Neovaginal perforation following sexual intercourse in a transsexual patient
© Deliktas et al.; licensee BioMed Central Ltd. 2014
Received: 23 July 2014
Accepted: 27 October 2014
Published: 15 November 2014
Neovaginal perforation can develop following sexual intercourse in patients that have undergone male to female gender reassignment surgery. In such cases urinary tract symptoms may mimic acute cystitis and acute pyelonephritis.
A 33-year old white transsexual patient presented to the emergency department with dysuria, hematuria, difficulty urinating, widespread groin pain, bilateral side pain, clear vaginal discharge, abdominal pain, and nausea 2-3 h after sexual intercourse. Abdominal tomography showed fluid around the vaginal cuff and air throughout the abdomen. Vaginography showed contrast leaking to the abdomen from the vaginal cuff. The patient was considered as vaginal perforation and admitted to clinic.
Vaginal perforation should be considered in transsexual patients that develop urinary system symptoms following sexual intercourse. Such cases were treated medically without the need surgery.
In male to female gender reassignment surgery penile and scrotal skin graft, or the rectosigmoid intestinal segment can be used to create a neovagina [1, 2]. Creation of a neovagina using penile and scrotal skin graft is associated with more scar tissue and insufficient vaginal cuff length [3, 4]; therefore, the likelihood of vaginal perforation following sexual intercourse is elevated in such cases. Herein we present the radiological findings and treatment in a 33-year old gender reassignment surgery patient with vaginal perforation.
A 33-year old white transsexual patient presented to the emergency department with dysuria, hematuria, difficulty urinating, widespread groin pain, bilateral side pain, clear vaginal discharge, abdominal pain, and nausea 2-3 h after sexual intercourse. The patient had undergone male to female gender reassignment surgery 7 years earlier, in which penile and scrotal skin graft was used to create a neovagina. Physical examination showed that there was sensitivity in the suprapubic region, costovertebral angle sensitivity, and defense and rebound.
The patient’s abdominal pain, examination findings, and laboratory findings were evaluated by a specialist general surgeon. The patient was admitted to clinic. As there was no pathology other than vaginal perforation based on abdominal ultrasonography and abdominal tomography, and as the neovagina appeared normal upon vaginal examination, it was thought that with close monitoring the patient would recover and a combination of ceftriaxone 1000 mg b.i.d. and metronidazole 500 mg t.i.d. antibiotherapy was started and continued for 7 d. The patient’s abdominal pain became less severe and the fluid discharge from the neovagina stopped. On d 4 of the treatment the leukocyte count returned to normal, and on d 7 of the treatment the patient was discharged with oral antibiotic therapy. At the 1-month follow-up examination the patient was problem-free. At 6 weeks post treatment the patient recommenced sexual intercourse and at the 6-month follow-up had no complaints.
Penile and scrotal skin graft is the most common method for creating a neovagina, as it is associated with the lowest complication rate and is the easiest to perform; however, there are some disadvantages to the method, such as scar formation, an insufficient vaginal cavity, a narrow vaginal, intravaginal hair, the need for continuous dilatation, and the need for lubrication for sexual intercourse [3, 4]. The literature includes 2 case reports of neovaginal perforation. Amirian et al.  reported a case of neovaginal perforation after washing with a douche pump and Giovanni Liguari et al.  reported spontaneous perforation in the neovagina after stenosis. To the best of our knowledge the present case report is the first to describe neovaginal perforation following sexual intercourse. In addition, in the 2 earlier cases the sigmoid colon segment was used for the creation of the neovagina. In the presented case scrotal and penile skin graft was used, and to the best of our knowledge this is the first report of neovaginal perforation in a neovagina formed from scrotal and penile skin graft.
Franco et al. reported that in transsexual individuals in which penile and scrotal skin graft was used neovaginal length was 8-10 cm, which is longer than the natural vagina ; however, even with a vagina of 8-10 cm created using penile and scrotal skin graft the expansion and extension potential of the neovagina in those cases were lower than those of a normal vagina and those created using the sigmoid segment. As such, the likelihood of vaginal perforation during sexual intercourse is higher in such cases. In transsexual surgery sacrospinous ligament fixation of the neovagina is performed in order to prevent prolapse during the postoperative period . By inhibiting the mobilization capability of the neovagina such fixation facilitates perforation during sexual intercourse.
In the presented case there was an indication for laparotomy because of the acute abdominal findings; however, as the patient had undergone surgery 7 years earlier it was thought that performing laparotomy again could have resulted in additional complications. Moreover, the neovaginal perforation case reported by Amirian et al. was followed up conservatively and the patient recovered without any surgical intervention .
As seen in previous studies on transsexual females in which penile skin was used to create the neovagina, the flora of the neovagina is formed of aerobic and anaerobic microorganisms in the mixed structure found in skin and intestinal flora [9, 10]. In the presented case administration of antibiotherapy that was effective on both aerobic and anaerobic microorganisms, and close monitoring resulted in complete recovery without the need for surgery.
In transsexual patients that present with urinary system symptoms following sexual intercourse vaginal perforation should always be a consideration. Minimal perforations in such patients can be treated medically, without surgery.
Written informed consent was optained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.
- van Noort DE, Nicolai JP: Comparison of two methods of vagina construction in transsexuals. Plast Reconstr Surg. 1993, 91 (7): 1308-1315. 10.1097/00006534-199306000-00018.PubMedView ArticleGoogle Scholar
- Dalton JR: Use of sigmoid colon in sex reassignment operations. Urology. 1981, 17 (3): 223-227. 10.1016/0090-4295(81)90033-9.PubMedView ArticleGoogle Scholar
- Perovic SV, Stanojevic DS, Djordjevic ML: Vaginoplasty in male transsexuals using penile skin and a urethral flap. BJU Int. 2000, 86 (7): 843-850.PubMedView ArticleGoogle Scholar
- Kwun Kim S, Hoon Park J, Cheol Lee K, Min Park J, Tae Kim J, Chan Kim M: Long-term results in patients after rectosigmoid vaginoplasty. Plast Reconstr Surg. 2003, 112 (1): 143-151. 10.1097/01.PRS.0000066169.78208.D4.PubMedView ArticleGoogle Scholar
- Amirian I, Gogenur I, Rosenberg J: Conservatively treated perforation of the neovagina in a male to female transsexual patient. BMJ Case Rep. 2011, 2011:Google Scholar
- Liguori G, Trombetta C, Buttazzi L, Belgrano E: Acute peritonitis due to introital stenosis and perforation of a bowel neovagina in a transsexual. Obstet Gynecol. 2001, 97 (5 Pt 2): 828-829.PubMedView ArticleGoogle Scholar
- Franco T, Miranda LC, Franco D, Zaidhaft S, Aran M: Male-to-female transsexual surgery: experience at the UFRJ University Hospital. Revista do Colegio Brasileiro de Cirurgioes. 2010, 37 (6): 426-434.PubMedGoogle Scholar
- Stanojevic DS, Djordjevic ML, Milosevic A, Sansalone S, Slavkovic Z, Ducic S, Vujovic S, Perovic SV: Sacrospinous ligament fixation for neovaginal prolapse prevention in male-to-female surgery. Urology. 2007, 70 (4): 767-771. 10.1016/j.urology.2007.06.1086.PubMedView ArticleGoogle Scholar
- Weyers S, Verstraelen H, Gerris J, Monstrey S, Santiago Gdos S, Saerens B, De Backer E, Claeys G, Vaneechoutte M, Verhelst R: Microflora of the penile skin-lined neovagina of transsexual women. BMC Microbiol. 2009, 9: 102-10.1186/1471-2180-9-102.PubMedPubMed CentralView ArticleGoogle Scholar
- Weyers S, Lambein K, Sturtewagen Y, Verstraelen H, Gerris J, Praet M: Cytology of the ‘penile’ neovagina in transsexual women. Cytopathology. 2010, 21 (2): 111-115. 10.1111/j.1365-2303.2009.00663.x.PubMedView ArticleGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.