Volume 6, Number 1, January - March 2002
Fourniers Gangrene in a Male to Female Transsexual
By Andrew C. Lee M.B. Ch.B, A.F.R.C.S.Ed.
Citation: Lee A, Wilson C, George W (2002) Fourniers Gangrene in a Male to Female Transsexual. IJT 6,1, http://www.symposion.com/ijt/ijtvo06no01_02.htm
Keywords: Fournier gangrene, necrotising fasciitis, transsexualism, surgery.
A 41-year-old non-insulin dependent diabetic male to female transsexual, who had genital reassignment 11 years previously, presented to gynaecologists with a large right labial abscess. The abscess was managed with simple incision and drainage with an excision of a 35mm by 10mm ellipse of skin overlying the abscess cavity. Histology of the excised tissue showed subcorneal bulla and extensive necrosis of fascia and muscle, consistent with necrotising fasciitis. Bacteriology culture grew mixed aerobic and anaerobic streptococci and coliforms. The patient was commenced on appropriate intravenous antibiotics.
Postoperative recovery was complicated by an inferior wall myocardial infarction and subsequent complete heart block requiring temporary pacing and inotropic support in coronary care unit for 24 hours.
Despite intravenous antibiotic therapy, progressive deterioration of the infection was evident with systemic sepsis and renal impairment. On day four, a radical debridement was performed removing a bridge shaped piece of skin measuring 120mm by 135mm with 60mm of underlying fat. Post-operative recovery was uneventful, and the patient was transferred to the regional plastic surgical centre for reconstruction on day nine.
Necrotising fasciitis of the scrotum is commonly known as Fourniers gangrene following Jean-Alfred Fourniers report on five cases of fulminant gangrene in 1883 (Fournier, 1883). Despite persistent controversies over its terminology to include the recto-perineal regions and the female sex, the prognosis and treatment remain the same ( Elliott et al. 1996; Eke 2000).
The keys to successful management are prompt diagnosis, immediate resuscitation with intravenous antibiotics, early aggressive surgical debridement of all necrotic tissues and medical support in an intensive care setting (Ben Aharon et al., 1996; Elliott et al. 1996; Corman et al., 1999; Olsofka et al., 1999; Eke, 2000; ). Delay in diagnosis and inadequate intervention lead to rapid extension of infection and necrosis, overwhelming septicaemia, multiple organ failure, and are the prime causes of death.
Predisposing factors to Fourniers gangrene include male sex (by 10:1 ratio), impaired immunity such as diabetes mellitus, and previous surgical procedure to uro-gentialia (Eke, 2000). These are present in this case illustrating the subtle and sinister way Fourniers gangrene often presents.
Since the 1960s, gender reassignment surgery has been increasing in particular male to female reassignments. It is important for clinicians to be familiar with transsexualism and the surgical procedure. With advance reconstructive techniques and hormonal manipulation, medical conditions unique or prevalent to the male sex could be overlooked. Had this patient presented before genital reassignment, Fourniers gangrene would have been attained sooner, and treated appropriately. Subsequent extensive second debridement might have been avoided.
Although male to female transsexuals should be treated to the extent possible like other female patients, clinicians must be aware gender reassignment surgery alters the appearance of the external genitalia and patients retain their biological sex and internal genital organs.
Ben Aharon, U., Borenstein, A., Eisenkraft, S., Lifschitz, O. and Leviav, A. (1996) Extensive necrotizing soft tissue infection of the perineum. Israel Journal of Medical Science, 32(9): 745-749.
Corman, J. M., Moody, J. A. and Aronson, W. J. (1999) Fourniers gangrene in a modern surgical setting: improved survival with aggressive management. B J U International, 84(1): 85-88.
Eke, N. (2000) Fourniers gangrene: a review of 1726 cases. British Journal of Surgery, 87(6): 718-728.
Elliott, D. C., Kufera, J. A. and Myers, R. A. (1996) Necrotizing soft tissue infections. Risk factors for mortality and strategies for management. Annals of Surgery, 224(5): 672-683.
Fournier, J. A. (1883) Gangrene foudroyante de la verge. Semaine Medicale, 3: 345-347.
Olsofka, J. N., Carrillo, E. H., Spain, D. A. and Polk, H. C., Jr. (1999) The continuing challenge of Fourniers gangrene in the 1990s. American Surgeon, 65(12): 1156-1159.
Correspondence to Mr. Andrew C. Lee, National Medical Laser Centre, Charles Bell House, 67-73 Riding House Street, London, W1W 7PN, UK (firstname.lastname@example.org)