Sacral Pressure Ulcer-induced Fournier’s Gangrene Extending to the Retroperitoneum: A Case Report

Introduction. Fournier’s gangrene (FG) is a type of necrotizing fasciitis of the perineum and scrotum that is characterized by very rapid progression. Sacral pressure ulcers are one of the causes of FG. Case Report. An 85-year-old man was referred to the National Hospital Organization Nagasaki Medical Center (Ohmura City, Japan) with a diagnosis of FG extending to the retroperitoneum caused by a sacral pressure ulcer. Immediate debridement was performed; however, it was not possible to remove all necrotic tissue from the pelvis. The wound was cleansed with continuous irrigation combined with negative pressure wound therapy, which brought the infection under control. The exposed rectum was resurfaced with a gracilis musculocutaneous flap, and the remaining wound in the sacral region was covered with a gluteal artery perforator flap. Conclusions. The authors consider continuous irrigation combined with negative pressure wound therapy as extremely useful for patients with FG in whom sufficient debridement cannot be performed.

Fournier’s gangrene (FG) is a life-threatening form of necrotizing fasciitis that develops in the genital and perineal region. It progresses rapidly and destroys significant amounts of local tissue; therefore, early diagnosis and treatment are crucial.^1,2 Fournier’s gangrene is usually associated with advanced infections, including anorectal, genitourinary, and skin infections, as well as sacral pressure ulcers. The early symptoms of FG consist of local tenderness, edema, and erythema of the genital and perianal skin, which progress to skin necrosis. These pathological changes are caused by microthrombosis of the subcutaneous blood vessels. The main principles for the treatment of FG are early aggressive debridement, broad-spectrum antibiotic therapy, and fluid resuscitation. Prompt debridement of any necrotic tissue is critical during the management of FG.

The authors present a severe case of sacral pressure ulcer-induced FG that extended to the retroperitoneum and was successfully treated with emergency debridement, intensive care, and continuous irrigation combined with negative pressure wound therapy (NPWT). Written informed consent was obtained from the patient for publication of this paper. 

An 85-year-old man was referred to the National Hospital Organization Nagasaki Medical Center (Ohmura City, Japan) emergently because he had gone into shock due to severe soft tissue gangrene of his genital area. He had previously suffered paralysis of the lower extremities caused by lumbar spinal canal stenosis. He had been using a wheelchair and was living at home with his son, but he had developed a sacral pressure ulcer and repeated local infections in the past 6 months. He had chronic renal failure and chronic obstructive pulmonary disease, had not been using corticosteroids, and had no history of surgery. The patient was admitted to a peripheral hospital because of an infection of the sacral pressure ulcer, but, on the day of his admission, he suffered respiratory discomfort and his blood pressure fell. He was diagnosed with septic shock and required emergency debridement, so he was transferred to the medical center by helicopter. 

At the first examination, he had a blood pressure of 81/61 mm Hg, a blood oxygen saturation of 96% (O₂ 8L), a pulse rate of 117 beats per minute, a respiratory rate of 19 breaths per minute, and a body temperature of 35.5°C. He exhibited necrotic tissue around the infected sacral pressure ulcer (7 cm x 5 cm), which demonstrated redness, localized warmth, and a foul smell and had spread to the sacrum, anorectal region, and perineum (Figure 1). A computed tomography scan revealed fluid retention and a gas shadow around the sacrum, rectum, and retroperitoneum (Figure 2). A series of blood tests showed a white blood cell count of 7500/µL, a hemoglobin level of 10.1 g/dL, a blood urea nitrogen level of 55.1 mg/dL, a creatinine level of 1.3 mg/dL, a serum albumin level of 2.5g/L, and a C-reactive protein level of 30.6 mg/dL. Bacterial cultures of the wound detected Streptococcus dysgalactiae, Escherichia coli, and coagulase-negative staphylococci. 

Immediate debridement of the necrotic tissue of the coccygeal bone, right gluteus maximus muscle, anal sphincter muscle, and levator ani muscle was performed (Figure 3). However, it was not possible to remove all necrotic tissue because the patient was suffering from disseminated intravascular coagulation and was too ill to tolerate aggressive and prolonged surgery; thus, the necrotic tissue in the pelvis was left intact. The wound was left open and cleansed via continuous irrigation (2400 mL/day normal saline) combined with NPWT at -40 mm Hg for 37 days.³ Broad-spectrum antibiotic therapy was administered (meropenem 3g/day for 7 days and clindamycin 1800 mg/day for 14 days). 

In response to these treatments, the wound infection and the patient’s general condition improved (Figure 4). A colostomy was performed on day 11. After resolution of the infection, the exposed rectum was resurfaced with a gracilis musculocutaneous flap on day 46, while the remaining wound in the sacral region was covered with a gluteal artery perforator flap on day 68 (Figure 5). The patient underwent rehabilitation in a wheelchair for 3 weeks following the third operation (gluteal perforator flap on day 68), and his condition improved to the extent that he was able to operate the wheelchair by himself. No surgical site complications were observed, and he was transferred to another hospital to undergo rehabilitation on day 104.

Fournier’s gangrene is a type of necrotizing fasciitis affecting the perineum and scrotum that is characterized by a very rapid progression. It is a life-threatening disease, with a mortality rate ranging from 3% to 67%.^1,2 Many underlying conditions have been reported to be associated with FG, such as diabetes mellitus, immunosuppression, trauma, and genitourinary infections. In addition, sacral pressure ulcers can cause FG. Retroperitoneal necrotizing fasciitis is uncommon, and it was reported that the primary sources of infection in such cases are chronic pyelonephritis, diverticulitis, colonic cancer, and perianal abscesses.^4,5 Furthermore, several cases of severe sacral pressure ulcer-induced FG extending to the pelvic cavity and retroperitoneum have been reported.^6-8 Kudo et al⁸ reported 2 infection routes for sacral pressure ulcer-induced FG: (1) the sacral pressure ulcer becomes advanced, forms a retroperitoneal abscess, and finally induces FG; and (2) the sacral pressure ulcer directly induces FG. 

In the present case, osteomyelitis of the coccygeal bone was present, and the necrosis and infection had spread to the anorectal region, which suggested the infection had directly progressed from the coccygeal bone to the pelvic cavity and then spread to the retroperitoneum. Retroperitoneal necrotizing fasciitis also is reported to be more common in immunocompromised patients, such as those with diabetes mellitus, chronic renal failure, and human immunodeficiency virus.⁵ The patient presented herein had a history of chronic renal failure, chronic obstructive pulmonary disease, and a poor nutritional condition, and he was considered to be in an immunosuppressed state.

Emergent surgical removal of any necrotic tissue is indispensable during the treatment of FG.^1,2 Usually, debridement is performed repeatedly, and the wound is left open to allow frequent wound cleansing and washing. After surgical debridement, hyperbaric oxygen also is reported to be useful in hemodynamically stable patients.⁹ In the reported case, the authors could not debride all of the necrotic tissue because the necrosis had spread to the prostatic gland, bladder, and rectal artery. Therefore, they performed irrigation combined with NPWT (which cleans wounds mechanically, destroys anaerobic organisms, separates sloughing tissue, and promotes the formation of granulation tissue).^1,3 Kiyokawa et al³ reported the use of intrawound continuous negative pressure and irrigation treatment to treat severely infected wounds. This method resulted in the infection being brought under control and the formation of granulation tissue. The authors herein also performed continuous irrigation based on the procedure by Kiyokawa et al,³ which improved the condition of the patient’s wound.

In patients with FG, reconstruction is carried out to cover the wound and retain genital function.¹ A gracilis musculocutaneous flap can reach up around and provide protection for the rectum. In some cases, a colostomy is required to avoid fecal contamination and promote faster wound healing. Colostomy facilitates the early resumption of food consumption and stimulates wound healing. The authors of this report also conducted a colostomy as it was difficult to maintain the patient’s ability to defecate since the sphincter and levator ani muscles had developed necrosis and thus had been removed. After the colostomy, the wound was easier to manage.

A critical case of FG caused by a sacral pressure ulcer extending to the retroperitoneum was presented. The FG was treated with emergent debridement and continuous irrigation combined with NPWT. The authors consider that the combination of continuous irrigation and NPWT for the treatment of FG makes it possible to obtain good infection control, especially in patients in whom it is not possible to achieve sufficient debridement.

Affiliation: National Hospital Organization Nagasaki Medical Center, Ohmura City, Japan

Correspondence: Kiyoko Fukui, MD, Plastic and Reconstructive Surgery, National Hospital Organization Nagasaki Medical Center, 1001-1 Kubara 2 , Ohmura City, Japan 856-8562;
k.ku.r@hotmail.co.jp

Disclosure: The authors disclose no financial or other conflicts of interest.