Gangrene of the External Genitalia at the Regional University Hospital Center of Ouahigouya: Epidemiological Profile and Therapeutic Aspects

Introduction: Gangrene of extern genitary organs is a rapidly progressive necrotizing fasciitis of the perineum and external genitalia that results from a polymicrobial infection. Mortality remains high despite advances in resuscitation. We report the experience of the surgery department of the Regional University Hospital Center (CHUR) of Ouahigouya in order to describe the epidemiological profile and the therapeutic aspects of GOGE. Patients and methods: We carried out a descriptive and analytical retrospective study collecting 41 cases of Fournier’s gangrene treated over 63 months (from March 2013 to July 2018) in the surgical department of the Ouahigouya regional university hospital center. Ethical clearance was taken from the institutional ethics committee. Results: The mean age of the patients was 65.02 ± 17.92 years with extremes of 23 years and 95 years. All patients were male. Urologic causes were the most common with 36.58% of cases. The average consultation time was 15.44 ± 16.04 days with extremes of 1 day and 60 days. All patients received resuscitation, bi or triantibiotherapy and surgical debridement. The mortality rate was 24.39%. The mean duration of hospitalization was 10.83 ± 6.257 days with extremes of 1 day and 60 days. Conclusion: The Fournier’s gangrene always has a very high lethality. Improving the prognosis requires fast and effective management.


Introduction
Fournier external genitalia gangrene (GOGE) is a rapidly progressive necrotizing fasciitis of the perineum and external genitalia that results from polymicrobial infection [1]. In 1883 a French dermatologist named Jean Alfred Fournier reported five cases of gangrene of the external genitalia with no apparent cause in young men. This disease was called gangrene of Fournier [2]. The source of the infection can be urological, proctological or dermatological. However, in about 5% of cases GOGE is said to be idiopathic [1]. It is a rare urological emergency that can quickly put life threatening into play. Mortality remains high despite progress in resuscitation. It is estimated between 16% and 40% [3]. Management must be rapid and effective [4]. We report the experience of the surgery department of the Regional University Hospital Center (CHUR) of Ouahigouya in order to describe the epidemiological profile and the therapeutic aspects of GOGE.

Patients and Method
This was a descriptive and analytical retrospective study of 41 patients treated over a period of 63 months (from March 2013 to July 2018) in the surgical department of CHUR Ouahigouya in Burkina Faso. Data were collected from hospital records and patient records. Epidemiological (age, sex, profession), diagnostic (time to consult, clinical examination on admission, biology), therapeutic (resuscitation, antibiotic therapy, debridement) and evolutionary (duration of hospitalization, survival) were studied. The statistical analysis was performed by the Statistical Package for the Social Sciences (SPSS) software in version 21.0. The tests used were Student's t test and Fisher's exact test. P < 0.05 was considered statistically significant. The figures and tables were produced using Excel 2013 software. The confidentiality of the data was respected.

Results
During the study period, we collected 41 cases of GOGE, an average of 7.8 cases per year. GOGE accounted for 0.54% (41/7617) of all admissions during the study period. The mean age of the patients was 65.02 ± 17.92 years with extremes of 23 and 95 years. Figure 1 shows the distribution of patients by age group. All of the patients were male. Cultivators represented 85.36% (35/41) of the patients. Table 1 gives the distribution of patients according to the favorable factors. Urological causes were the most frequent with 36.58% of cases. Table 2 gives the distribution of patients according to etiologies. The mean consultation time was 15.44 ± 16.04 days with extremes of 1 day and 60 days. The anatomical location of the lesions is given in Table 3.
Therapeutically, all the patients benefited from resuscitation, bi or triantibio- but with no statistically significant difference (p = 0.455). We noted that the mortality rate was higher in patients who had a hemoglobin level lower than 10 g/dl compared to those who had a hemoglobin level higher than 10 g/dl (p = 0.008). The mean hospital stay was 10.83 ± 6.257 days with extremes of 1 day and 25 days. Table 4 gives the comparison of clinical and biological elements between the series of mortality and survival.

Discussion
In our series the GOGE hospital frequency was 0.54%. In the United States Sorensen estimated its frequency to be less than 0.02% [5]. In the Kambou series in Burkina Faso, the GOGE represented 2.3% of hospitalizations [6]. In other words, it is a rare condition. However, the most important series come from developing countries [1].
All of our patients were male. Indeed, GOGE is known to be a condition which mainly affects the male subject. Most studies on the issue point to the clear male dominance [7] [8] [9]. This is explained by the fact that in women there is better drainage of the perineal region through the vaginal secretions [1] [10] [11]. Yücell, on the other hand, reports in its series a female predominance at 56% [12]. GOGE was initially described by Jean Alfred Fournier as an affection of the young subject. But nowadays there is a change in the age of onset of this condition which reaches 61.7 years in certain series [13]. This would be linked to the increase in life expectancy. The average age of our patients was 65.65 ± 17.69 years with extremes of 23 and 95 years. Our study effectively confirms this evolution in the epidemiology of GOGE. Older age has been reported as a factor of poor prognosis in GOGE [14] [15]. In our series, however, we did not find a statistically significant difference between the age of the survivors and that of the deceased (p = 0.180).
In our series, high blood pressure was the most common comorbidity with 22% of cases. In addition, there were two cases of diabetes and one case of infection with the human immunodeficiency virus. What is decisive in these comorbidities is the decrease in cellular immunity which thus promotes infection [9]. However, there was no statistically significant difference between the survivors and the deceased concerning the presence or not of co-morbidity (p = 0.467). Four patients were paraplegic in our series. Spinal cord injured people are three times more likely to develop GOGE during their lifetime due to pressure ulcers and chronic urethral catheterization [10].
The three major etiological groups in GOGE are urogenital, proctological and dermatological [1] [9]. In our series gangrene without recognized cause represented 29.27% of cases. This high rate of gangrene without recognized cause could be explained by the lack of means of exploration in our context. Indeed, nowadays a cause is almost always identified in the GOGE [16]. Urological causes predominated in our series with 36.58% of cases. Fall in Senegal found a similar result [14]. We noted 5 cases (12.19%) of iatrogenic GOGE following a hydrocelectomy (3 cases) and a transvesical prostatic adenectomy (2 cases). Our result is higher than that of Ersay in Turkey who reported 2.9% postoperative gangrene in his series [17].
The mean consultation time for the deceased (19 days) was higher than that for the survivors (14.37 days), but the difference was not statistically significant (p = 0.455). Lujan Marco in Spain made the same observation [2]. However, some have established that rapid management is a good prognostic factor in GOGE [18]. Unfortunately, as Ruiz-Tovar pointed out, the period of consultation does not depend on the medical profession [19]. In our context, populations rarely consult health structures in the first place.
GOGE is a urological emergency whose treatment consists of a therapeutic tripod: resuscitation, triple antibiotic therapy and surgical debridement [20]. All our patients benefited from surgical debridement after resuscitation and bi or tri-antibiotic therapy. A first aggressive debridement often avoids a second intervention in the operating room [3]. GOGE's prognosis remains poor despite improved resuscitation facilities. Mortality varies between 16% and 40% and can go up to 80% in certain series [3] [8]. The mortality rate in our series was 24.39%. This means that about a quarter of our patients die. This result is clearly higher than that of Kambou, who noted a mortality rate of 5.5% [6]. This could be explained by the long consultation period in our series but also and above all by an inadequate resuscitation linked to the lack of biological explorations. There is still controversy as to the factors that influence mortality in GOGE [17]. Several prognostic factors have been reported. These include advanced age, diabetes, delay in treatment, and certain biological parameters [15] [19]. We were unable to establish prognostic scores in our series due to the unavailability of biochemical examinations in our health structure. This is a limiting factor in the correction of hydro-electrolytic disorders of our patients. However, we were able to demonstrate that the presence of septic shock as well as anemia was factors of poor prognosis in our series. Indeed, we noted that the mortality rate was higher in patients who had a hemoglobin level lower than 10 g/dl compared to those who had a hemoglobin level higher than 10 g/dl (p = 0.008). Ruiz-Tovar has shown that the risk of dying is 9.6 times higher if the hemoglobin level is less than 10 g/dl [19].
We did not find a statistically significant link between the survivors and the deceased with regard to serum creatinine (p = 0.072). Unlike our study, several studies have shown that elevated serum creatinine is associated with high mortality [4] [19].

Conclusion
GOGE still has very high lethality. Contrary to the initial description made by Jean Alfred Fournier, GOGE occurs today at an advanced age in patients with low immunity. Several factors determine its prognosis. But in our context, it is mainly the delayed diagnosis which seems to be the main factor. Thus, health education as well as an improvement of the technical platform with a resuscitation service will improve the prognosis of this condition.