Vaginoplasty for Gender Affirmation: what you should know prior to and after the surgery.

TLDR

A vaginoplasty is a surgical technique used to either create or revise a vagina. While it is commonly recognized as a surgery for transgender women, it has other uses as well. For example, a woman seeking reconstruction of the vaginal canal after a traumatic birth or radiation from cancer treatments might have a vaginoplasty. Read more basics about the procedure here.

As it pertains to gender affirmation, this surgery has a wonderful benefit in improving gender dysphoria so the individual may find their appearance more consistent with their identity. This can drastically improve quality of life and overall mental health. Beyond any consequence, this is most often a pro that will outweigh all of the cons.

The purpose of this blog post is to cover pelvic floor recommendations both prior to and post operative with a vaginoplasty.

Prior to surgery...

It's important to see a Pelvic Floor Physical Therapist prior to your surgery to identify any pelvic floor dysfunction you may have and improve it for better outcomes post-op. Realistically, your post-operative journey is lifelong so understanding how to maintain a healthy and happy pelvic floor prior to jumping in is recommended.

What are common dysfunctions most often seen?

• Any type of incontinence: leaking of urine, gas, or feces at unintentional times, no matter the size of the leak. This can be due both to weakness or ineffective pressure management within your abdominopelvic cavity.

• Hypertonic pelvic floor, which is a fancy way of saying a tight pelvic floor. We want muscles to be at an optimal length to function properly, so if tight muscles are unable to relax it can lead to pain or even inability to achieve sexual satisfaction. One goal individuals may have with a vaginoplasty is the ability to have sexual intercourse that is pleasurable.

• This bullet is not a dysfunction, but being aware of your anatomy and how the pelvic floor relates to your bodily functions is important. It is never a bad thing to learn more about your body, but the frequency in which any of us take a mirror and visualize our pelvic floor is probably low. Getting used to how your anatomy looks will be important so you can notice and adverse changes after surgery you'd want to have checked. Pelvic floor PT will teach you what the female anatomy is, what the different structures are (name and purpose), and how to recognize changes.

This list is not comprehensive by any means, and since you are a unique individual, your experience will not match another's.

One helpful option to visualize female anatomy to prepare for the variability and uniqueness you will have post-operatively is to just look at as many vulvas as you can! A great resource is the labia library.

Read more about the research for pre-op pelvic floor PT here.

Surgery

There are numerous surgical techniques out there for a vaginoplasty, however the "gold-standard", or the way that results in the most success, is the Penile Inversion Technique. This is where the surgical team harvests structures from the penis and scrotum to turn into the labia majora and minora, clitoris, and neovagina. In the case of a zero-depth vaginoplasty, a vaginal canal is not created.

There are extensive risks that accompany any surgery, not just a vaginoplasty. Being aware of these risks and understanding all that you need to do to avoid them is instrumental to improving outcomes in the long term. Most surgeons will cover complications that may arise in their consent process to ensure you have a full picture.

The risks associated with vaginoplasty include (but are not limited to):

• Bleeding, hematoma, transfusion

• Infection (eg UTI)

• Deep vein thrombosis or Pulmonary Embolism; aka a blood clot

• Partial or total graft loss

• Graft non-adherence

• Vaginal stenosis, shortening

• Vaginal prolapse

• Wound healing issues (eg dehiscence where it reopens, or excessive scarring)

• Bladder, urethral, rectal injury

• Neovaginal - rectal fistula

• Need for additional / secondary interventions

• Need for prolonged urinary catheterization

• Urethral fistula

• Urethral stricture, abnormal urinary stream

• Urinary incontinence

• Inability to orgasm, or a change in orgasm

It cannot be stressed enough how important it is to follow your surgeon's instructions following the surgery. The strongest recommendation will always include being compliant with vaginal dilation, which will help mitigate a lot of these complications listed above.

The main takeaway in this section is that no surgery is performed without risk, and understanding those risks and how to prevent them will lead to better outcomes. General recommendations are to not smoke (or quit smoking at least a year prior), maintain a nutritious diet, and prioritize exercise, sleep, and mental wellbeing.

Post surgery...

One of the key elements for post-operative success is a referral to pelvic floor physical therapy, especially if you were not able to see one prior to surgery.

Role of pelvic floor physical therapy post surgery:

• Post op ambulation: A PT should come visit you around one day post op to help you get up and walk, both to maintain mobility & prevent muscle wasting, as well as prevent blood clots from forming.

• Assist with pelvic relaxation in preparation for dilation: Dilation of the vaginal canal is a life-long process to prevent stenosis (which is narrowing of the cavity). If your pelvic floor muscles are very tight, or hypertonic, pushing a firm dilator into the vaginal canal may be extremely uncomfortable, if not painful. There are many techniques you can implement to help prepare the pelvic floor to accept the dilator.

• Treat pelvic pain, muscle spasms, and dyspareunia (painful penetration). Facilitate dilation (as listed above), and assist with relaxation strategies for sexual intercourse (if that is your goal).

As mentioned in the surgical section, there may be consequences that arise post surgery for a multitude of reasons, so staying in regular contact with your medical team is important. One experience individuals may have is pain with dilation. Often a lot of pain in terms of dilation is a result of a hypertonic pelvic floor, for which seeing a pelvic floor PT is the main treatment.

Surrounding the vaginal canal where you need to dilate are surgical wounds. Wounds heal over a period of time, most often ~6 weeks, although sometimes revision is necessary 3-6 months later. Keep your hands off of the wound!! Don't try to intervene with it, even though it does not look pretty. The key component to healing is to keep dilating!

***If you have any bleeding with dilation, however, make an appointment ASAP with your surgeon, or call their office.

Sometimes the use of a dilator can uncover an issue at the rectum that wasn't previously seen, as the dilator is a firm, blunt tool that is penetrating the vaginal canal. However it is extremely rare you could cause an injury with your dilator unless you find yourself being overly aggressive. If you notice any passage of gas or stool from your vagina or foul smelling discharge, call your surgeon's office. If you're experiencing pain as well with penetration that does not improve with pelvic floor PT, call your surgeon's office.

The big picture: you are the main center of your medical team, which is here to support you through your transition. No question or concern is ever too small or stupid, so ask any or all of us about your thoughts or concerns.

TLDR:

1. A vaginoplasty for gender affirmation requires both pre-operative and post-operative care by an extensive medical team, one such member being a pelvic floor physical therapist.

2. Pre-operatively, it's important to see a pelvic floor PT to assess any pelvic floor dysfunction you might have, and mitigate the issue prior to surgery for a better outcome.

3. There are many risks involved with surgery -- any type of surgery, not just a vaginoplasty. Being strictly compliant with post-op recommendations such as dilation can help mitigate these risks.

4. One of the main roles of pelvic floor PT after your surgery is to help you with dilation, prevent or alleviate pain that may arise, and prepare you for activities you want to partake in (e.g. sexual intercourse via vaginal penetration).

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About the Author:

Caroline Gamwell, DPT is a Doctor of Physical Therapy, specializing in Pelvic Floor and Women's Health. She is the founder of Worth It PT based in Denver, Colorado, a clinic whose focus is to help others achieve their health and wellness goals through a higher quality of healthcare.