metal rings b Fig. 21.37.2. a A firefighter is detaching the scrotal rings using an angle grinder. Note the imperatively required cooling with ice cubes. b The detached scrotal rings other skin defects and especially the left testicle were covered with meshed split-thickness skin to allow exact molding of the skin onto the underlying tissue. Because of its elongation, the left spermatic cord was pulled up underneath the groin skin and fixed there with mount- ing sutures before plastic coverage. Split-thickness skin grafts and mesh grafts were covered with gentle pres- sure dressing for the first 5 days to ensure a tight adhe- sion of the grafts to the underlying tissue, which facili- tates neovascularization. Fig. 21.37.4. The genitalia after right-sided orchiectomy and af- Figure 5a–d depicts the findings after surgery. Fig- ter skin debridement ure 21.37.5a – still in the operating room – shows the penile split-thickness skin graft with insular puncture holes to allow wound fluid drainage. Furthermore, the resect the nonviable overlapping margins. Figure molding of the mesh graft is clearly visible. Fig- 21.37.5c, 1 year later, shows that the patient is very sat- ure 21.37.5b, 2 weeks later, shows that the apertures of isfied with the aesthetic and functional results of plas- the mesh graft are already in the process of sealing, tic coverage. Erectile function resembles the state with the patient one last time in the operating room to before onset of the disease; the penis is furnished with
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