Fournier’s gangrene (FG) is a rare and life-threatening necrotic soft tissue infection. This type of necrotizing fasciitis initially affects the scrotum, perineum, labia majora, and the inflammation can reach the soft tissues of the abdominal and chest wall. The majority of patients are men. Major risk factors are diabetes mellitus and alcoholism. The diagnosis is primarily determined through physical examination findings. FG is an emergency, and immediate surgical treatment is essential.^[1–5]

A substantial body of research has been published on FG in the scientific literature. Despite the various therapeutic strategies proposed by different authors, the morbidity and mortality of this type soft tissue infection remains significant.^[6–8] The following study is one of the few similar conducted in Bulgaria to date.

The objective of this study was to analyze the demographic and clinical characteristics of a small cohort of patients with Fournier’s gangrene.

Fournier’s gangrene is a rare but serious surgical emergency, accounting for less than 0.02% of all hospital admissions. While it can affect individuals of any age or sex, it is more commonly observed in males, with an average reported age of 61±12 years.^[9–11] Mortality rates in the literature vary widely, ranging from 7% to 45%.^{[7, 12]} The primary risk factors associated with increased mortality include diabetes mellitus and alcohol abuse. Other contributing factors include recent trauma or surgical procedures, injection drug use (e.g., heroin, cocaine), and the use of sodium-glucose cotransporter 2 (SGLT2) inhibitors. Most patients also have at least one additional comorbidity.^[13–15] Etiologically, Fournier’s gangrene is classified into four types—Type I: polymicrobial (accounts for more than 80% of cases, with Bacteroides being the most common anaerobic organism); Type II: monomicrobial, typically caused by Streptococcus or Staphylococcus species; Type III: clostridial infections; and Type IV: fungal infections.^[16–18]

Diagnosis is primarily clinical and is based on symptoms such as severe genital pain and tenderness, localized skin erythema followed by necrosis and blistering, fever, and general weakness.^[19] There are no specific laboratory tests or biomarkers for Fournier’s gangrene. However, lab findings are utilized in severity and prognosis scoring systems such as the Fournier’s Gangrene Severity Index (FGSI) and the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC). While FGSI helps assess severity and prognosis, studies have shown it does not significantly correlate with mortality.^[20–22]

Imaging techniques like computed tomography (CT) and point-of-care ultrasound (POCUS) can be valuable for evaluating the extent and depth of the infection and for surgical planning. However, imaging should not delay immediate surgical intervention, as it is not essential for diagnosis.^[23–25]

The cornerstone of treatment for Fournier’s gangrene includes prompt and repeated surgical debridement, broad-spectrum antibiotics, and general supportive measures. These should be initiated urgently to reduce the risk of mortality. Additional supportive care may involve daily wound management using agents such as silver dressings, iodinated solutions, proteolytic enzymes, or vacuum-assisted closure (VAC), along with hyperbaric oxygen therapy (HBOT), blood and plasma transfusions, and proper nutritional support.^[26–30] Many patients also require adjunctive procedures and reconstructive surgeries.^[31–33]

An analysis of our study data revealed that the sex and age distribution of patients aligns with findings reported in previous research. The majority of Fournier’s gangrene cases occurred in the 56–75 age group, which also tended to have multiple comorbidities. Our observed mortality rate of 25.8% was consistent with the range reported in the literature. In terms of classification, type I FG was the most prevalent in our cohort, with Escherichia coli being the most frequently isolated organism—again, in agreement with other studies. Diabetes mellitus was not the predominant comorbidity in our patient group.

Although FG severity scoring systems were not applied in our study, they may be considered in future research. All patients underwent surgical intervention within 12 hours of hospital admission, with extensive incision and debridement procedures performed. Our preferred method for wound management was proteolytic enzyme therapy using pancreatic enzymes (trypsin and chymotrypsin), which effectively removed necrotic tissue and promoted epithelial regeneration. The enzymes were administered as a spray, allowing easy application over large areas. This approach was not only effective but also cost-efficient. Patients who received proteolytic therapy had better survival outcomes compared to those treated with alternative methods (Table 2).

Vacuum-assisted closure (VAC) was used in only one patient due to its higher cost, although it is a proven effective option. Hyperbaric oxygen therapy (HBOT), while recognized as a supportive treatment for FG, was not utilized in this study due to its limitations—such as the need for patient stability and access to a hyperbaric chamber. Nonetheless, it may be considered in future investigations.

Adjunctive surgical procedures were reserved for more severe cases. Although the testicles are usually spared in FG, bilateral orchiectomy was performed in cases involving testicular vessel thrombosis and necrosis. Colostomy was indicated in patients with fecal incontinence to prevent wound contamination, as fecal soiling is associated with impaired healing and increased risks of sepsis and mortality.

Patients with penile and scrotal tissue loss exceeding 25% were evaluated for reconstructive surgery. Consultations with plastic surgeons were conducted, and split-thickness skin grafts were used as the reconstruction method of choice.

Effective management of Fournier’s gangrene often requires a multidisciplinary approach, along with adjunctive and reconstructive surgical procedures. Our findings indicate that enzymatic proteolysis is an effective wound care method and may be considered a preferred option in the treatment of FG patients.

V.H.: conceptualization, methodology, formal analysis, investigation, writing – original draft, visualization, project administration; G.M., A.S., and L.P.: conceptualization, and formal analysis; S.K. and K.K.: conceptualization, methodology, statistical analysis, and validation; A.T.S. and K.K.– conceptualization and formal analysis; AB: supervisor, conceptualization.

The authors have no conflicts of interest to declare. All co-authors have perused the manuscript and consent to its content, and there are no financial interests to disclose. We hereby affirm that the submitted work is an original piece and is not currently under review by any other publication.

Prior to hospitalization, all patients provided written informed consent for further treatment and study participation.

The authors have no funding to report.