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Can the SIARI score be used at initial admission to predict testes involvement in patients with fournier’s gangrene; a single-centre, retrospective study

BMC Urology volume 24, Article number: 173 (2024) Cite this article

Abstract

Background

To predict testicular involvement in patients diagnosed with Fournier’s gangrene (FG) using the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score and the site other than lower limb (SIARI) score.

Methods

The medical records of 51 patients operated for FG in our clinic between December 2012 and April 2022 were evaluated retrospectively in this study. Patients’ demographics, and laboratory test results were compared with the testisticular involvement status. Patients with testisticular involvement (n = 10) were compared with patients without testicular involvement (n = 41). The SIARI score at initial admission was analysed using logistic regression analyses for its performance in predicting testicular involvement with FG. Receiver operating characteristics (ROC) curves and the area under the receiver operating characteristic curve (AUROC) were used to evaluate its discriminating ability.

Results

The SIARI score had modest performance for diagnosing testicular involvement in FG patients, with ROC analysis showing an AUROC value of 0.83 (p < 0.001). With a SIARI cut-off score of ≥ 3, the sensitivity was 90% and the specificity was 68%. For a SIARI cut-off score of ≥ 5, the sensitivity was 40% and the specificity was 97%.

Conclusions

The ability of the SIARI score to discriminate FG with testicular involvement is modest. The SIARI score should be employed cautiously as a routine diagnostic tool for the prediction of testicular involvement in FG at the initial admission. More research is needed to develop a better understanding of the relationship between the SIARI score and testicular involvement in FG.

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Introduction

Fournier’s gangrene (FG) is characterized by progressive necrotizing fasciitis (NF) involving the perineal, perianal and genital regions, the anterior abdominal wall muscles or medial compartment thigh muscles, and the subcutaneous and deep fascia [1]. FG requires urgent intervention and can be fatal [2]. It is a polymicrobial condition usually caused by aerobic and anaerobic microorganisms [3], with multidisciplinary care required after emergency surgical debridement [4]. FG is more common in men and in the elderly. Predisposing factors include age, diabetes, and conditions that lead to immunosuppression [3, 4]. Treatment consists of broad-spectrum antibiotic therapy, maintenance of serum electrolyte balance, and surgical debridement. Repeated surgical interventions are sometimes required. Effective dressing is also important for wound healing in FG. In addition to antibiotic therapy, hyperbaric oxygen therapy (HBOT) and vacuum-assisted closure (VAC) are also used in the care of wounds from FG [2,3,4]. In a recent article, Wong et al. reported that the laboratory risk indicator for necrotizing fasciitis (LRINEC) score was a valuable tool for distinguishing FG from other tissue infections [5]. The LRINEC score is obtained by evaluating haemoglobin, white blood cell (WBC) count, and the levels of serum glucose, creatinine, sodium and C-reactive protein (CRP) [5]. In addition, the SIARI (Site other than the lower limb, Immunosuppression, Age ≤ 60 years, Renal impairment, Inflammatory markers) score can also be used to distinguish FG from other tissue infections [6].

Testicular involvement is sometimes observed in patients diagnosed with FG and aggressive debridement or orchiectomy is often performed in such patients. To date, testicular involvement in FG has not been formally investigated. Hence, the aim of this study was to investigate whether the LRINEC and SIARI scores are predictive of testicular involvement in patients diagnosed with FG at initial admission.

Materials and methods

The study protocol was reviewed and approved by the Institutional Review Board of Sakarya University College of Medicine (approval number: 145948-178). The need for informed consent was waived due to the retrospective design of the study. The diagnosis of FG was based on signs, symptoms, laboratory measurements and occasionally by imaging or consultation if available. Patients younger than 18 years and/or who had previously used antibiotics or had debridement were excluded from the study.

Medical records for 57 patients who underwent surgery for FG in our department between December 2012 and April 2022 were extracted for this study. Five patients whose data was not fully accessible and one patient who refused treatment were excluded from the study. Written and digital records for demographic information, medical history, laboratory measurements, medications, smoking status, site of infection, defect closure, and use of HBOT or VAC were collected. Diabetes control was not assessed because access to HbA1c levels was not practical in the emergency department setting. Blood tests conducted at admission were used to calculate the LRINEC and SIARI scores [5, 6]. Outcome data included the length of hospital stay (HS), testicular involvement, number of debridements and 30-day mortality.

Statistical analysis

Shapiro–Wilk test was used to assess the normality (p > 0.05) of data. Groups were compared using Mann-Whitney U test due to the sample size (n = 10) of one group.

Area under the receiver operating characteristic curves (AUROC) analysis was used to determine the performance of the SIARI score in predicting testicular involvement in patients with FG. Values for diagnostic accuracy were computed using the previously reported SIARI cut-off value of ≥ 3 [6]. Analysis by univariable odds ratio was used to assess the ability of demographics, clinical and laboratory test results, and LRINEC and SIARI scores to predict testicular involvement in FG. Laboratory parameters were recorded as categorical variables using cut-off points described by the developers of the LRINEC and the SIARI scores [5, 6]. Multivariable logistic regression was performed and this incorporated all variables showing p < 0.05 in univariable analysis. The AUROC of the SIARI was compared using the Youden optimal diagnostic cut-off, and the sensitivity and specificity values were also calculated. Statistical analyses were conducted using SPSS (version 26, Chicago, IL, USA). All tests were two-sided, and a p value < 0.05 was considered statistically significant.

Results

Patient characteristics

A total of 51 male patients were enrolled in the study, with a mean age of 60.9 ± 15.6 years. All patients had operative and pathology reports consistent with FG. The mean duration of hospital stay (HS) was 13.8 ± 7.9 days. Common comorbidities included diabetes (58.8%), hypertension (21.6%) and ischemic heart disease (15.7%). Table 1 presents an overview of the demographic, clinical and laboratory characteristics of the patient cohort.

Table 1 Demographic, clinical, and laboratory characteristics of patients with Fournier’s gangrene
Full size table

Site of infection, predisposing factors, treatment and bacterial culture results

The infection in 32 patients (62.7%) was limited to the scrotum, 13 (25.4%) had scrotal and penile infection, 4 (7.8%) had scrotal penile and perineal involvement, while the infections in two patients (3.9%) extended to the anterior abdominal wall. Seventeen patients (33.3%) lacked a predisposing factor or evidence of immunosuppression (idiopathic) (Fig. 1). Ten patients (19.6%) had testicular (tunica albuginea) involvement, and 9 patients (17.6%) had two or more surgeries. Temporary diversion of faecal matter (colostomy) was performed in one patient (1.9%). Two patients (3.9%) who died were characterized by a delay in treatment, age ≥ 65 years, poor hygiene, diabetes, spread of gangrene to the abdominal wall, renal failure, and septic shock.

Extensive and aggressive debridement was performed in all patients. VAC was added to debridement in 17 patients (33.3%), and HBOT was added in 6 patients (11.8%). The mean HS duration was 17.1 ± 1.5 days (range: 8–26) in patients who underwent VAC, 17.2 ± 7.8 days (range: 5–40) in patients who underwent HBOT, and 11.7 ± 1.3 days (range: 3–32) in patients whose debridement did not include VAC or HBOT.

E. coli was the most common monomicrobial FG microorganism and was found in 10 patients (19.6%). Coagulase (-) staphylococcus is spread by faecal contamination and was found in four patients (7.8%). Polymicrobial infection was observed in 12 patients (23.5%), while 14 patients (27.5%) showed no bacterial growth. Other types of monomicrobial infections were reported in 11 patients (21.6%).

Relationship between tunica albuginea of testes and second debridement

There was no evidence that laboratory test results has an influence on the need for a second or more surgery (p > 0.05). However, significant differences were found between involvement of the testes in FG and WBC (p = 0.004), the LRINEC score (p = 0.025), and the SIARI score (p = 0.008) (Table 2).

Table 2 Clinical and biochemical characteristics of cases with Fournier’s gangrene with testicular involvement
Full size table

The discriminative abilities of WBC and of the SIARI and LRINEC scores to predict testicular involvement in FG patients are presented in Table 3. The SIARI score showed a clear ability to diagnose testicular involvement (AUROC = 0.83, p < 0.001, 95% Confidence Interval (CI): 67–98%). The receiver operating characteristic curve for SIARI scores in the FG patient group are shown in Fig. 2.

Table 3 Univariable and multivariable logistic regression analysis of potential comorbidity, laboratory predictors, LRINEC scores and SIARI scores in the diagnosis of Fournier’s gangrene with testicular involvement
Full size table

Using a SIARI cut-off score of ≥ 3, the sensitivity to diagnose testes involvement was 90% (95% CI 55–97%), the specificity was 68% (95% CI 51–81%), the positive predictive value (PPV) was 24% (95% CI 16–34%), and the negative predictive value (NPV) was 98% (95% CI 90–99%). Using a SIARI cut-off score of ≥ 5, the sensitivity was 40% (95% CI 12–73%), the specificity was 97% (95% CI 87–99%), PPV was 64% (95% CI 18–93%) and NPV was 93% (95% CI 89–96%).

Discussion

FG is an acute, swiftly progressive, and potentially lethal form of genital, perineal and perianal NF resulting from polymicrobial infection [2, 7]. Although the incidence of FG is still uncertain, Sorensen et al. reported an overall incidence rate of 1.6 cases per 100,000 men/year, with a peak of 3.3 cases per 100,000 men/year in those aged ≥ 50 years [8].

FG can affect all age groups, with the mean age being 50 years [9, 10]. Men are much more likely to be affected than women [7]. FG is mostly diagnosed by performing a physical examination [11, 12]. Pain, inflammation, erythema, oedema, necrosis and subcutaneous crepitation are often observed in the involved region. The current study, physical examination and laboratory results were used to determine testicular involvement in FG.

Some scholars have reported predisposing factors for FG such as diabetes, alcoholism, immunosuppression, and malignancy [13, 14], with diabetes appearing to be the most common [15]. Furthermore, diabetes is reported to have detrimental effects on cellular immunity [16, 17]. In the current study, 21 of 51 patients (41.7%) were diabetic. A recent study from India by Sockkalingam et al. found that 29.8% of FG patients were idiopathic FG [18]. The predisposing factors for FG in the present study were unclear in a significant proportion (33.3%) of patients.

Etiological factors for FG include perineal, urogenital and anorectal cleanliness, as well as prior surgical interventions in these regions. FG may also develop due to the spread of abdominal or retroperitoneal infections [3]. Urological origins explain 17–87% of cases [7], whereas cutaneous origins are rarely implicated [7, 19]. The proportion of patients in this study with a urological origin for their FG (17.6%) was similar to literature reports. In our study, infections were limited to the scrotum in 62.7% of patients. However, 10 patients (19.6%) also had testicular (tunica albuginea) involvement, and in two patients (3.9%) the FG had spread to the anterior abdominal wall.

The basis for good management of FG requires adequate resuscitation, broad-spectrum antibiotics, aggressive debridement of necrotic tissues, intensive supportive care, and adequate reconstruction that starts with closure of the tissue defect after surgical debridement [4, 20, 21]. The debrided perineal region is usually near the anus, which is an area prone to faecal contamination [22]. The most frequently reported predictors of poor prognosis are female gender, advanced age, diabetes, malignant diseases, multiple organ failure at presentation, the spread of gangrene outside the perineum, delay in consultation, delayed treatment, high FG index, elective colostomy, and septic shock [8, 13, 21]. Despite advances in diagnosis and treatment, the mortality rate for FG has been reported as 16–50% [12, 23]. However, Aliyu et al., reported a mortality rate of just 3.6% [24]. In the present study only two patients died (3.9%), hence the mortality rate was similar to that reported by Aliyu et al.

Hsiao et al. carried out a study to determine whether the LRINEC score could discriminate between NF and severe cellulitis [25]. Using a LRINEC cut-off score of ≥ 6, the sensitivity was 43%, specificity was 83%, PPV was 25% and NPV was 92%. With a LRINEC cut-off score of ≥ 8, the sensitivity was 27%, specificity was 93%, PPV was 33% and NPV was 91%. Thus, they found low sensitivity (43%) using a LRINEC cut-off score of ≥ 6, and even lower sensitivity (27%) using cut-off score of ≥ 8. Moreover, the LRINEC score was found to have low accuracy, with an AUROC of 0.70 [25]. Breidung et al. reported a sensitivity of 59% and specificity of 82% when using a LRINEC cutoff score of ≥ 6, with a PPV of 57% and NPV of 84% [26]. A major retrospective validation study by Liao et al. found that use of the LRINEC score alone was not helpful for the initial diagnosis of NF [26]. Their study included 233 patients in the NF group and 1394 in the severe cellulitis group, with an AUROC value for the LRINEC score of 0.78.

A considerable amount of literature has been published the laboratory score can predict the involvement of anatomy. Recent evidence suggests that modified LRINEC score may differentiating NF from other severe soft-tissue infections [27]. Previous study showed that serum-procalcitonin might be diagnostic parameter discriminate NF from celulitis [28]. Also study on a New Zealand cohort reported that the SIARI score have high ability for detecting NF [6]. Using a cut-off value of ≥ 6 points, the LRINEC score showed 64% specificity, 60% sensitivity, 62% PPV, and 62% NPV. Another interesting study in Switzerland, the authors performed six orchiectomy among twenty FG patients. Fournier’s gangrene severity index score (p = 0.01), LRINEC (p = 0.04), and Neutrophil-to-lymphocyte ratio (p = 0.01) scores were found significantly correlated with orchiectomy, as well as with penectomy [29].

Previous studies have shown significant variation in the accuracy of the LRINEC score. An AUROC value of > 0.97 has been reported in both development and validation cohorts, with a PPV of 92% and a of 96% the optimal diagnostic LRINEC cut-off score of ≥ 6 [5]. Narasimhan and colleagues retrospectively reviewed 98 patients with NF [30]. These authors reported that with a LRINEC cut-off score of ≥ 5, the specificity was 93.1%, sensitivity was 76.3%, PPV was 95.5%, and NPV was 88.1% [30].The above results suggest the LRINEC score may be useful for distinguishing NF from severe cellulitis. In addition, a meta-analysis by Bechar et al. evaluated 16 studies with a total of 846 patients and, reported AUROC of 0.93 [31]. The authors concluded the LRINEC score was a valuable clinical tool for predicting the diagnosis of NF patients and their surgical operation [31].

Few studies have compared the diagnostic accuracy of the LRINEC and SIARI scoring systems for NF. In a prospective study, Karthikk et al. [32] reported that a SIARI cut-off score of ≥ 4 had sensitivity of 55.2% specificity of 90.9%, and C-statistic of 0.60 (95% CI: 0.43–0.79,  p > 0.05). Conversely, the LRINEC score showed a sensitivity of 89.7%, specificity of 63.6%, and C-statistic of 0.84 (95% CI 0.68–0.99, p < 0.001) [30]. However, the present results suggest the LRINEC score is not an accurate tool for predicting involvement of the testes in NF in an emergency department setting.

The LRINEC score is a representative, laboratory-derived marker for septic shock, which is almost always a feature of necrotizing soft tissue infections. The major problem in defining the LRINEC score is that it does not take into account any clinical parameters that could affect the laboratory results [6]. Diabetic cohorts in particular may be misdiagnosed and this population is rapidly affected by NF. This possible limitation of the LRINEC score is important, because NF has a higher prevalence in diabetic patients [33].

The SIARI score is comprised of clinical and laboratory factors listed in order of decreased weighting. This score has the advantages of being simpler to use than the LRINEC score, requires fewer laboratory variables, and also considers basic clinical predictors [6]. Clinical risk factors incorporated the SIARI score include soft tissue infections at sites other than the lower extremities, immunosuppression (e.g., resulting from AIDS, steroids, or immunosuppressive drugs), and being under 60 years of age. The three laboratory measurements incorporated into the SIARI score (creatinine > 141 µmol/L, CRP ≥ 150 mg/L, and WBC > 25 per mm3) are each defined by a weighting of one point. Hence, to reach the optimal diagnostic cut-off score of 3, all three laboratory variables must be fulfilled in the absence of a clinical risk factor [6].

In the present study, a SIARI cut-off score of ≥ 3 showed a sensitivity of 90%, specificity of 68%, PPV of 24%, and NPV of 98%. With a SIARI cut-off score of ≥ 5, the sensitivity was 40%, specificity was 97%, PPV was 64% and NPV was 93%. Therefore, the SIARI score may be as a valuable diagnostic adjunct for predicting testicular involvement in patients with FG. This is the first study to investigate the power of different scoring systems for predicting FG-related testicular involvement and the likelihood of a second or more debridement.

It is important to note that scoring systems should not be used as the sole method of diagnosis. Clinical decisions and diagnoses should be based on a combination of physical examinations, age, sex, comorbidities, laboratory parameters, and if needed also imaging. The LRINEC score can help emergency physicians to quickly calculate the predictive results for FG. Further research should aim to improve the clinical decision rules in order to achieve high precision, conformity and validation. Furthermore, multicentre prospective comparative study should compare is needed to compare the discriminative ability of any new clinical decision rules with the SIARI score and with other diagnostic tools.

Limitations of the present study included its retrospective nature, single-centre design, the low patient numbers and low number of events. These factors may reduce the reliability of our results.

Conclusions

The current results suggest the SIARI score has only moderate ability to predict FG with testicular involvement. However, the LRINEC scoring system may not be a suitable tool for FG cases with testicular involvement. In the emergency department setting, the SIARI score should be used prudently as a routine diagnostic tool to determine testicular involvement in FG. From a practical point of view, patients who present with extensive FG should be counselled at the time of debridement about the high probability of orchiectomy. Multicentre prospective comparative studies are needed to compare results using the SIARI score with those of other diagnostic tools.

Fig. 1
figure 1

Distribution of identifiable predisposing factors in patients with Fournier’s gangrene

Full size image
Fig. 2
figure 2

The receiver operating characteristic (ROC) curve for SIARI scores in the diagnosis of patients with Fournier’s gangrene

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Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

FG:

Fournier’s gangrene

HBOT:

Hyperbaric oxygen therapy

LRINEC:

Laboratory Risk Indicator for Necrotizing Fasciitis

NF:

Necrotizing fasciitis

NPV:

Negative predictive value

PPV:

Positive predictive value

SIARI:

Site other than lower limb, Immunosuppression, Age ≤ 60 years, Renal impairment, Inflammatory markers

WBC:

White blood cell

VAC:

Vacuum-assisted closure

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Acknowledgements

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Funding

The study did not receive any funding.

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Authors and Affiliations

  1. Department of Urology, Sakarya Sadıka Sabancı Hospital, Sakarya, 54580, Turkey

    Anil Erdik

  2. Department of Urology, School of Medicine, Sakarya University, Sakarya, 54100, Turkey

    Kemal Demirhan, Haci Ibrahim Cimen, Yavuz Tarik Atik, Deniz Gul, Osman Kose & Hasan Salih Saglam

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  4. Yavuz Tarik Atik
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  5. Deniz Gul
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  6. Osman Kose
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  7. Hasan Salih Saglam
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Contributions

Research conception and design: Kemal Demirhan, Haci Ibrahim Cimen. Data acquisition: Kemal Demirhan, Yavuz Tarik Atik. Statistical analysis: Anil Erdik, Deniz Gul. Data analysis and interpretation: Anil Erdik, Haci Ibrahim Cimen, Osman Kose, Hasan Salih Saglam. Drafting of the manuscript: Anil Erdik, Kemal Demirhan. Critical revision of the manuscript: Anil Erdik, Haci Ibrahim Cimen, Hasan Salih Sağlam Supervision: Osman Kose Approval of the final manuscript: Hasan Salih Saglam.

Corresponding author

Correspondence to Anil Erdik.

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Ethics approval and consent to participate

The study protocol was reviewed and approved by the Institutional Review Board of Sakarya University College of Medicine (approval number: 145948-178). The need for informed consent was waived due to the retrospective design of the study. All experiments were performed in accordance with relevant guidelines and regulations.

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Not applicable.

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The authors declare no competing interests.

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Erdik, A., Demirhan, K., Cimen, H.I. et al. Can the SIARI score be used at initial admission to predict testes involvement in patients with fournier’s gangrene; a single-centre, retrospective study. BMC Urol 24, 173 (2024). https://doi.org/10.1186/s12894-024-01557-x

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Keywords

BMC Urology

ISSN: 1471-2490

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