Perineal Necrotizing Fasciitis: A Visual Atlas

INTRODUCTION: We will examine the crucial differences between a common labial abscess and the rare but life-threatening condition, necrotizing fasciitis. Understanding these conditions can make the difference between routine treatment and urgent, life-saving intervention. OBJECTIVE: The objectives of this video are to: 1) provide a detailed comparison of necrotizing fasciitis of the perineum (Fournier's gangrene) with the more commonly encountered labial abscess, highlighting key diagnostic differences; 2) examine the risk factors associated with necrotizing fasciitis of the perineum, with an emphasis on the role of diabetic medications and other comorbidities; and 3) present an in-depth case study, outlining the clinical course, progression, and management of necrotizing fasciitis of the perineum to illustrate key points in diagnosis and treatment. METHODS: The video is structured in three main sections. First, we describe the patient's initial presentation, including her clinical symptoms of left vulvar pain, erythema, and swelling. Key risk factors, such as her diabetic status and normal hemoglobin A1c, are highlighted to provide context. Second, intraoperative footage is used to illustrate the pathophysiology of necrotizing fasciitis. We focus on the visual progression of the disease, emphasizing the changes in tissue appearance as the fascia turns from healthy pink to necrotic gray due to a lack of adequate blood supply. Third, we present the surgical management of the case, documenting the five debridements the patient underwent to remove necrotic tissue. RESULTS: We present the case of a 60-year-old Caucasian woman with diabetes who presented with a 3-day history of left vulvar pain, erythema, and swelling. Despite having a normal hemoglobin A1c and no recent history of surgery or trauma, she rapidly decompensated into septic shock, necessitating immediate surgical intervention for suspected necrotizing fasciitis of the perineum. The infection's progression was evident during surgery as the once healthy, pink fascia turned gray, indicating necrosis. This discoloration results from insufficient blood flow, depriving the tissue of essential oxygen and nutrients, ultimately causing cell death and tissue breakdown. The affected fascia appeared dull, discolored, and nonviable. The patient underwent a total of five debridements of the left vulva to remove the necrotic tissue. With the support of wound care nursing, she recovered following the series of surgical interventions. CONCLUSIONS: This video is intended as an educational tool for gynecologists. It showcases the clinical progression of necrotizing fasciitis and the surgical approach to managing severe soft tissue infections (Figures 1 and 2).