International Wound Journal ISSN 1742-4801

ORIGINAL ARTICLE

Prognostic factors and treatment outcomes for patients with

Fournier’s gangrene: a retrospective study
Kyung Sook Hong1 , Hee Jung Yi2 , Ryung-Ah Lee2 , Kwang Ho Kim2 & Soon Sup Chung2
1 Department of Surgery and Critical Care Medicine, Ewha Womans University College of Medicine, Seoul, Korea
2 Department of Surgery, Ewha Womans University College of Medicine, Seoul, Korea

Key words Hong KS, Yi HJ, Lee R-A, Kim KH, Chung SS. Prognostic factors and treatment
Fournier’s gangrene; soft tissue infection; outcomes for patients with Fournier’s gangrene: a retrospective study. Int Wound J 2017;
negative-pressure wound therapy doi: 10.1111/iwj.12812
Correspondence to
Abstract
Soon Sup Chung, MD, PhD
Department of Surgery Fournier’s gangrene is a gas-forming, necrotising soft tissue infection affecting the
Ewha Womans University College of perineum. It spreads rapidly along the deep fascial planes and is associated with a high
Medicine mortality rate. With a growing elderly population with comorbidities, the frequency of
1071, Anyangcheon-ro severe cases of Fournier’s gangrene is expected to increase. We retrospectively reviewed
Yangcheon-gu
20 patients diagnosed with Fournier’s gangrene at our institution from 2003 to 2014 and
Seoul 07985
analysed data. Thirteen patients had diabetes mellitus, two had been diagnosed with
Korea
E-mail: colonclinic@ewha.ac.kr
liver cirrhosis, and four were chronic alcoholics. Of 15 patients admitted to an intensive
care unit, 11 underwent colostomy, and 4 required skin grafts for wound healing.
The wide wounds of two patients were healed using vacuum-assisted closure (VAC® )
dressing without additional surgery. The mortality rate was 25%, and the patients whose
Fournier’s gangrene severity index (FGSI) score was higher than 9 points or whose
blood urea nitrogen (BUN) level was higher than 50 mg/dl had a poor prognosis. In order
to treat Fournier’s gangrene, aggressive surgical treatment, including wide debridement
and stoma creation, should be considered as soon as possible to improve survival rates.
Additionally, VAC dressing is helpful in healing the wide debridement wound without
additional reconstructive surgery.

Introduction approach, based on an accurate assessment of the disease, is

Fourier’s gangrene is a polymicrobial necrotising fasciitis that
results in endarteritis of the perineal, urogenital or perianal
subcutaneous layers and causes gangrenous changes in the skin
and subcutaneous layers (Fig. 1) (1,2). When first described
by Jean Alfred Fournier in 1883, it was considered a disease
of young men, with rapid progression and without definite
cause (3). However, many studies have since revealed that there
are almost always predisposing causes that induce necrotising
infection and that this disease also affects women, infants
and the elderly (4). Early detection and diagnosis and active
treatment, including aggressive debridement and drainage and
administration of broad-spectrum antibiotics, are key in disease
management.
As Fournier’s gangrene is uncommon and doctors’ experi-
ence of it is limited, it is difficult to diagnose this disease before
necrosis or gangrene sets in, and disease progression, even to
mortality, is rapid (5). However, late detection and inappropri-
ate treatment lead to high mortality; thus, the initial treatment
very important.
The mortality rate of this disease, at 0–67%, varies widely
between studies (2) and has not improved over time in spite
Key messages
• despite medical developments, the mortality rate of
Fournier’s gangrene is high
• the patients with highter Fournier’s gangrene severity
index (FGSI) score or higher BUN level had a poor
prognosis
• for treating Fournier’s gangrene, aggressive surgi-
cal treatment, including wide debridement and stoma
creation would be required
• vacuum-assisted closure dressing is helpful in healing the
wide debridement wound without additional reconstruc-
tive surgery

© 2017 Medicalhelplines.com Inc and John Wiley & Sons Ltd doi: 10.1111/iwj.12812 1
Prognostic factors and treatment outcomes for Fournier’s gangrene
of medical advances. In particular, in developed countries with
aging populations and high levels of morbidity due to metabolic
diseases, such as diabetes mellitus, the incidence of Fournier’s
gangrene has been increasing. Therefore, it is important to
understand the risk factors, pathophysiology and clinical course
of this disease.
Here, we investigated the characteristics and clinical course
of patients diagnosed with Fournier’s gangrene at our institution
over a period of 10 years with the aim of determining the risks
and prognostic factors associated with this disease.
Material and methods
This study was approved by the institutional review board (IRB)
of our institution (IRB number: EUMC 2016-11-029).
The medical records of 20 patients diagnosed with Fournier’s
gangrene at our institution from January 2003 to July 2014
were reviewed retrospectively. There were no specific exclusion
criteria.
2 © 2017 Medicalhelplines.com Inc and John Wiley & Sons Ltd
K. S. Hong et al.
Figure 1 A case of a patient with
Fournier’s gangrene. (A) Fournier’s gan-
grene. Necrotic fasciitis spread to the
perianal area and scrotum. (B) After
debridement. Spontaneous orchiectomy
was performed. (C) Reconstruction with
skin graft. Skin defect was repaired with a
skin graft from the left thigh.
We investigated the following: gender, age, body mass
index (BMI), previous operative history and predisposing
factors of patients, the number of debridements, details
regarding the formation of diverting stoma, pathology and
bacteriology results and laboratory results [e.g. white blood
cell count, haemoglobin, haematocrit, sodium, potassium,
bicarbonate, glucose, blood urea nitrogen (BUN), creati-
nine, aspartate aminotransferase, alanine aminotransferase,
cholesterol, triglyceride, protein, albumin, C-reactive protein
and haemoglobin A1c]. In addition, predisposing factors,
aetiological factors and Fournier’s Gangrene Severity Index
(FGSI) scores were examined to determine risk factors and
prognostic factors. The FGSI score was devised by Laor
et al. (6), and this index included the parameters of tem-
perature, heart rate, respiratory rate, serum sodium, serum
potassium, serum creatinine, serum bicarbonate, haematocrit
and white blood cell count to evaluate the severity of the
disease.
Data were analysed using IBM SPSS version 20.0 (SPSS®
Inc., Chicago, IL). Numerical data, such as age or scale score,
K. S. Hong et al. Prognostic factors and treatment outcomes for Fournier’s gangrene

Table 1 Demographic characteristics of the patients Table 2 The aetiology of Fournier’s gangrene in this study

Characteristics n (%) Aetiology n (%)

Male 18 (90%) Perianal or perirectal infection 12 (60%)

Gender
Female 2 (10%) Genitourinary infection 2 (10%)
Age (years) Mean age 61⋅8 ± 12⋅7 Postoperative complication 2 (10%)
<65 10 (50%) Infection of sore 1 (5%)
≥65 10 (50%) Trauma 1 (5%)
BMI (kg/m2 ) Mean BMI 24⋅6 ± 5⋅1 Cancer-related radiotherapy 2 (10%)
<25 15 (75%)
≥25 5 (25%)
History of anorectal surgery Yes 2 (10%)
Table 3 Bacteriological results
No 18 (90%)
Predisposing factors Diabetes mellitus 13 (65%) Bacterial organism n (%)
Hypertension 10 (50%)
End-stage renal 2 (10%) Escherichia coli 7 (35%)
disease with Streptococcus milleri group 3 (15%)
haemodialysis Streptococcus agalactiae 1 (5%)
Liver cirrhosis 2 (10%) Enterococcus faecium 3 (15%)
Hepatitis B virus 1 (5%) Acinetobacter baumannii 3 (15%)
carrier Staphylococcus aureus 2 (10%)
Cerebrovascular 7 (35%) Klebsiella pneumoniae 2 (10%)
accident Proteus vulgaris 1 (5%)
Malignancy 3 (15%) Proteus mirabilis 1 (5%)
Alcoholism 4 (20%) Pseudomonas aeruginosa 1 (5%)
Anal surgery 2 (10%) No bacterial growth 2 (10%)
Data missing 4 (20%)
BMI, body mass index.

were represented as mean ± standard deviation, and the data
about patient characteristics and univariate analysis of prognos-
tic factors were analysed with the 𝜒 2 -test and Fisher’s exact test.
The mean values of laboratory examination in patients who sur-
vived and patients who expired were compared using Student’s
t-test. Logistic regression analyses were used for the multivari-
ate analysis of prognostic factors. We considered P-values less
than 0⋅05 to be statistically significant.
Results
Demographic characteristics and the proportion of patients with
a medical history of comorbidities were described in Table 1.
Seven patients (35%) were bedridden due to the sequelae of a
cerebrovascular event, two patients (10%) were diagnosed with
colorectal cancer and had adjuvant chemotherapy and radio-
therapy after curative surgery, and one patient (5%) underwent
hepatectomy due to hepatocellular carcinoma. Four patients
(20%) were chronic alcoholics, with a mean alcohol consump-
tion of 1⋅8 bottles of soju (Korean distilled spirits) per day
(Table 1).
Common symptoms included perineal pain (60%), perineal
oedema (50%) and anal bleeding (55%). Other symptoms
included perineal necrosis or discharge (10%), difficulty in
defecation (5%), difficulty in voiding (10%), suprapubic pain
(5%), fever (10%) and general weakness (25%). In addition,
some patients were admitted to the emergency room due to dys-
pnoea (5%) or a depressed mental status (5%).
The most common cause (12 patients, 60%) of Fournier’s
gangrene was a perianal or perirectal infection that spread to
the perineum, genitourinary organs, buttocks and abdominal
wall. Gangrenous infections also developed after anal surgery
and trauma and from sores. Two patients (10%) developed this
condition following radiotherapy associated with a malignant
disease (Table 2).
The mean number of detectable bacterial species was
1⋅5 ± 1⋅1. Among them, Escherichia coli was the most common
(35%), followed by Streptococcus species (20%). Enterococcus
faecium (15%), Acinetobacter baumannii (15%) and Staphy-
lococcus aureus (10%) were also detected in this study. Of
all patients, 6 (30%) demonstrated polymicrobial infections,
and there were no detectable organisms in 2 (10%) patients
(Table 3).
The mean FGSI score was 6⋅8 ± 5⋅1; eight patients (40%)
had a score > 9 points. Fifteen patients required treatment
in the intensive care unit (ICU) with a mean duration of
ICU stay of 7⋅4 ± 6⋅6 days. The mean number of debride-
ments was 1⋅7 ± 0⋅9, and 10 patients (50%) underwent >2
debridements. Colostomy was required in 11 patients (55%)
due to an anal sphincter impairment or contamination of a
debridement wound. Four patients (20%) required reconstruc-
tive surgery with a skin flap due to a broad wound defect
(Fig. 1), and vacuum-assisted closure (VAC® ) dressing suc-
cessfully decreased the size of the debridement wound, with-
out additional surgical requirement, in two patients (10%)
(Fig. 2). Five patients (25%) died because of gangrenous infec-
tion (Table 4).
We investigated the correlation between prognosis and old
age (≥65 years), high BMI [≥25 kg/m2 ], diabetes mellitus, liver
cirrhosis, renal failure, malignancy and FGSI score. There was
no significant association between diabetes mellitus and mor-
tality in both univariate (P = 0⋅417) and multivariate analysis
[P = 0⋅781, odds ratio (OR) 2⋅234, 95% confidence interval
(CI) 0⋅008–643⋅993]. Nor was there a significant association

© 2017 Medicalhelplines.com Inc and John Wiley & Sons Ltd 3

Prognostic factors and treatment outcomes for Fournier’s gangrene K. S. Hong et al.

Table 4 The clinical course of patients

Characteristics n (%)

FGSI (points) Mean score 6⋅8 ± 5⋅1

≤9 12 (60%)
>9 8 (40%)
Septicaemia Yes 3 (15%)
No 17 (85%)
Mean hospitalisation (days) 36⋅9 ± 41⋅3
ICU care Mean duration (days) 7⋅4 ± 6⋅6
Yes 15 (75%)
No 5 (25%)
Timing of operation Mean hospital day of 2⋅7 ± 1⋅9
operation (HD)
HD #1 or #2 11 (55%)
≥ HD #3 9 (45%)
Number of debridements 1 10 (50%)
2 9 (45%)
≥3 1 (5%)
Colostomy Yes 11 (55%)
No 9 (45%)
Reconstruction with skin flap Yes 4 (20%)
No 16 (80%)
Vacuum-assisted closure Yes 2 (10%)
No 18 (90%)
Mortality Yes 5 (25%)
No 15 (75%)

FGSI, Fournier’s gangrene severity index; HD, hospital day; ICU, intensive
care unit.

Figure 2 Vacuum-assisted closure (VAC® ) dressing. (A) Necrotis-
ing fasciitis had spread to the suprapubic abdominal wall. (B) A
vacuum-assisted closure dressing was applied.
for hypertension, liver cirrhosis, renal failure, malignancy,
cerebrovascular events and alcohol abuse (P < 0⋅05). Patients
with an FGSI score greater than 9 points had a higher mortality
rate in univariate analysis (P = 0⋅035); however, this was not
significant in the multivariate analysis (P = 0⋅526, OR 3⋅375,
95% CI 0⋅079–144⋅394).
In terms of laboratory analysis, the mean level of BUN
was higher and that of albumin was lower in patients who
died (79⋅0 ± 54⋅5 and 2⋅2 ± 0⋅3 mg/dl, respectively) than in
those who survived (25⋅1 ± 13⋅8 and 2⋅9 ± 0⋅6 mg/dl, respec-
tively). However, these findings did not show a statistical
association with prognosis (P = 0⋅091 and 0⋅052, respectively).
On the other hand, when prognosis was examined according
to BUN level, those with a level > 50 mg/dl had a higher
mortality rate than those with levels < 50 mg/dl by both uni-
variate (P = 0⋅001) and multivariate analysis (P = 0⋅033, OR
31⋅090, 95% CI 1⋅308–738⋅865) (Table 5). On the other hand,
there was no significant difference in the prognosis between
patients with and without hypoalbuminemia (P = 0⋅160)
(Table 5).
Discussion
Fournier’s gangrene is not common and can still be fatal despite
medical development. In particular, the prevalence of this dis-
ease has recently begun to increase due to various predisposing
factors, such as diabetes mellitus, immune-related disease and
malignancy (7). According to previous studies, the incidence
is 1:7500–1:750 000 people (2) or 1:25 000–1:250 000 peo-
ple (8), and the mortality rate is 3–67% (2,9). Kim et al. (7)
reported a mortality rate of 14⋅8%, and another study in Korea
(10) reported a rate of 27⋅2%. In this study, the mortality rate
was 25%.
This disease can occur in both men and women; how-
ever, men are known to be more susceptible, with a ratio of
10:1 (2,11). In this study, there were two female patients,
and the male-to-female ratio was 9:1. Bilton et al. (12) found
that Fournier’s gangrene occurred predominantly in individu-
als aged between 30 and 60 years, and another recent study
also reported that, although this disease can occur at all ages,
it is most common in individuals in their fifties (2). However,
the mean age of patients in this study was 61⋅8 ± 12⋅7 years,
and 50% of patients were aged over 65 years. This implies that
the age of those affected by Fournier’s gangrene is increas-
ing. In terms of BMI, 25% of the patients in this study were
obese according to World Health Organization (WHO) criteria
(Table 1). Norton et al. (13) reported that obesity was a predis-
posing factor in Fournier’s gangrene; however, our results did
not show a significant association with prognosis.
Various underlying diseases have been considered to con-
tribute to the occurrence and aggravation of Fournier’s gan-
grene. Diabetes mellitus, alcohol abuse, immune suppression,

4 © 2017 Medicalhelplines.com Inc and John Wiley & Sons Ltd

K. S. Hong et al. Prognostic factors and treatment outcomes for Fournier’s gangrene

Table 5 Risk factors for a poor prognosis in Fournier’s gangrene

Univariate analysis Multivariate analysis

Total (n = 20) Expired (n = 5) P-value RR P-value OR (95% CI)

Age (years)
<65 10 1 (10%) 0⋅121 6⋅000 0⋅807 1⋅595 (0⋅038–67⋅590)
≥65 10 4 (40%)
Gender
Male 18 4 (22⋅2%) 0⋅389 3⋅500 0⋅987 0⋅963 (0⋅008–110⋅394)
Female 2 1 (50%)
BMI (kg/m2 )
<25 15 3 (20%) 0⋅371 2⋅667 —
≥25 5 2 (40%)
FGSI (points)
≤9 12 1 (8⋅3%) 0⋅035* 11⋅000 0⋅526 3⋅375 (0⋅079–144⋅394)
>9 8 4 (50%)
Diabetes mellitus
Yes 13 4 (30⋅7%) 0⋅417 2⋅667 0⋅781 2⋅234 (0⋅008–643⋅993)
No 7 1 (14⋅3%)
Liver cirrhosis
Yes 2 1 (50%) 0⋅389 3⋅500 -
No 18 4 (22⋅2%)
Renal failure
Yes 2 1 (50%) 0⋅389 3⋅500 -
No 18 4 (22⋅2%)
Malignancy
Yes 3 1 (33⋅3%) 0⋅718 1⋅625 -
No 17 4 (23⋅5%)
Timing of operation
HD #1 or #2 11 2 (18⋅2%) 0⋅617 2⋅250 -
≥HD #3 9 3 (33⋅3%)
Number of debridements
≥2 10 2 (20%) 0⋅606 0⋅583 -
1 10 3 (30%)
Diversion stoma
Yes 11 2 (18⋅2%) 0⋅436 0⋅444 -
No 9 3 (33⋅3%)
ICU care
Yes 15 5 (33⋅3%) 0⋅136 0⋅667 -
No 5 0 (0%)
BUN level (mg/dl)
<50 15 1 (6⋅7%) 0⋅001* 56⋅000 0⋅033* 31⋅090 (1⋅308 − 738⋅865)
≥50 5 4 (80%)
Albumin level (mg/dl)
<3⋅0 14 5 (35⋅75) 0⋅160 0⋅692 -
≥3⋅0 4 0 (0%)

CI, confidence interval; BUN, blood urea nitrogen; BMI, body mass index; FGSI, Fournier’s gangrene severity index; HD, hospital day; ICU, intensive
care unit; RR, relative ratio; OR, odds ratio.

malignancy, liver disease and renal disease are reported to be
positively associated with mortality (2,14,15); in particular, dia-
betes mellitus is the most common and important predisposing
factor (2,16). However, the relationship between diabetes mel-
litus and mortality is controversial, with some studies showing
an association with both incidence and mortality (17,18), while
others show an association with incidence but not with mortal-
ity (6,16). In this study, 65% of patients had diabetes mellitus;
however, there was no significant association with mortality.
Reports on the timing of hospital presentation vary, with
the period from symptom manifestation to hospital attendance
ranging from approximately 1 to 30 days (19,20). Gener-
ally, patients attend an emergency room within 2–7 days of
complaining of symptoms such as perineal oedema or discom-
fort, purulent exudates, necrosis or shock (2). In this study,
patients already had advanced perineal inflammation upon
presentation.
Aetiological factors vary; in most cases, the disease is related
to sanitary conditions of the perineum (21). Infectious sources
are mostly anorectal diseases, urological diseases, intraperi-
toneal diseases or traumatic injuries (9), and in some cases, the
cause cannot be deciphered. In this study, perianal or perirec-
tal infections were the most common causes, while one patient
had an infected sore and another had an infection in a trau-
matic wound. Notably, two patients had severe infections after
rectal cancer radiotherapy, in keeping with a previous study,

© 2017 Medicalhelplines.com Inc and John Wiley & Sons Ltd 5

Prognostic factors and treatment outcomes for Fournier’s gangrene
which reported that malignant disease and immunosuppression
as a result of treatment could be risk factors for Fournier’s gan-
grene (15). The proportion of rectal cancer patients has recently
been increasing, and radiotherapy is a major and important part
of treatment; therefore, surgeons should be aware of the rela-
tionship between malignancy or radiotherapy and Fournier’s
gangrene.
The causative organisms in Fournier’s gangrene are mainly
aerobic Gram-negative bacilli or Gram-positive cocci, and most
cases include a mixed infection of more than three organisms
(14,19), such as Escherichia coli or Proteus, Enterococcus,
Pseudomonas or Klebsiella species (15,22). The most com-
monly detected bacteria is Bacteroides fragilis (14,23), while
Staphylococcus aureus or Streptococci are frequently identified
in patients with diabetes mellitus (24). In this study, E. coli was
the most commonly detected organism in 35% of patients, fol-
lowed by Streptococcus species at 20%. Enterococcus, Acineto-
bacter, Staphylococcus, Klebsiella, Proteus and Pseudomonas
species were also cultured, and for two patients, no bacterial
organisms were identified.
The management of Fournier’s gangrene can be summarised
into three parts: early detection, immediate and aggressive
debridement and adequate administration of broad-spectrum
antibiotics (2,6,19). Norton et al. (13) also suggests patient sta-
bilisation, broad-spectrum antibiotic administration and early
invasive surgical management, with the most important aspect
being prompt surgical management. In this study, all patients
underwent aggressive debridement and broad-spectrum antibi-
otic therapy. If additional necrotic lesions were identified after
the first debridement, debridement was repeated, with a mean
number of 1⋅7 debridements conducted. In this study, 55% of
patients required ostomy, and although there was no significant
association between ostomy and prognosis, other studies have
reported that patients with ostomy had a poor clinical course
(25). In fact, ostomy can help to heal the wounds caused by
an anorectal infection in Fournier’s gangrene (2). Four patients
(20%) required skin grafts, and in two, the wide wounds were
healed by a VAC dressing without additional surgical require-
ments. The VAC device usually consists of a sterile, open-cell
foam sponge that is placed in the wound and then covered with
a transparent adhesive drape and non-collapsible tubing that is
connected to a suction pump that provides continuous negative
pressure. This device promotes debridement and increases per-
fusion, fibroblast migration and cell proliferation in the wound,
thus facilitating rapid wound closure, drawing the wound edges
together and reducing the would surface area (2). Thus, the ade-
quate application of VAC dressings may be helpful in wound
healing, thereby reducing the requirement for additional skin
graft surgery.
The mortality rate for Fournier’s gangrene is 3–67% (2,9).
The known prognostic factors are age; a history of hyperten-
sion, heart failure, renal failure or coagulopathy; procedures
performed during admission (e.g. ostomy, ventilator care with
intubation and haemodialysis); hospitalisation (2,25); the size
of the necrotic area (26,27); FGSI score (2,6); and sepsis or
shock at admission (28). In this study, 65% of patients had
diabetes mellitus; however, there was no significant association
between diabetes mellitus and mortality. Other underlying
diseases, such as hypertension, liver cirrhosis, renal failure,
6 © 2017 Medicalhelplines.com Inc and John Wiley & Sons Ltd
K. S. Hong et al.
malignancy, cerebrovascular events and alcohol abuse, were
not significantly associated with prognosis either. Only patients
with a FGSI score higher than 9 points had a higher mortal-
ity rate. FGSI describes severity by scoring vital signs and
metabolic parameters (6) and may be helpful in making initial
therapeutic decisions, such as the performance of more active
and broad treatments in patients with a score >9. In terms of
laboratory analysis, cases with higher BUN levels (>50 mg/dl)
(29) or with hypoalbuminemia (30) have been shown to have
a poorer prognosis. In this study, if the initial BUN level was
>50 mg/dl, patients were predicted to have a poorer prognosis;
however, there was no significant difference in prognosis for
patients with and without hypoalbuminemia. Although these
prognostic factors can help to determine the principles of
treatment, the most important factor is adequate and active
treatment according to disease manifestations, vital signs and
laboratory results, which may vary depending upon the timing
of hospital presentation.
The main limitation of this study was the small sample size.
However, as the incidence of Fournier’s gangrene is low, the 20
patients presenting at this one institution is representative.
Conclusions
The incidence of Fournier’s gangrene is predicted to increase
due to the aging demographics and increases in metabolic or
immune-related diseases in developed countries. Despite med-
ical developments, the mortality rate of this disease is high as
ever. The most effective form of disease management is aggres-
sive debridement and combined antibiotic therapy. Moreover, a
VAC dressing can help to promote wound healing and to reduce
the chance of reconstructive surgery with skin grafting. In
addition, an adequate understanding of Fournier’s gangrene by
treating physicians is very helpful. Therefore, surgeons should
be mindful that prognosis can be improved through a thor-
ough understanding of predisposing diseases or prognostic fac-
tors at initial presentation and that the performance of proce-
dures, such as diverting stoma or haemodialysis, can improve
prognosis.
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