Gangrena di Fournier: Riflessioni di un urologo sul salvare vite attraverso la chirurgia e la connessione

Ultimo aggiornamento: 15 agosto 2026

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It is a profound honour to share this reflection. Looking back at the 26° Congresso Scientifico Annuale della Società Cambogiana di Chirurgia, tenutosi il 6 febbraio 2021, I recognise it as a pivotal milestone in my career. Serving as the speaker for the Cambodian Urology Society while representing the Urology Department of Royal Phnom Penh Hospital was not just a professional duty — it was a chance to share lessons learned from the front line of surgical emergencies.

Today I want to walk through a case that tested every part of my clinical skill and the foundation of the doctor-patient relationship. This is a reflection on managing Fournier’s gangrene — a life-threatening urological emergency — during the height of the COVID-19 pandemic, while I was practising urology in Cambodia.

Cos'è la gangrena di Fournier?

Chiamato dal dermatologo francese Dott. Alfred Fournier, questa condizione è una forma di necrotising fasciitis affecting the genital and perineal area. It is a true surgical emergency — every hour of delay matters.

La malattia è polimicrobico, il che significa che coinvolge un mix di batteri aerobici e anaerobici, come E. coli e Pseudomonas aeruginosa — working together to destroy soft tissue at an alarming rate. It often begins subtly: a urinary tract infection, a small perineal abscess, or a minor genital procedure. Once it takes hold of the fascia, the layer of tissue beneath the skin, it spreads rapidly.

Perché la diagnosi precoce salva vite

Reported mortality varies widely between published series — older reports describe figures above half of all patients, while modern series with early surgery and intensive care report considerably lower rates. That spread is itself the point. The single variable that moves it most is time from onset to the operating theatre, which is one of the few things a patient can influence directly by seeking help early. Outcome also depends on age, the extent of tissue involvement, and how unwell the patient is on arrival.

È per questo early diagnosis is the key to survival. The window between a small painful area and a life-threatening emergency can be measured in hours rather than days.

Chi è a rischio?

Certain conditions make people significantly more vulnerable. The most important risk factors include:

• Diabete mellito non controllato o non diagnosticato — il singolo fattore di rischio più comune.
• Uso pesante di alcol — il che indebolisce il sistema immunitario e compromette la nutrizione.
• Immunosoppressione — da malattie croniche, chemioterapia, HIV o uso a lungo termine di steroidi.
• Malnutrizione — riflesse in bassi livelli di albumina sierica.
• Interventi perineali recenti, ascessi perianali o infezioni urinarie non trattate.

Two things that are commonly missed, and both matter.

It is not only a men’s disease. Fournier’s gangrene is far more common in men, which is why it is usually discussed in a urological setting, but women and occasionally children develop it too. A woman with rapidly worsening perineal or vulval pain out of proportion to what can be seen should be taken exactly as seriously.

SGLT2 inhibitors carry a specific warning. This class of diabetes medicine — the drugs whose names end in -gliflozin, such as dapagliflozin, empagliflozin and canagliflozin — has been the subject of a regulatory safety warning about a rare association with Fournier’s gangrene. These are valuable drugs with real cardiovascular and kidney benefits, and the risk is small. Do not stop taking one because you have read this. What is worth doing is knowing the warning signs below, and seeking care urgently rather than waiting if genital or perineal pain, swelling or redness develops while you are on one.

Segnali di avvertimento che non dovresti mai ignorare

One of the most dangerous features of Fournier’s gangrene is that early symptoms can resemble a simple infection or abscess — but the disease behaves entirely differently. The following table is intended as a patient-safety guide:

Infezione comune	Segnali di emergenza "bandiera rossa"
Dolore localizzato nel sito interessato	Dolore che si diffonde rapidamente oltre l'area originale, spesso sproporzionata rispetto a ciò che si vede sulla pelle
Leggero arrossamento e gonfiore	Pelle che diventa scura, nerastra o macchiata, or develops blisters or a foul odour
Dolore controllabile con paracetamolo	Dolore forte che antidolorifici comuni non riescono a controllare
Febbre lieve, generalmente in buone condizioni	Confusione, battito cardiaco accelerato, pressione bassa o malessere grave — segni di sepsi
Sintomi che migliorano con antibiotici orali	Sintomi che peggiorano nonostante gli antibiotici, in particolare in un diabetico o chi fa uso di alcol

If you or someone you know experiences any of these red-flag signs, go to the nearest emergency department immediately — not to a clinic appointment, and not to a message. Fournier’s gangrene is one of the few conditions in urology where the difference between life and death is measured in hours.

Una storia di un paziente: lezioni dalla prima linea

The account that follows is drawn from cases I managed during my years in urology. Identifying details have been changed or combined, and it is presented for what it teaches rather than as a record of any one person.

A man reached our department after several days of worsening perineal pain. He had been treated elsewhere for what was thought to be a simple perianal abscess, with oral antibiotics and ordinary pain relief. By the time he arrived the pain was unbearable, the skin was changing colour, and the tests showed what neither he nor the doctors before us had known: the familiar and dangerous combination of uncontrolled diabetes, heavy alcohol use and poor nutrition. Imaging confirmed Fournier’s gangrene. Circumstances at the time made transfer elsewhere impractical, and the cost of treatment was a real burden for him — both of which shaped everything that followed.

Il Dilemma del Chirurgo: Quando la Fiducia Diventa Cura

Understandably, the patient was frightened and angry. He was dissatisfied with our inability to give him an exact timeline for recovery or a fixed final cost. At his lowest point he refused to speak with the urology team at all.

I realised that to save his life, I first had to repair our relationship. So I changed approach:

1. Rebuild the bond. I moved from being a provider of a service to being someone he could trust through the hardest weeks of his life.
2. Personal care. Ho eseguito medicazioni di ulcere da decubito al letto del paziente da sola, due volte al giorno, ogni giorno.
3. Terreno comune. We talked about things he cared about — politics, the economy — and let those conversations carry us through the medical work.

La Battaglia Chirurgica: Una Maratona, Non Uno Sprint

Treating Fournier’s gangrene is rarely a single operation. It is a marathon of escissione chirurgica in fasi, where the surgeon returns to theatre repeatedly to remove infected tissue until only healthy tissue remains. Each return allows the team to reassess what is alive, what is recovering, and what must still be removed. It is worth being honest that this can mean losing a significant amount of tissue, and that reconstruction afterwards is part of the plan rather than an afterthought.

Accanto al lavoro chirurgico, tre cose si svolgevano in parallelo:

• Antibiotici: broad-spectrum coverage first, narrowed to targeted therapy once tissue cultures identified the responsible organisms.
• Lavoro di squadra multidisciplinare: internal medicine colleagues brought his blood sugar under tight control, and the nursing team led meticulous wound care.
• Ricostruzione: once the infection was defeated, reconstructive surgery closed the wound and restored form and function.

Recupero e Riflessione

By the time he left hospital, he was pleased with his outcome. Today he is doing well: his diabetes is controlled, his wound has healed, and he has returned to ordinary daily life.

What stayed with me is not the surgery. It is that the turning point came when the relationship was repaired — a quiet reminder that while an operation repairs the body, it is trust that carries the person through the weeks afterwards.

Messaggi chiave da portare a casa

• Le basi contano. Sound clinical practice and basic surgical skill are the foundation of every good outcome.
• The team wins it. Surgery, internal medicine, nursing and nutrition together — not the surgeon alone.
• The relationship is part of the treatment. The ability to connect with a frightened patient can matter as much as the scalpel.
• And for the reader, the only one that really counts: pain in the genital or perineal area that is spreading, disproportionate, or accompanied by feeling seriously unwell is an emergency — particularly with diabetes, heavy alcohol use or a suppressed immune system.

If you notice any of the red-flag signs above — especially if you have diabetes, are immunosuppressed, or take an SGLT2 inhibitor — do not wait, and do not message anyone for advice. Go to the nearest emergency department.

For non-urgent urological concerns or follow-up, Dr. Soarawee Weerasopone consults at Bangkok Hospital Headquarters e al Samitivej Sriracha Hospital, Chonburi — 088-022-1445. The wider range of conditions covered is set out under Urologia generale.

Bangkok Hospital Telemedicine is available for non-urgent matters, including for international patients — arrange it in advance by email to the Urology department at bhquro@bdms.co.th. It is not appropriate for anything described on this page as a red flag: that needs an emergency department, in person, now. Samitivej Sriracha is in-person only.

Domande Frequenti sulla Gangrena di Fournier

La gangrena di Fournier è una grave infezione batterica che colpisce i genitali, l'ano e le aree circostanti. Causa un rapido deterioramento dei tessuti, che può portare a complicazioni potenzialmente letali.

Fournier’s gangrene is a rare but life-threatening bacterial infection of the soft tissues of the genital and perineal area. It is a form of necrotising fasciitis, meaning the infection rapidly destroys the deep tissue layer beneath the skin and can lead to sepsis and death if not treated urgently with surgery and antibiotics.

Chi è più a rischio per la gangrena di Fournier?

The most important risk factor is uncontrolled or undiagnosed diabetes mellitus. Others include heavy alcohol use, immunosuppression from HIV, chemotherapy or long-term steroids, severe malnutrition, and recent perineal infections, abscesses or procedures. It is far more common in men, but women and occasionally children are affected too.

Do SGLT2 inhibitors cause Fournier’s gangrene?

This class of diabetes medicine — the drugs ending in -gliflozin — has been the subject of a regulatory safety warning about a rare association with Fournier’s gangrene. The risk is small and these drugs have important cardiovascular and kidney benefits, so nobody should stop one on the basis of an article. What matters is awareness: if genital or perineal pain, swelling or redness develops while taking one, seek urgent assessment rather than waiting, and tell the doctor which medicines you are on.

Quali sono i primi segnali di allarme della gangrena di Fournier?

Pain in the genital or perianal area that spreads quickly and feels disproportionate to what is visible on the skin, dusky or darkening skin, foul odour, severe pain not controlled by ordinary painkillers, and signs of sepsis such as confusion, rapid heartbeat or low blood pressure. Symptoms worsening despite oral antibiotics is another warning. Any of these need emergency assessment.

Il trattamento della fascite necrotizzante di Fournier include antibiotici, un intervento chirurgico per rimuovere il tessuto infetto, terapia endovenosa e, nei casi più gravi, ossigenoterapia iperbarica.

Three things working together: emergency surgical debridement, often in several stages, to remove infected tissue; broad-spectrum intravenous antibiotics narrowed once cultures identify the bacteria; and aggressive support of underlying problems such as diabetes and nutrition. Once the infection is controlled, reconstructive surgery closes the wound. Significant tissue may be lost in the process, which is part of why speed matters so much.

La fascite necrotizzante di Fournier può essere curata?

Yes, with rapid recognition and aggressive treatment. With early surgery, modern antibiotics, intensive care and good control of underlying conditions, many patients recover fully. Mortality remains significant across published series, and the strongest determinant is how quickly the patient reaches an operating theatre — which is why the warning signs matter more than any other part of this article.

Avvertenza: This content is written and reviewed by Dr. Soarawee Weerasopone, a board-certified urologist at Bangkok Hospital Headquarters. It is intended for educational purposes only and does not constitute medical advice. Patient details in this article have been generalised to protect privacy. No advice, diagnosis or prescription is given through personal messaging channels or social media — and a suspected necrotising infection is not something to ask about by message. If you suspect a serious infection, go to an emergency department immediately.