Vaginoplasty procedures, complications and aftercare

Introduction

The most common vaginoplasty proficiency is some mutant of the penile anastrophe operation. In this proficiency, a vaginal vault is created between the rectum and the urethra, in the lapp placement as a non-transgender female between the pelvic floor ( Kegel ) muscles, and the vaginal lining is created from penile skin. An orchidectomy is performed, the labium majora are created using scrotal peel, and the clitoris is created from a part of the glans penis. The prostate is left in space to avoid complications such as incontinence and urethral strictures. furthermore, the prostate has erogenous sensation and is the anatomic equivalent to the “ g-spot. ” Great care is taken to limit the external scars from a vaginoplasty by locating the incisions appropriately and with meticulous settlement. typical depth is 15 centimeter ( 6 inches ), with a range of 12-16cm ( 5-6.5 inches ) ; in comparison, typical vaginal depth in non-transgender females is between 9-12cm ( 3.5 to 5 inches ). In the case of anterior circumcision a clamber bribery, typically scrotal in origin, may be required. If there is insufficient skin between the penis and the scrotum to achieve 12cm ( 5 inches ) of depth, a clamber bribery from the hip, lower abdomen or inner thigh may be used. resultant scar at the donor locate may be minimized or hidden using standard techniques. Because the penile inversion approach does not create a vaginal mucous membrane, the vagina does not self-lubricate and requires the use of an external lubricant for dilation or penetrative arouse .
scrotal skin has abundant hair follicles and it is possible to transfer skin with sparse haircloth growth into the vagina unless hair is removed in advance. Some surgeons rely on treating all the visible haircloth with aggressive reduce of the skin and cautery of visible haircloth follicles at the time of surgery. however, since hair’s-breadth grows in stages this approach might not adequately address dormant follicles. The most authentic method of preventing hair emergence in the vagina is to perform scrotal electrolysis, at least three fully clearings 8-12 weeks apart, depending on electrologist preference and hair type and distribution. Surgeons should provide a diagram of the specific area for clearance .
A common result of penile inversion vaginoplasty performed in a single stage ( a “ one-stage ” vaginoplasty ), with penile skin positioned between scrotal skin, is labium majora that are spaced excessively far apart. There may besides be minimal if any clitoral hood ( except in heavier patients ) and the labium minora may be insufficient after one operation. Although there are different variations of the one-step procedure, it has been the author ‘s feel that these previously mentioned deficiencies are coarse. This constraint is due to factors implicit in to the penile inversion border on and the limitations of the blood provide. From the standing placement and with the branch in concert, most results appear satisfactory ; however, upon direct examination or intimate view, the deficiencies discussed above will be apparent. In order to adequately address these deficiencies, the generator believes that a moment operation is required. A secondary labiaplasty provides an opportunity to bring the labium majora closer to the midplane in a more anatomically discipline placement, provide adequate clitoral hood, and define the labium minora. In accession, there are many variables that can affect mend and the final consequence. specifically, this secondary procedure besides allows the surgeon to deal with differences in healing, such as revision of the urethra, correction of any vaginal webbing or persistent asymmetries, or revise scars that are unsatisfactory. These revisions will improve functionality and the concluding result for the affected role and might not differently be addressed .

Immediate postoperative considerations

Gauze carry or a stenting device is placed in the vagina intraoperatively and remains in stead for 5-7 days. once removed, the affected role is instructed in vaginal dilation, with dilators broadly provided by the surgeon ; dilation schedules vary between surgeons. table 1 shows sample postoperative instructions, and Table 2 shows dilation instructions and a sample distribution dilation schedule.

Table 1. Vaginoplasty Postoperative Instructions
Focus area
Instructions
Source: Brownstein & Crane Surgical Services
Activity
Avoid strenuous activity for 6 weeks. Avoid swimming or bike riding for 3 months.
Sitting
For the first month post-op, sitting may be uncomfortable, but not unsafe. Recommendation to use donut ring to relieve pressure at surgical site.
Bathing
Resume showering following first postoperative visit, patting incisional areas dry. Do not take baths or submerge in water for 8 weeks post-op.
Swelling
Labial swelling is normal and will gradually resolve 6-8 weeks postoperatively. Swelling may be aggravated with long-term sitting or standing. For the first week post-op, applying ice on the perineum for 20 minutes every hour can assist in relieving some swelling.
Sexual intercourse
You may resume sexual intercourse 3 months after surgery, unless you have been instructed otherwise.
Hygiene
Wash hands before and after any contact with the genital area. Shower or wash daily. When washing, wipe from front to back to avoid contamination by bacteria from the anal region. Avoid tight clothing; friction may facilitate bacteria transfer.
Vaginal discharge
Vaginal discharge that is brownish yellow should be expected in the first 4-6 weeks postoperatively. Bleeding and spotting should be expected in the first 8 weeks postoperatively. Soap and water douche should help reduce this. Chamomile or lavender liquid soap can help cleanse the neo vagina as well.
Tobacco/smoking
Avoid tobacco use or smoking 1 month postoperatively, as this can interfere with the healing process.
Diet/nausea/constipation
Begin with a liquid diet and increase to your usual diet as tolerated. Anti-nausea medication may be prescribed. Narcotic pain medication may cause constipation; a stool softener such as Colace can help prevent constipation.
Pain medication
Postoperative pain is normal, and pain medication may be prescribed. Pain medication is to be taken as prescribed, and can be switched for Extra Strength Tylenol at any time.
Dilation
Dilation is an important part of recovery. Dilators may be provided to patient with instructions regarding dilation in the post-op period.

Dilation Instructions

Source: Brownstein & Crane Surgical Services
Please be aware that each person ‘s dilation schedule may vary .

  • Prior to insertion into the vagina, ensure the dilator is clean.
  • Clean the dilator with warm water and antibacterial soap. Rinse well and dry with a clean paper towel or cloth.
  • Apply Surgilube or KY Jelly to the dilator prior to insertion. Only use water based lubrication.
  • Avoid silicone-based lubricants.
  • Gently insert dilator into the vagina at an angle of 45 degrees until under the pubic bone, and then continue inserting straight inward.
  • Expect to feel a small amount of resistance and tenderness. Stop immediately if there is too much resistance or severe pain.
  • Insert the dilator into the full depth of the vagina (until you feel moderate pressure or resistance) and leave in place for 10 minutes. You should be inserting until only one or two white dots remain outside of the vagina.
  • Start dilating three times daily for three months on the day the vaginal packing is removed.
  • You may start using the next size dilator after three months of dilating. You should use the next size for three months.
  • Dilation frequency: 0-3 months after surgery 3 times/day for 10 minutes each time, 3-6 months after surgery 1/day for 10 minutes each time, more than 6 months after surgery 2-3/week for 10 minutes each time, more than 9 months 1-2x/week.
  • If the vagina begins to feel tight, increase the frequency of the dilation schedule.
  • You should use soap and water to cleanse the vaginal canal after each dilation.

Table 2. Vaginoplasty Postoperative Instructions
Months Since Surgery
Color of Dilator
Diameter of Dilator
Frequency
Source: Brownstein & Crane Surgical Services
0-3
VIOLET
1-1/8″
3X per day
3-6
BLUE
1-1/4″
Once daily
6-9
GREEN
1-3/8″
Every other day
9-12
ORANGE
1-1/2″
1-2x per week
immediate risks include shed blood, contagion, skin or clitoral necrosis, suture line dehiscence, urinary retention or vaginal prolapse. Fistulas from the rectum, urethra or bladder normally present early on .
Acute bleeding normally originates from the urethra and most often can be controlled with local imperativeness. If local blackmail is ineffective to achieve hemostasis, then placing a larger catheter ( 20F ) in the urethra alone may stop the run. If necessary, placing a suture around the bleed web site ( with the catheter in place ) will stop the shed blood in about all cases. It is not strange for set hematoma to ad lib drain through the vagina or suture production line. This normally occurs a week or greater after operation as the hematoma liquefy. The blood characteristically appears blue and old, and is not accompanied by clots. Although frightening to the affected role, no discussion is indicated .
The genitalia and perineum have an excellent blood add, so infections should be rare and rarely necessitate more than a broad-spectrum antibiotic. Skin slough or loss is besides rare, and should be treated conservatively. separation of the suture lineage can occur, most frequently at the posterior perineum due to the pressure and stretch that occurs with dilation. Separations should be treated conservatively with antibiotic ointment, most will heal without consequence. Dilation should not be discontinued, and is critical at this stage. failure to adequately dilate in the immediate postoperative menstruation will probably result in hard vaginal stenosis. No undertake at immediate secondary settlement of the dehiscence is indicated since it is a contaminated hurt and would likely fail. In some cases, dehiscence may result in the development of a back tooth world wide web, which can be easily revised at a late degree .
partial or complete clitoral necrosis may occur and should be treated conservatively with antibacterial ointments. In the majority of cases, the neurovascular package and a part of the clitoris is still stage and will normally maintain effective sensitivity .
urinary memory due to swelling and/or impermanent peripheral heart injury ( neuropraxia ) should be treated with substitute of a catheter for 5-7 days. Flomax is helpful, and this is about constantly temp. early strictures are very rare .
A patient may lose a fortune of the lend skin bribery and pass it out through the vagina. This normally occurs at least 2 weeks from surgery, and typically due to excessive skin grafting into the vagina. It is not accompanied with bleed and the shed skin appears nonviable. recovery is uneventful and patients should continue to dilate. A more austere scenario is ejection of the entire vaginal hide lining, which occurs earlier ( normally within the first postoperative week ) and is frequently accompanied with at least some bleed. While uncommon, in most cases it is a black complication and the patient will require surgical treatment, typically one year late to re-line the vagina.

Delayed / long-term postoperative maintenance and considerations

attachment to the dilation regimen is critical to healing and maintaining vaginal depth and cinch. After the initial curative period, dilation must continue regularly for at least one year postoperatively. The depth and the width of the vagina should be checked regularly as one tapers down the dilation agenda. If it is noticed that vaginal depth or width are diminishing either by affected role report or in-office interrogation, the dilation schedule should be increased. If the affected role experiences difficulty with dilation ascribable to discomfort, instillation of lubricant ahead of the dilator with either a 3cc syringe, or the applicator device supplied with vaginal antifungals may be helpful. Patients may develop a sensitivity to the preservative in the water based lubricant ; plainly changing the stigmatize of lubricant is frequently an effective solution .
Loss of vaginal girth due to inadequate dilation can frequently be remedied by increasing dilation frequency ; loss of vaginal depth is more unmanageable to address by dilation entirely. persistent pain or otherwise baffling dilation should be discussed with the surgeon. other potential causes of irritating or inadequate dilation include a small pelvic inlet or muscleman spasm and vaginismus. Approaches may include but are not limited to botulinum toxin injections, removal of webbing at the introduction of the vagina, and/or a referral to a physical therapist that specializes in pelvic trouble and pelvic floor issues .
The vagina is skin-lined and under normal conditions is colonized with a combination of hide plant angstrom well as some vaginal species ; a report of vaginal flora in a desegregate of transgender women with and without symptoms of smell and discharge found Staphylococcus, Streptococcus, Enterococcus, Corynebacterium, Mobiluncus, and Bacteroides species to be most common. Lactobacilli were found in only 1 of 30 women, and candida was not found. There was no correlation between the bearing of vaginal symptoms and any one particular species. [ 1 ] These findings suggest that vaginal release and olfactory property in transgender women is unlikely to due to common causes in non-transgender women such as bacterial dysbiosis or candida ; indeed the miss of a mucous membrane or low pH are coherent with this study ‘s findings of rare lactobacillus and no candida. In most cases discharge is most likely due to sebum, dead skin or keratin debris, or retained semen or lubricant .
Since the vagina does not contain a mucous membrane, routine cleaning or douching with buttery water should be adequate to maintain hygiene. initially the affected role should douche daily during frequent dilation. Douching can be reduced to 2-3 times a workweek when dilation is less patronize. If olfactory property or exhaust persists, an examen for lesions or granulation tissue should be performed. Use of a solution of vinegar or 25 % povidine tincture of iodine in water for 2-3 days may help in cases of plant overgrowth or imbalance, after which the affected role can return to unconstipated soap and urine clean. If the drain and olfactory property prevail, an empiric 5-day course of vaginal metronidazole is fair .
It is reasonable to consider a annual ocular pelvic examination to screen for lesions, granulation weave, or undesired loss of depth and cinch, though no evidence exists to support this recommendation. Since the vagina is clamber lined, there is a hazard of developing the like skin cancers that occur on the penile and scrotal skin ( squamous cell, basal cell, melanoma ). early skin disorders such as psoriasis can besides affect the vagina and should be treated similarly. If indicated, a prostate examination may be performed endovaginally since the rectal approach may be obscured by the new presence of the vaginal walls in between the rectum and the prostate gland .
A far less coarse approach to vaginoplasty is the function of either colon or little intestine to pipeline the vaginal vault. This technique has the advantages of diminished want for dilation, greater depth and is naturally self-lubricating. however, this border on requires abdominal surgery with a gamble of serious or even dangerous complications. The primary reading for an intestinal approach is the revision of prior penile-inversion vaginoplasties. Since the secretion is digestive there is a risk of malodor and frequent secretions, and secretions are constant rather than alone with arousal. Wearing pantie liners or pads may be necessary for the long condition. bacterial overgrowth ( diversion colitis ) is coarse and may present with a green release, treatment includes. The intestine line is besides not adenine durable as skin. Use of intestinal tissue besides places the vagina at risk of diseases of the intestine including inflammatory intestine disease, arterio-venous malformations ( AVM ) or neoplasms ; screening or diagnostic evaluations for these conditions should be performed as indicate .

Fistulas

The most coarse fistula is a rectovaginal fistulous withers. These normally occur at the midplane within 5 centimeter of the vaginal opening, and are about universally the result of a surgical injury to the rectum. Small fistula may only pass fart, while larger fistulas can allow stool to drain through the vagina. A temp amusing colostomy may be required for hygiene. Dilation should continue to avoid blockage of the vagina, with the plan to repair the fistula in a minimal of 6 months .
Urethrovaginal fistulas present with urine escape from the vagina. The majority of cases do not need or require immediate interposition, and in most cases the affected role will hush be celibate. The patient should be counseled that they will be more susceptible to urinary tract infections — particularly after intercourse. Voiding promptly after intercourse and/or acidifying the urine with juices or cranberry pills is normally adequate preventive care. Fistulas between the bladder and vagina are the least common, but are the most difficult to manage. A foley catheter in the bladder will divert a majority, but not all of the urine ; in general surgical treatment will be required.

Granulation tissue

Granulation tissue in the vagina is the leave of check curative and is common. The need for frequent dilation in the early post-operative period exacerbates the problem by causing repeated injury to the area of granulation. The typical charge is of mildly blood-streaked yellow fire. In most cases this will heal as the need for frequent dilations diminishes over time. If haunting, regular eloquent nitrate treatments and topical treatment of steroid hormone cream ( triamcinolone ) or medical grade honey ( Medihoney ) will speed the mend. Silver nitrate can be applied to granulation areas until cautery is observed with result grey scabbing and curdling. steroid cream or honey can be applied on the tip of the dilator. long term, the penile hide lined vagina should be very durable .

Urinary tract infections (UTIs)

urinary tract infections are not uncommon, since the urethra is shortened during a vaginoplasty. Proper hygiene and hydration are by and large adequate preventive measures. A patient who has perennial urinary tract infections should be evaluated for a urethral stenosis. A elementary diagnostic test is to attempt to pass a 16F catheter into the bladder to rule out strictures, including post-bulbar or meatal stenosis. Patients with a mucosal dither causing a large meatus will require meticulous hygiene and possibly prophylaxis. Most patients will see a reduction in their ability to hold larger volumes of urine over longer times as a consequence of the engagement of the prostate. rarely some may even experience urgency incontinence. Bladder relaxants like tolterodine or darifenacin are helpful in these cases .

Sensation and orgasm

No major sensational nerves should have been divided during operating room, so sensitivity should not be adversely affected after vaginoplasty. In an result study published in 2002, 86 % of the author ‘s patients were orgasmic. [ 2 ] Pre-operative functionality is an important indicator, though it is possible that a previously anorgasmic patient will be orgasmic following vaginoplasty. The combination of drawn-out estrogen/anti-androgen therapy and orchidectomy during operation may result in a report decay in libido for some patients, which is discussed elsewhere in these guidelines .

References

  1. Weyers S, Verstraelen H, Gerris J, Monstrey S, dos Santos Lopes Santiago G, Saerens B, et al. Microflora of the penile skin-lined neovagina of transsexual women. BMC Microbiol. 2009;9(1):102.
  2. Lawrence AA. Factors associated with satisfaction or regret following male-to-female sex reassignment surgery. Arch Sex Behav. 2003 Aug;32(4):299-315.

 

Leave a Reply

Your email address will not be published.