Vaginoplasty: Long-Term Care

Vaginoplasty—also called transfeminine bottom surgery—is a gender-affirming surgery that entails creating a new vagina (called a "neovagina"), usually from the inverted skin and tissue of the penis.

Most patients are satisfied with the outcome of the surgery, feeling more physically and emotionally comfortable with their bodies.

While vaginoplasty is considered a relatively safe procedure when performed by an experienced surgeon, complications may arise that necessitate future surgeries. In addition, making lifestyle adjustments after surgery is critical for optimizing the surgery's outcome and the patient's overall health.

Benefits of Surgery

For most patients, there are lifelong psychological and physical benefits to undergoing a vaginoplasty. While it is most often a gender-affirming procedure, vaginoplasty is also less commonly done as part of vaginal reconstructive surgery for cis-gendered women.

Psychologically, after a vaginoplasty, patients usually feel more affirmed in their gender as a female, experience higher self-esteem, and have decreased stress related to their bodies.

In one study of 49 transgender women who underwent vaginoplasty using the penile skin inversion technique, the functionality and cosmetic appearance of their neovagina were given an average score of 8 out of 10 (10 being the highest satisfaction).

In another study of 117 patients who underwent penile inversion vaginoplasty, 94% of the patients reported "feeling positive about their genitals" and "would do this operation again." Seventy-one percent of patients reported resolution of their gender dysphoria.

Physically, patients often report an increase in sexual functioning and fulfillment after a vaginoplasty. With a new inner and outer vagina, patients may undergo vaginal intercourse and experience an orgasm through stimulation of the clitoris, which is made from the head of the penis.

Follow-Up Care

After a vaginoplasty, it's important to follow up with your surgeon for regular preventive care. Your surgeon will perform an exam of the vulva, perianal region, and neovagina. They will monitor for potential long-term complications of a vaginoplasty (which may vary based on the surgical technique used).

Some of these complications include:

• Neovaginal prolapse
• Fistula formation (when an abnormal tract forms between two tissues)
• Vaginal stenosis
• Neovaginal colitis can occur as a complication of the less common approach of using the colon to form the vagina

Cancer Screening

Anal cancer screening may also be considered in HIV-positive transgender women, considering infection with HIV is linked to a 30-fold increased risk of developing anal cancer.

Your provider may perform a speculum examination to evaluate the skin of the inverted penis to look for pre-cancerous lesions of the penis (called penile intraepithelial neoplasia). It is reasonable to have a regular visual pelvic exam to look for growths/cancers that could typically occur on the skin of the penis. Alternatively, if the less common procedure using the bowel is used to create the neovagina, colon cancer screening would be recommended as applicable.

Although there have been cases of HPV-related cancers in neovaginas, there is limited data on cancer screening for transgender women with neovaginas and there is no recommendation for routine human papillomavirus (HPV) testing.

It's important to discuss prostate cancer screening with your healthcare provider. The decision to perform screening should be based on the same guidelines used for non-transgender men. The only difference is that in a transgender woman who has undergone vaginoplasty, the upper limit of normal for the prostate-specific antigen (PSA) test should be reduced to 1.0 nanograms per milliliter (ng/mL).

Possible Future Surgeries

While a vaginoplasty is a relatively safe operation, future surgical procedures may be needed if certain complications arise.

These surgeries may involve:

• Drainage of a large hematoma (collection of blood)
• Drainage of a large abscess (collection of infected fluid)
• Correction of a rectovaginal fistula formation (when an abnormal tract forms between the vagina and the rectum)
• Correction of urological problems (for example, narrowing or blockage of the urethra)
• Correction of the size or shape of the vagina, clitoris, or labia, if deemed unsatisfactory in appearance

Moreover, a vaginoplasty is one step in the journey of surgically transitioning from a male to a female. Besides a vaginoplasty, many patients will choose to undergo additional surgeries, such as breast augmentation and facial feminization surgery.

Lifestyle Adjustments

After your vaginoplasty, you will need to engage in various lifestyle practices.

Vaginal Dilation

Vaginal dilation is essential for maintaining the girth and depth of the newly created vaginal canal. Your surgeon will provide you with the dilators, as well as a precise dilation schedule to follow.

A typical schedule may include:

• First three months after surgery: Dilate three times a day for 10 minutes
• Three to six months after surgery: Dilate once a day for 10 minutes
• More than six months after surgery: Dilate two to three times a week for 10 minutes
• More than nine months after surgery: Dilate one to two times a week for 10 minutes

Hygiene Practices

After a vaginoplasty, it's important to be extra diligent about keeping your genital area clean and dry.

Some healthy hygiene habits to adopt include:

• Washing your hands with soap and water before and after touching your genital area
• Wiping from front to back
• Drying vaginal area after showering or dilating
• Regularly douching with soapy water—starting once a day and eventually reducing to two to three times a week, as dilation becomes less frequent
• Cleaning your dilator with soap and warm water before and after each use

Infection Monitoring

Because of the shortening of the urethra, urinary tract infections (UTIs) are more common after a vaginoplasty. Call your healthcare provider if you are experiencing UTI symptoms, such as:

• Burning with urination
• Increased hesitancy or frequency with urination
• Blood in your urine

Due to increased vaginal moisture from dilating and/or from antibiotic use after surgery, vaginal yeast infections may also occur after a vaginoplasty.

Call your healthcare provider if you are experiencing these possible symptoms of a yeast infection:

• Vaginal itching
• Having white, curd-like vaginal discharge

Pelvic Floor Physical Therapy

After a vaginoplasty, patients are enrolled in a pelvic floor physical therapy program. Besides strengthening your pelvic muscles, a physical therapist can help with issues like painful or insufficient vaginal dilations, as well as urinary leakage after surgery (if persistent).

A Word From Verywell

No doubt, after a vaginoplasty, most patients are satisfied with the outcome, both functionally and aesthetically. Nevertheless, a vaginoplasty is a major surgery—it can be costly (close to $25,000), and requires an extensive recovery and lifelong commitment to vaginal dilation.