Vaginoplasty

Having gender affirming vaginoplasty surgery should come with many questions and while the web can be a great source of information, can also be a great source of misinformation.   One would be well advised to carefully take into consideration the content read, the author’s expertise, and to discuss any concerns with your surgeon. Based on my medical knowledge and experience with vaginoplasties, I trust you find the content of this website to be at minimum informative and helpful.

Background

What is the importance of WPATH standards of care?

The World Professional Association for Transgender Health (WPATH) has developed standards of care for FTM bottom surgery, standards that I follow.  These standards are important because prior to their development, many gender affirmation surgeries were done without good rules to follow in a “wild-west” surgical atmosphere. By implementing and following said guidelines, surgeons can do their best to ensure that you receive the most up-to-date care and most stable outcome as possible

What is the problem with the WPATH guidelines?

Some trans-patients have rightly complained about “gatekeeping” among medical professional and not being able to access care because of the strictness of WPATH guidelines.  Another problem with the guidelines is that much of it is formulated as the opinion of experts.  Unfortunately, there is lack of qualitative and quantitative data in many aspects of transgender medicine – as a result the guidelines can be subject to debate.  While the guidelines may change overtime, they do stand as the best set of soft rules to follow based on the available data and medical experience.

Before Your Surgery

OK, I’ve decided to proceed with gender affirming vaginoplasty, what are the pre-op requirements?

A few things:

1) You will need to have 2 letters from a psychiatrist or mental health professional that attests to your overall psychiatric health and readiness for surgery

2) WPATH recommends that you live as a female for at least one year prior to surgery. Is there data on this?  Not really – but the reason to consider doing this is not so much to prevent regret, as much as for you to understand what the social, financial and psychological implications may be for you once you have your surgery.

For example, because of bias and prejudice, some women may be terminated from their position of employment after transitioning. This can put result in a tremendous financial burden that may make harnessing the medical resources needed after surgery very difficult.  Other times, family support may be lacking in your transition.  This does not mean that you shouldn’t have surgery done – it only means that it is imperative to know what to expect from your career and family after surgery.  By knowing what support you will have – planning for surgery becomes much easier

3) WPATH also recommends that you be on hormones for at least 1 year prior to surgery

a. See our section on hormones for more information (link to section on hormones)

4) Medical clearance from your primary doctor or health care provider is usually needed

a. It’s important to make sure you don’t have an undiagnosed problem that might affect your recovery from surgery

b. If you do have a medical problem like diabetes or asthma, then it should be optimally managed and stabilized to minimize any risk from surgery

c. I am HIV positive – Can I still have gender affirming vaginoplasty?

i. Absolutely! but you should be on medications to ensure your immune system is the strongest it can be before having surgery done

5) Laser hair removal and/or electrolysis depends a little on the type of surgery you are having performed. The large majority of cases we do, are penile inversion vaginoplasties.  In this surgery, some scrotal tissue is used to create the lining of the vagina.  To prevent hair growing in the vagina, hair removed prior the surgery is required.

a. Is there a difference between laser hair removal and electrolysis?

i. Ultimately, the end result is the same between the two. However, laser hair removal is generally better suited for patients who have dark colored hair and lighter colored skin. Great enhancements in laser technology have expanded the safe efficacy to darker skin tones. It is very important to find an experienced laser technician and laser suitable for your skin and hair type. Laser hair removal can be done much more rapidly than great number of standard electrolysis hour. On average, only 6 to 8 quick laser treatment spaced 4 to 6 weeks apart may be needed to resolve the area.  The key is to start as soon as possible. 

b. Will insurance cover hair removal with laser or electrolysis for my vaginoplasty?

i. Sometimes – it depends on your insurance

ii. If insurance does not pay – how much does electrolysis cost? Generally, patients advise the cost can range from $300 to $1300. 

c. Can I do electrolysis for vaginoplasty close to where I live?

i. Yes! As long as it is done by professionals who know what area to get rid of hair. Most women want to keep the hair in the pubic area post-operatively so it is important to plan for this appropriately

ii. Click here to see a map of the area I advise to get electrolysis done for our penile inversion vaginoplasty.

d. Geez! Getting rid of hair before a vaginoplasty is kind of a pain and might delay my surgery – do I really need to do electrolysis?

i. Depends – do you really want a hairy vagina?
ii. Hair can sometimes knot up and form stones on it
iii. Hair in the vagina can also result in a bad odor because it can be more difficult rid the bacteria in the area

e. Oh no! I still have a little hair left and my vaginoplasty is coming up next week! Does it have to be perfectly hairless like a newborn baby?

i. Newborn babies do have a little hair so that’s probably a bad analogy!
ii. A little bit of left over hair is usually ok and can be removed during surgery
iii. Too much hair however, can be a problem

Surgery

What are the different types of gender affirming vaginoplasty?

1) Penile inversion vaginoplasty

a. Without a skin graft

What is a penile inversion vaginoplasty?

Penile inversion vaginoplasty is a procedure where the penis is disassembled, some parts are removed and other parts are utilized to create a new vagina.  We try to place similar tissues with similar tissues in an effort to emulate how humans develop in the womb, as to create most natural vagina possible. (FIGURE) So for example, the glans of the penis is derived from the same set of fetal cells as the clitoris and this tissue is used to make a new clitoris.  The scrotal tissue is used to create labia and the shaft skin of the penis is used to make the vaginal wall.

What are the important things to think about or ask your surgeon before gender affirming vaginoplasty?

There are a few questions to ask yourself before surgery.  How important is receptive sex to you? And, how deep a vagina do you desire?  Generally, I aim to create about 5-7 inches of depth.  Even if receptive sex is not that important to you, I do not advise a “zero” depth vaginoplasty. The biggest problem with “zero” depth vaginoplasty, is that without vaginal depth, an unnatural vaginal appearance occurs.  Some depth is important to give a more natural appearance to the vagina and help define the labial folds and the clitoris.  Also, sometimes patients can change their mind after surgery about sex and in some cases, sexual oriental may shift to some degree post-surgery.  The rare cases to consider zero-depth vagina is if the cosmetic appearance is not at all important to you and you may have other medical problems or if you have had radiation to the pelvis or surgery such as a prostate removal (radical prostatectomy).

What other things do I need to know before surgery?

You should healthy enough to tolerate a long surgery under general anesthesia.  If you have a chronic condition like diabetes or HIV, then these must be optimally managed before your surgery.  Be prepared for lifelong vaginal dilations and need to lubricate the vagina before sex. 

Is the shaft skin of the penis enough to create a deep vagina in vaginoplasty?  

It depends, but usually not. If you are not circumcised, a bit more skin maybe available to create a deeper vagina. 

So how can you get more depth in the new vagina? 

There are a few different tissues that can be used to make the vagina deeper, each have their own advantages and disadvantages.  The most common tissue is scrotal skin.  The advantage of scrotal skin is that it is present in most transwomen, which gets removed anyway, so why not use it?  In some women, this skin has hair which will need to be removed (see electrolysis versus laser section) prior to surgery.  In some younger women, particularly if they had started hormone therapy very early in their life, the scrotal skin may not have developed very much and additional tissue may be needed.

Another option to generate additional tissue to deepen the vagina includes skin grafts from other parts of the body. The problem is that such grafts can lead to scar tissue in the area the skin graft is taken.   Tissue from the lining of the abdomen called peritoneum may also be used (see section on peritoneum), as can tissue from around the testicles called the tunica vaginalis.

What about the peritoneum for vaginoplasty? What are the advantages and disadvantages?

The first thing to recognize is that the peritoneum can be used both as a flap or as a graft. A flap is tissue that is transplanted to another location that is still attached to its blood supply. A graft is just transplanted tissue that is no longer attached to its blood supply.  Flaps are usually better than grafts because they have a better oxygen and nutrient supply to keep them healthy in their new location.

Doesn’t the peritoneum give you the chance to have a naturally self-lubricating vagina?

This is a pretty controversial topic. Good medicine tries as best as possible to rely on data and science, unfortunately there is no great bank of information in this arena and in my experience, probably not. If anything, it makes more sense to use the peritoneum as a flap if you want lubrication. Because the blood supply will allow the peritoneum to act more like a natural peritoneum which does produce some lymphatic fluid.  Unfortunately, even as a flap the peritoneum doesn’t have any good evidence of making lubrication

Of course, evidence to the contrary and new developments would certainly garner my consideration.

One of the advantages is that the peritoneum can provide additional tissue in patients who don’t have enough scrotal tissue and, the tissue is hairless! That certainly make electrolysis and/or laser hair removal prior to surgery is non-factor.

So, what’s the downside of using peritoneum? 

Well for one, it involves doing an operation inside your abdomen where there’re a lot of other organs. There’s always a small chance of injury, infection, and/or bleeding to some of these organs and tissues. Additionally, the unknown is the long-term consequences of peritoneum tissue utilization and how suitable the substitute truly is for the vagina in the long term. Ultimately, historical data is simple not available at this juncture.

So, how about the robotic approach to vaginoplasty? 

The robotic approach to me, seems like a fairly reasonable approach because it allows for a good visualization of the top of the vaginal pocket. My own feeling, is that if patients can have a standard scrotal skin vaginoplasty, it is preferable. If this scrotal skin is absent, then using the robotic peritoneal flap or even a graft is probably a good option.

What about the tissue around the testicles – the tunica vaginalis – for gender affirming vaginoplasty?

You can also consider using tissue around the testicles, appropriately called a tunica vaginalis, which from an embryological standpoint is the same tissue as the peritoneum. The advantage of using this approach is that it does not require an incision in the abdomen to harvest the peritoneal graft. The disadvantage is that some patients don’t have enough of this tissue to be useful.

How about using the colon or intestines such as a sigmoid vaginoplasty?

An alternative to using skin grafts would be to utilize a small part of your colon for your vagina. If you think about it, the colon is also canal like, is soft on the inside, and is very close to the vagina. But, it is less commonly used in transwoman for vaginoplasty because intestines make mucus which may require wearing a panty liner or a pad all of the time. Using a piece of the colon does not affect the ability to digest food very much however. We tend to reserve the use of the colon in patients who have had prior surgeries or for whom a standard penile inversion vaginoplasty cannot be done for whatever reason. Currently, the colon can be harvested either laparoscopically or robotically which makes for a much nicer cosmetic appearance on the abdomen after surgery also.

What are the risks of a penile inversion vaginoplasty?

This is a big surgery and there are risks. Fortunately, in expert hands risks are low.  Standard risks of any surgery that I worry about include bleeding, infection, and general recovery from anesthesia and anesthesia complications.

One of the big things we worry about is the formation of a fistula between the urethra and the rectum or between the vagina in the rectum. The reason this can happen is that the vaginal wall has to be created in the space between the urethra or prostate and the rectum. If the rectal wall is accidentally injured this can lead to the creation of a fistula.

Other risks of surgery include losing sensation at the clitoris. This usually happens because the nerves that feed the clitoris can be damaged during surgery. It is a problem because patients can have a difficult time having an orgasm without sensation to the clitoris.

Sometimes the blood supply to skin of the labia can be compromised causing the wound breakdown to occur. In my experience when this does happen the body often heals itself very well and the cosmetic outcomes will be okay after a few months.

Vaginal stenosis or scarring in the vaginal canal may also occur after surgery. This may occur if the vagina is not dilated or sometimes it just happens as the tissue heals. Treatment usually involves a minor revision surgery to open up the walls of the vagina.

What can I expect after surgery?

Typically, my patients stay in the hospital for 3 to 4 days. The first day after surgery I ask patients to stay in bed. This allows enough time for the grafts to stick and for wound healing to begin. Usually we have patients getting up and moving around the day two days after surgery and they’re fully up and walking around by the third after surgery. Everyone is a little bit different, however, and surgeries can be different. So, every day I make a judgment about what the plan is for the day based on how you are feeling and recovering.  I tend to be conservative and keep patients in the hospital as long as I think they need to be in the hospital to fully recover.

Will I have any tubes or things left inside of me after surgery?

Usually I leave patients with a packing in the vagina which stays in for 5 to 7 days. A urinary catheter to drain the bladder will also be in place for 5-7 days. In addition, you may have some drains to allow for any fluid buildup inside the body to come out.

After Your Gender Affirming Vaginoplasty

Will urination change after my gender affirming vaginoplasty?

Again, there is no great data on this.  Most patients are able to urinate when the urinary catheter is removed in the office. But urination can feel different. Sometimes patients can have some urinary urgency and frequency that is usually temporary. Some patients report a great deal of sensation or a high threshold of sensation to push past in order to initiate urination during the first week or two post cathedral removal.  Intense sensations and urination difficulty will continue to resolve over time as swelling decreases, nerves heal, and the body relearns this function.

If the urethra has not properly been created women can spray when they urinate or urinate over their toilet seat when they sit down to pee. If this does happen it’s usually correctable but may require additional surgery.

Can I orgasm?

YES!! But or orgasms may be different compare to before surgery. Orgasms go from being a “male” orgasm prior to surgery which is has high-intensity buildup and immediate release to a more “female” orgasm – which has a more gradual build up with a longer sustained release.

Wow, things look great how do I take care of my new vagina?

Well, for one, you have to periodically dilate the vagina to prevent it from scarring down. A twice daily dilation regimen should be considered a minimum for the first 6 to 12 months. Dilation frequency may vary on a case by case basis and in the long term. Once healed and intercourse is approved by your surgeon, sex can also be a way of keeping the vagina open as well! Just remember to always use lubrication with during intercourse and penetrative foreplay.  Periodically patients find that douching can prevent odors from forming and keep the vagina clean. Otherwise there really isn’t any special maintenance!