Brazilian scientific evidence on Fournier’s gangrene

The objective of this study was to describe the Brazilian scientific reports published over the past twenty years on Fournier’s gangrene. It is an integrative review conducted through incursions in the LILACS, MEDLINE, BDENF and Coleciona SUS da tabases with the descriptor ‘Fournier’s Gangrene’. Texts published between January 1994 and July 2014, in Portuguese, and freely available online were selected. According to the 14 articles found, the main symptoms of Fournier’s gangrene include discomfort with painful sensations, high fever, edema, malaise, and sweating. In most cases erythema and blistering are observed, evolving into a wound. The clinical profile assists in the selection of empirical antimicrobial therapy even before the culture results. It was concluded that early diagnosis and appropriate and aggressive treatment are crucial in patient prognosis. There is still a shortage of Brazilian scientific production with a high power of evidence on the subject.


Introduction
The present study has as theme the lesions concerning Fournier's gangrene. The option for this theme was due to professional and academic experiences of the authors who observed the existence of barriers formed by the lack of knowledge on this type of lesion among health and nursing professionals, besides the difficulty to stablish the early diagnosis. In addition, there is an urgent need to have a better theoretic and scientific basis on Fournier's gangrene based on evidences which can actually contribute for better practices of care made by nurses and other health professionals, as well as for a better understanding of the patients and their family members on this pathology.
It was reported for the first time in 1764 and referred in the literature as a rich synonymy. It received the name Fournier's gangrene as a homage to the French urologist Jean Alfred Fournier, who described it in detail in a work published in 1863, 1864 and 1883 on the cases of scrotal gangrene in young patients apparently healthy. Fournier's gangrene (or Fournier's syndrome) is rare, and has as characteristics the acute start and the progression to sepsis. It especially attacks the genital structures due to bad sanitation of this body topography and/or by the lack of air circulation (1)(2) .
Fournier's gangrene is also known as necrotizing fasciitis, scrotal gangrene, necrotizing synergistic, synergistic gangrene and fulminant idiopathic gangrene. Besides attacking the perineal genital and anal regions, it can provoke intense odor and subcutaneous emphysema. At this stage the local nervous system can be jeopardized, which provokes the reduction of the pain (2) .
This infectious process has the symptoms of fever, early pain and edema. As evolution, it presents necrosis of all the tissue, so its debridement is necessary. This symptom can also be caused due to traumas, loose cell tissue, small infections, low vascularization and thrombosis. Fournier's gangrene attacks both men as well as women, although the prevalence in the male sex is notorious (2)(3) .
Besides the above mentioned regions, Fournier's gangrene can appear after surgical procedures such as the implantation of penis prosthesis, anal and gynecological procedures, as in the case of orchitis, hydrocele, vasectomy and urinary catechization, besides bladder cancer, epididymitis, and urinary retention, among others (4) .
There are other predisposing causes which can be associated to the occurrence of this pathology, such as diabetes mellitus, the age of the patient, lupus, cirrhosis, hemodialysis, malnutrition, radiotherapy, chemotherapy, carcinoma, cortical therapy, alcoholism, renal failure and Acquired Immunodeficiency Syndrome (AIDS). After the case has been confirmed, the immediate treatment must start. It is based on the use of wide spectrum antibiotics and needs to be followed seriously (4) .
The treatment of urgency is a surgery with the debridement of the necrotic tissue, even knowing that the process can or not be successful, possibly requiring a new surgical procedure. Even after this procedure it is possible to observe a growing rate of mortality when related to the infection and associated diseases (5) .
Considering the above mentioned, the question which guided the present research was: 'Which are the scientific evidences published in the last twenty years on lesions such as Fournier's gangrene?' Its sources were the Brazilian scientific evidences on Fournier's gangrene published in the last twenty years . And at last, its objective was to describe the Brazilian scientific registers on Fournier's gangrene published in the last twenty years.

Method
In order to reach the proposed objective, a study of integrative revision of the literature was developed, aiming at integrating the data abstracted from different studies which, in turn, adopted different methodologies, which enables the search, the critical evaluation and the synthesis of the available evidences on a specific theme. Six steps inherent to this method were followed; which were: the establishment of the matter of research, the search in the literature, the categorization of the studies, the evaluation of the studies included in the revision, data interpretation of the results and the presentation of the revision (6)(7) .
This investigation was guided by the following question of research: 'Which are the scientific evidences published in the last twenty years on lesions such as Fournier's gangrene?' The criteria of inclusion adopted to guide the search and selection of the publishing were: a) Thesis, papers and articles published in national scientific journals revised by peers, who approach the Fournier's gangrene theme in their multiple aspects and contexts; b) Published in the Portuguese language, with the objective to highlight researches which are specifically Brazilian on the theme; c) Published from 1994 to 2014, in order to reflect the scientific evidences inherent to the last twenty years in Brazil; d) Indexed in at least one of the following data basis: Latin-American and Caribbean literature in Sciences of Health (LILACS), Nursing data basis (BDENF), Medical Literature Analysis and Retrieval System Online (MEDLINE) or Coleciona Unified Health System (COLECIONA SUS), which are in the Virtual Library in Health (BVS) or in the Scientific Electronic Library Online (SciELO); e) Placed through the term which is registered in the Portal of Descriptors of the Science of Health: 'Fournier's gangrene'. There was no need of launching others descriptors in other languages besides Portuguese due to its register, codification and unique meaning, dully standardized in the portal of the above mentioned descriptors.
The criteria of exclusion were: a) Publishing which were not available with the complete text (only the abstract); b) Publishing without adherence to the proposed object; c) Publishing that presented availability of the complete text, but whose link presented mistake through the attempt of accessing it.
For the selection of the studies, there was a careful reading of the title and the abstract of each publishing in order to verify the consonance with the guiding question of the investigation. When there was a doubt referring to the inclusion or exclusion of the study, the same was totally read, so that it was possible to reduce the risk of losses of publishing relevant to the study. The data collection occurred from August 2013 to August 2014, and had the support of a data collection instrument elaborated in the Microsoft Office Excel 2010 software, which had the following variables: Title of the article, journal and year of publication, level of evidence and synthesis of the main results.
The analysis of the data was true to the prerogatives of the integrative revision of the literature. In this sense from the exhaustive reading of the texts, emerged the present evidences of each one of the same.

Results
The search made in the data basis originated a total of 684 texts, which, when submitted to the crite-   Figure 1 shows the steps accomplished in the search and selection of the articles. Furthermore, it also has the distribution of scientific registers per data basis. It is highlighted that, although there have been incursions in diversified bases, there was a very low use of the registers identified in the Medical Literature Analysis and Retrieval System Online. Such characteristic is a limitation of this study. Figure 2 complements this result. In it, the articles which were found can be observed as well as those selected, based on the established methodological criteria.

Data basis Found Selected
Latin American and Caribbean Literature in Health Sciences 90 9 Data Basis of Nursing 3 3 Medical Literature Analysis and Retrieval System Online 547 1 Collection Unified Health System 1 1 Total 641 14 Figure 2 -Quantitative of the articles found and selected after the integrative revision through a data basis using the descriptor 'Fournier's gangrene' In turn, Figure 3 and 4 present a synthesis of the variables within the data collection instrument. Each one of the articles received a number from 1 to 14, present in the first of the columns of Figure 4. It is necessary to highlight the low level of evidence (6)(7) of most part of the studies identified, which in most cases, obtained a punctuation around 4 and 5 points. This result shows the still modest character, in quantitative terms, of the controlled and experimental clinical studies on Fournier's gangrene published in Brazil in the last twenty years. The quality of the evidences is classified in level 1, for meta-analysis of controlled multiple studies; level 2, individual study with experimental outline; level 3, study with quasi-experimental outline as a study without randomization with pre and post-test only group, time series or control-case; level 4, study with non-experimental outlining as a correlational and qualitative descriptive research as correlational and qualitative descriptive research or case studies; level 5, case or datum report obtained systematically, with verifiable quality or data of evaluation data of programs; level 6, opinion of respectable authorities based on their clinical competence or on the opinion of committees of specialist, including interpretation of information not based on researches (6)(7) . All the fourteen identified texts were published articles in journals revised by the peers.

Discussion
Fournier's gangrene was first described by Hippocrates in the fifteenth century b.C, as a complication of erysipelas. Fournier's gangrene is a synergic necrotizing fasciitis of the perineum and of the abdominal wall, which has its origin the scrotum and in the penis, in the case of men, and in the vulva and groin, in the case of women (8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19) . The causes of Fournier's gangrene can also be associated to cuts, burns, abrasions, lacerations, contusions, animal bites, insect bites and subcutaneous and intravenous injections.
Fournier's gangrene is considered a disease of extreme gravity once it is frequently associated to toxicity and presents a rapid evolution. That is why, it is important that the nurse or another health professional has the knowledge of bacteria involved in Fournier's gangrene, once this, associated to the global evaluation of the clinical picture, helps in the selection of the empiric anti-microbial therapeutics even before the results of the cultures. Therefore the early diagnosis and the aggressive and adequate treatment are determining factors of the prognosis of the patient (8,13,20) .
As the dissemination of aerobic and anaerobic bacteria occurs, the concentration of oxygen in the tissues is reduced. With the hypoxia and ischemia tissue, metabolism is impaired, causing further spread of facultative microorganism which benefits from the energy sources of cells, especially in the early 48 to 72 hours of infection.
The most important aspect in the management of the patient with Fournier's gangrene is the early diagnosis and treatment (11) . The health professional who provides the first assistance must do it in a thoroughly, thus avoiding the risk to have a wrong diagnosis. Image exams such as the computerized tomography can be useful in the diagnosis of Fournier's gangrene (14) . Because of the urgency of the early diagnosis of this type of infection, it is suggested to have a joint evaluation of the multidisciplinary team, especially the one made by the stoma therapist nurse, both for being an extensive wound, dangerous to life, as well as for having the potential to justify the confection of a stomach -both are areas of expertise of that health professional. It is necessary to highlight that once, it usually attacks the urogenital topography of the patient, the confection of eliminations stomas must be necessary.
The synergic action of aerobic and anaerobic bacteria can be responsible for the frequent and fulminant evolution of the disease (16,21) . The quantitative and the types of microorganisms involved in Fournier's gangrene will be intimately related to the site of the infection, especially if it is on the abdominal wall, extremities and perineal. The most common Gram-negative microorganisms found in lesions of this type are Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa and Proteus mirabilis. Among the Gram-positive aerobics the Staphylococcus aureus, Staphylococcus epidermidis, Streptococcus viridans and Streptococcus fecalis are highlighted (13) . Metronidazole and gentamicin antibiotics of choice are the pharmacological treatment of such infection (2) .
Concerning the signs and symptoms, discomfort can be felt with painful sensations, high fever, and malaise and sweating. An edema apparently without lesion can also be observed. But, in most of the cases, erythema and blistering are observed, evolving to a wound (2) . The nurse can make a detailed and periodical examination of the skin in order to verify such alterations.
Despite all the current therapeutic advances, Fournier's gangrene is still presenting high rate of mortality. Death can occur in patients with prolonged disease, dissemination of the infection and impairment of the lungs, which can be foreseen through the clinical assistance and evidences of septicemia (5) . The early recognition of the infection associated to an aggressive and invasive treatment are essential measures to decrease those cases. As to the quality of life, the skin grafting or fasciocutaneous flap are satisfactory alternatives (9,13,16) .
The clinical and surgical treatment must be immediate, with the use of broad-spectrum, covering Gram-positive and Gram-negative microorganisms. The surgical procedure is indispensable, including hyperbaric oxygen therapy and the medium chain triglycerides such as sunflower oil as complementary therapies. As adjuvant measure, the nutritional support is also indicated. Besides that, the use of hormones of the growth, which have the potency to promote a faster healing of the wound, have also been useful. It is also mentioned the use of papain, which helps in the debridement, attacks infection and accelerates healing, depending on its concentration (22)(23)(24)(25) . As to the treatment with hyperbaric oxygen therapy, the results have been controversial, once some authors defend its use while others state that there is the need of more studies when it is applied on the several types of fasciitis (9,11) .
It is understood that pain deserves special attention during the completion of dressing or other movements of the body of the patient, even if analgesia can be present during the performance of procedure at the site.
As one of the most relevant results, a study identified the lack of orientation from the caregivers to the patients on the causes and preventive measures of Fournier's gangrene. So, it is evident that there is the need that the caregivers, whether they are health professionals or not, are better trained in the cognitive, psychomotor and affectional aspects, so that they can promote a more professional and/or human assistance (8) .

Conclusion
Fournier's gangrene is a theme which is little debated in the scope of health in the last twenty years, especially in the areas of nursing. However, the patient still suffer due to the need of long periods of hospitalization, being subject to several complications which could be minimized. So, it is urgent to have new initiatives of investigation with high power of evidence on the theme, once articles were identified in this revision, mostly in level 4 or below. This revision showed the scientific trends on Fournier's gangrene according to the articles published in the last twenty years on the theme. It is suggested to make more clinical and experimental studies on Fournier's gangrene.
It is concluded that Fournier's gangrene can unleash several complications such as trauma of urethra, rupture of the bladder and increase of its gravity, the latter influenced by the age of the patient, when it is advanced.
An early diagnosis, the adequate treatment and the assistance of nursing with precise interventions are important. Although the daily examination of evolution of the wound is necessary, all the nursing team must have full knowledge of the pathology, otherwise, it will not be possible to identify the signs of complications of the disease. The periodical assistance with a stoma therapeutic nurse is recommended for the register of the clinical evolution of the pathology and specialized assistance to the patients with the loss of cutaneous integrity.
Because this disease is mutilating and promotes problems of self-image, it results in a feeling of insecurity, fear and loss, it is fundamentally important to have the assistance of the nursing team to the patient, clarifying doubts, leading the patient to trust in the team and in the treatment, in order to have a better preparation to cope with it.
This integrative revision, despite the limitations imposed by the high specificity of the criteria of inclusion and exclusion of the study, as well as by the small number of productions identified, allowed to notice the scarcity of studies on Fournier's gangrene in Brazil in the last two decades. It is a function of the health professionals to promote preventive actions and early outline plans of care in cases of Fournier's gangrene.