Gangrena de Fournier vulvar relacionada con prolapso uterino total / Vulvar Fournier gangrene related to a total uterine prolapse

Resumen ANTECEDENTES: La gangrena de Fournier es una fascitis necrotizante polimicrobiana, de comienzo agudo y rápida progresión. Afecta los genitales externos, el periné y la región perianal y es de elevada mortalidad. Es diez veces más frecuente en varones, sobre todo, en los de 50-60 años. Entre los factores de riesgo conocidos están: diabetes mellitus, hipertensión y alcoholismo. CASO CLÍNICO: Paciente de 62 años, con diabetes mellitus tipo 2 de larga evolución, hipertensión y obesidad, sin exploraciones ginecológicas previas, que consultó por fiebre, dolor abdominal y perineal. Se le diagnosticó gangrena de Fournier vulvar, quizá originada por una erosión vulvar, producida por el prolapso genital total. La exploración (absceso vulvar crepitante) y las pruebas de imagen ayudaron a establecer el diagnóstico. El tratamiento se inició con antibiótico de amplio espectro, por vía intravenosa, seguido de intervención quirúrgica urgente para desbridamiento amplio del tejido necrótico. Debido a la rápida propagación de la fascitis, la paciente fue reintervenida 48 h después. El aislamiento de anaerobios y Streptococcus constelatus en los tejidos, junto con el estudio histológico, confirmaron el diagnóstico definitivo. El posoperatorio evolucionó favorablemente. CONCLUSIONES: La gangrena de Fournier es un padecimiento poco frecuente y en la mujer la clínica es más insidiosa. Conocer los factores de riesgo y los síntomas iniciales puede ayudar a establecer el diagnóstico y tratamiento más temprano, permitir intervenciones quirúrgicas más conservadoras, aumentar la supervivencia y mejorar el pronóstico de las pacientes. El buen control de la diabetes, su principal factor de riesgo, es decisivo para su prevención.

Abstract BACKGROUND: Fournier´s gangrene is a polymicrobial necrotizing fasciitis, with acute onset and rapid progression. It affects perineal, perianal and genital regions and it has a high mortality rate. It is 10 times more frequent in men than in women, with highest incidence amongst patients aged 50 to 60. Its known risk factors include diabetes mellitus, hypertension and alcoholism. CLINICAL CASE: A 62-year-old woman with type II long-standing diabetes mellitus, hypertension and obesity, without previous gynecological exams was hospitalized with fever, abdominal and perineal pain. She was diagnosed with vulvar FG, probably caused by a vulvar erosion, produced by the total genital prolapse presented. Exploration (crepitant vulvar abscess) and imaging tests helped the diagnosis. Broad-spectrum intravenous antibiotics therapy was initiated, followed by an urgent surgical procedure in which a debridement of the necrotic tissue was performed. Due to spreading of the infection, the patient had to be reoperated 48 hours later. Streptococcus Constelatus and anaerobes were isolated from tissues and an anatomopathological study confirmed the diagnosis. Postoperative care ended favorably. CONCLUSIONS: Fournier's gangrene constitutes a very rare pathology, especially in women due to a more insidious clinic. Knowing about the risk factors and initial symptoms, can help to make an early diagnosis and apply urgent treatment, allowing more conservative surgeries, increasing the survival and improving the prognosis. The right handling of diabetes, its main risk factor, becomes key in the prevention of this pathology.

Infantile Vulvar Abscess with a Normal Anus: A Suspicious Sign of Rectovestibular Fistula

PURPOSE: We investigated whether infantile vulvar abscesses are predictable features of rectovestibular fistula with a normal anus. MATERIALS AND METHODS: A retrospective analysis of five infants with vulvar abscesses and rectovestibular fistulae with normal anuses was performed. RESULTS: Four cases had a left vulvar abscess, and in one case the vulvar abscess was on the right side. All caregivers reported passage of stool from the vagina. The fistulae were almost uniformly located from the vestibule to the rectum above the anal dentate line, observable by visual inspection and probing under anesthesia. The first two cases were treated with division and closure of the fistulae after a diverting loop colostomy, and the remaining three cases with fistulotomy and curettage. There was no recurrence during the median follow-up period of 38 months. CONCLUSION: This unique rectovestibular fistula should be suspected in female infants with vulvar abscesses, especially when parents report passage of stool from the vagina. Fistulotomy and curettage may be an initial treatment and effective as a temporary diverting colostomy and delayed repair of the fistula.