Vaginoplasty Considerations, Complications, and Outcomes for Trans Women
- ocherie
- Aug 1
- 6 min read
Updated: Aug 16
Back when I was a physical therapy student, I went to the largest physical therapy conference called Combined Sections Meeting (CSM). The presenters of one of the lectures I went to were from Johns Hopkins hospital: a surgeon and a physical therapist, along with their mutual patient. It was super fascinating because the surgeon was head of the department for gender affirming surgery and brought up a lot of interesting facts from his point of view as a surgeon. The same for the physical therapist and the patient. I was enthralled.
I knew that when I obtained my doctorate and became a licensed physical therapist, I wanted to learn more about this niche so I could better serve this patient population. I've since treated a few patients who had undergone vaginoplasty.
Vaginoplasty is a gender affirming surgery that gives the opportunity for trans women to remove masculine-appearing genitalia and replace it with "a gender-congruent appearance" (Pariser & Kim, 2019). The road to getting a vaginoplasty is a long and difficult one. There are several considerations that one must tackle before any surgery can take place. The World Professional Association for Transgender Health (WPATH) has guidelines for gender affirming surgery:
Persistent well-documented gender dysphoria
Capacity of informed consent
Age of majority
Well-controlled medical and mental health concerns
12 months of continuous hormones unless contraindicated
12 months of continuously living in the gender role congruent with their gender identity
Two referrals from qualified mental health professionals
Transgender vaginoplasty: techniques and outcomes (Pariser & Kim, 2019)
This study discusses preoperative considerations. One such consideration is that it is important that genital hair is removed for either phalloplasty or vaginoplasty due to the potential for infection if hair remains on the skin.
Managing hormones is important as chronic estrogen supplementation is associated with venous thromboembolism (VTE). VTE is a blood clot in one's veins, which can lead to deep vein thrombosis and pulmonary embolism. As well, surgeons differ in protocols for hormone management. Some may prefer a patient to stop estrogen prior to surgery for up to a month. Other surgeons may want their patients to continue estrogen during this time, though perhaps on a lower dosage. This is something you'll need to clarify with your own surgeon.
Another consideration is whether a patient wants to have orchiectomy (removal of one or both testicles) as a separate procedure done before vaginoplasty or performed with the vaginoplasty.
Advantages to separating the two surgeries:
Simplification of hormone management
Decreased procedure time for the vaginoplasty
Disadvantages of separating the two surgeries:
Theoretical risk of increased scarring
Further Reading
This study does go in-depth about the surgical process from beginning to end, if anyone is interested in the details. There are even pictures.
A potential issue that should be discussed with one's surgeon is the maximum depth obtained from the vaginoplasty along with the maintenance that will come after the surgery. If a patient is not interested in penetrative intercourse, then limited depth in the vaginal canal would be ideal. The upside to this surgical technique is that:
decreased risk for rectal and urethral injury
removes the need for additional grafts and flaps to create additional vaginal length
decreases the duration of the surgery
A common complication that may stem from labiaplasty is reopening the superficial surgical incisions, so proper aftercare and hygiene is a must.
Dilator protocol may differ between surgeons. In this study, their patient protocol is starting dilating 7-10 days post-op at their first clinic visit. Included in their dilation protocol:
3 months of 3 times daily for 15 minutes, then
6 months of 2 times daily, then
Lifelong dilation every 1-2 days
The study mentions outcome results that stemmed from large case studies from high volume institutions. Some possible complications mentioned:
2.3% rate of rectal injury with 0.6% overall rate of rectovaginal fistula
1.1% rate of intraoperative urethral injury and a 1.7% rate of postoperative urethroneovaginal fistula
minor necrosis occurring in 24.6% of patients with only 0.6% classified as "major necrosis."
Other results and outcomes from other published series:
rectal injury reported in 0.4-4.5%
urethral injury rates of 1.1% to 3.6%
long-term stenosis of the neovagina reported in 2-12% range, though this occurs if the patient completely stops dilations.
Systematic Review of Neovaginal Prolapse After Vaginoplasty In Trans Women (Tran et al., 2024)
This systematic review provides an overview of prolapse complications in reference to transgender vaginoplasty. There is not a lot of research when it comes to information about prolapses after having a vaginoplasty, but this systematic review provides what it can.
The gold standard for this type of gender affirming surgery is penile inversion vaginoplasty. This is where the penile skin is used to create the vaginal canal.
There are alternative techniques that may be used when there is not enough penile tissue available to create the vaginal cavity. Surgeries may use alternative tissue from the colon, the perineum, or a combination of tissue.
Another type of surgery that a trans woman may opt for is vulvovaginoplasty. This is where the vaginal cavity is not created and instead the surgery focuses on creating the labia. This type of surgery is for patients who "may not have the desire or need for a vaginal canal but still seek extreme feminization."
A risk that may occur is organ prolapse. This may occur due to the levator ani muscle getting cut to help expand the new vaginal cavity. The levator ani is the third and deepest layer of the pelvic floor muscles, and one of their functions is supporting organs above them.
A neovaginal prolapse may occur due to graft or flap loss and/or non-adherence, so a true pelvic organ prolapse from this surgery is rare. However, if a bowel vaginoplasty was performed, then a bowel segment prolapse may occur.
Prolapses within the literature for vaginoplasty is ill-defined, and may be referring to skin graft failure, mucosal or skin prolapse due to poorly adhered skin flap.
The results from the systematic review is that the percentage of a neovaginal prolapse occurring ranged from 0% to 7% if the surgery utilized the penile skin inversion technique. If the sigmoid colon-derived vaginoplasty was utilized, then the prolapsed range went up to 11.1%. One of the studies within the systematic review reported a prolapse rate of 22.7% when patients underwent a secondary laparoscopic right colon vaginoplasty.
While available data for treatment and management for neovaginal prolapse is scarce, it means that pelvic health physical therapy may be even more needed to treat pelvic floor symptoms in this population as they occur. Just like with any surgery, the first part is getting through the surgery, but it is just as important to do the rehab and maintenance afterward.
Complications and Patient-Reported Outcomes in Transfemale Vaginoplasty: An Updated Systematic Review and Meta-analysis (Bustos et al., 2021)
The complications noted in this systematic review and meta-analysis were: fistula, stenosis and/or strictures, tissue necrosis, and prolapse. Overall though, patient–reported outcomes were positive for satisfaction, functional outcomes and aesthetical outcomes. This review also reported 76% for the ability to achieve orgasm after a successful surgery.
Gender affirming surgeries like vaginoplasty have increased over the years and that is wonderful. I hope that trend continues as these surgeries save lives. There may be complications associated with vaginoplasty, but many may be treatable through pelvic health physical therapy.
Resources
https://thecenterlv.org/ The Center - serving the LGBTQIA+ community of Nevada
https://www.thetrevorproject.org/ The Trevor Project - suicide prevention for LGBTQ+ young people
https://forge-forward.org/ FORGE - building strength and resilience in our transgender communities
https://www.mshmemphis.org/ My Sistah's House - a grassroots, transgender-led organization in Memphis, Tennessee, that provides wraparound services for primarily Black and Brown transgender and non-binary individuals, including safe spaces, emergency shelter, and access to health and social services.
Alavar Pelvic Health Physical Therapy is offering virtual pelvic health appointments within Nevada. If you live outside of Nevada, we offer virtual coaching sessions.
Ready to book your first appointment?
References
Bustos, S. S., Bustos, V. P., Mascaro, A., Ciudad, P., Forte, A. J., Del Corral, G., & Manrique, O. J. (2021). Complications and Patient-reported Outcomes in Transfemale Vaginoplasty: An Updated Systematic Review and Meta-analysis. Plastic and reconstructive surgery. Global open, 9(3), e3510. https://doi.org/10.1097/GOX.0000000000003510
Pariser, J. J., & Kim, N. (2019). Transgender vaginoplasty: techniques and outcomes. Translational andrology and urology, 8(3), 241–247. https://doi.org/10.21037/tau.2019.06.03
Tran, S., Guillot-Tantay, C., Sabbagh, P., Vidart, A., Bosset, P. O., Lebret, T., Biardeau, X., Schirmann, A., & Madec, F. X. (2024). Systematic Review of Neovaginal Prolapse After Vaginoplasty in Trans Women. European urology open science, 66, 101–111. https://doi.org/10.1016/j.euros.2024.06.013
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