Introduction: Negative Pressure Wound Therapy (NPWT)
has evolved over the past decade because of its remarkable
effects on healing of chronic and difficult wounds and has
become the mainstay of their treatment, including Fournier’s
gangrene (FG). In this case report we describe the procedure
and discuss the difficulties of NPWT in such a patient.
Case report: A 58 year old patient with a FG was put on
NPWT on the 15th postoperative day after initial wound debridement.
Wound changes were performed every 2-3 days
with the patient in a lithotomy position under local anesthesia.
The pressure in the vacuum pump was set in a constant
mode in -80mmHg. The process of wound change and application
of the device was simple and quick. Nine days after the
treatment, the wound was fully covered by granulation tissue
and its size was remarkably decreased. On the 10th day, the
wound was reconstructed and repaired with split thickness
skin graft. Aggressive management with this therapy, accelerated
wound healing and also simplified the final reconstruction
of the wound.
Conclusion: NPWT constitutes the modern method of treatment
of GF wound. The technique of application is easy and
reproducible and simplifies reconstruction. It should be included
in the urologist’s armamentarium.
Keywords: Fournier’s Gangrene; Negative pressure; Wound
Fournier’s gangrene (FG) is a rare disease first described in
1764 . It is a rapidly expanding necrotic multi microbial
inflammation of perineum and scrotum with high mortality
rate . Extended and repeated surgical wound debridement
may lead to extensive wound defects which later require
complex reconstruction. Negative pressure wound therapy
(NPWT) has evolved over the past decade because of its remarkable effects on healing of chronic and difficult
wounds and has become the mainstay of their treatment, including
FG [3,4]. In this case report, we describe the procedure
and discuss the difficulties of NPWT.
A 58 year old patient with a previous history of alcoholism
was presented in our department with clinical symptoms of
severe sepsis. Clinical examination revealed a FG. After fluid
resuscitation and initiation of broad spectrum of antibiotics,
the patient was taken to the operating theatre for surgical debridement
of the anterior perineum, scrotum and inguinal
areas under general anesthesia (Figure 1). Postoperatively local wound care with wet to dry changes was
applied and surgical debridement was repeated twice. On the
15th postoperative day, the trauma was still covered by pseudo
membranes (Figure 2). Also, the granulation tissue was scant. It was decided the patient
to be put on NPWT. The necessary equipment for NPWT
application is outlined on (Table 1).
The steps for application of the device are the following: The
patient is placed in lithotomy position under local anesthesia.
Initially, wound cleaning and debridement is performed. We
then place the first layer of the special sterile gauze to cover
both the wound and the testicles. We ensure the gauze fits the
contours of the wound. The special flat drain is placed onto the
first gauze layer. We make sure that the proximal part of the
drain comes out of the groin area. Following, we place the second
layer of the gauze to fill the wound and apply a transparent
adhesive membrane to cover part of the wound. A sterile
tongue depressor is used to seal with stoma paste the edges of
the wound in the inguinal folds, the posterior perineum and
the area under the film layer where the drain tube and the catheter
enter (Figure 3). Finally, we place the remaining of the
adhesive membranes onto the trauma and we connect the tube
to the vacuum pump. The pressure of the vacuum device is set in a constant mode in
-80mmHg. If the wound is completely sealed, both the gauze
and the film layer contract and harden (Figure 4). In case of failure of the airtight mechanism, the device alarms
(Table 2). In such a case, we inspect the trauma for any leak
and we may need to seal it with extra film layer, hydrocolloid
membrane or stoma paste. Wound change is performed every
2-3 days. If the trauma drains heavy and infected exudate, especially
in the early phases of the treatment or there are frequent
failures of the airtight mechanism, then the wound may
require earlier change and inspection. The process is usually
simple and quick and its duration is less than half an hour. No
surgical debridement was required after the application of the
treatment. After nine days of treatment, the wound was completely
covered by granulation tissue (Figure 5). The following day the wound was reconstructed with spit
thickness skin graft. The final result was cosmetically acceptable
and the patient was fully satisfied (Figure 6).
The popularity of NPWT for the treatment of difficult wounds
is due to its unique mechanisms on wound healing physiology
. It produces a microstrain that removes the exudate from
the trauma, increases the local blood flow and promotes local
angiogenesis and the formation of granulation tissue. Proteins
and enzymes which act as inhibitors of wound healing decrease
their concentration in the wound area . The macrodeformation
causes a reduction of wound size and depth which in
some cases may reach up to fifty percent [6,7]. Moreover, local
edema decreases, thus enhancing the delivery of local nutrients.
Finally, there is not any scientific evidence to support
that NPWT decreases bacterial load . Generally, NPWT is
contraindicated in the presence of necrotic tissue and wound
infection. However, a vacuum assisted closure dressing may be
applied after initial wound debridement if the trauma is simple
with uncomplicated infection. In such, a case the wound must
be inspected on a daily basis for signs of infection and necrosis.
Also, the device itself should be inspected regularly for loss
of its watertight mechanism. Reasons for that are presented on
the (Table 2).
The rarity of the disease itself is a barrier for randomized
control studies. However, all the published studies and case
reports show a substantial benefit of NPWT to conventional
dressings [8,9]. In a recent publication, it was also mentioned
that early reconstruction has a positive impact on quality of
life . NPWT combined with other modalities, such as parenteral
nutrition, astronauts’ diet and a fecal collector may
obviate the need for diverting colostomy which increases the
overall morbidity .
Although some patients may experience pain with this treatment,
the pain is not usually so severe to lead them to withdraw
the treatment. We agree with other authors that the decrease
in surface area and the depth of the trauma makes final
reconstruction simpler and easier.
NPWT constitutes the modern method of treatment of GF
wound. The technique of application is easy and reproducible
and simplifies reconstruction. It should be included in the