Vaginoplasty
What is a vaginoplasty and what are the various techniques used? This section provides more information about vaginoplasty, what the procedure entails, and what to expect after the operation.
About vaginoplasty
Vaginoplasty is a procedure whereby a vagina is created with the use of your own tissue. The surgeon creates a clitoris, inner and outer labia and a vaginal cavity. The testicles and biological male sex characteristics are removed
There are three surgical techniques for vaginoplasty: penile inversion, vaginoplasty with skin graft, and bowel vaginoplasty. Bowel vaginoplasty is only chosen if certain physical characteristics make it necessary.
Vidual information about the vaginoplasty operation, complications, and pelvic floor and vaginal care can be found in these animation videos.
Before undergoing surgery, it is important that you are well prepared. Information on how to prepare for a vaginoplasty can be found here.
Surgical methods
There are three surgical methods for vaginoplasty (vaginal cavity with depth):
In most cases, the testicles are removed during this operation, but in some cases this is done previously. Depending on the surgical method used, the operation will last anywhere between 3 and 5 hours.
Note that the details of the surgical procedure may differ for any Dutch care facility. It is, therefore, important to check the exact procudure with the institute where you are having surgery.(1) Penile inversion vaginoplasty
During the vaginoplasty with penile inversion, a vagina is created from the skin and underlying tissue of the penis.
This technique is used when the skin of the penis is of sufficient length and size. Usually, a penis of average length and width will be sufficient.
The operation is performed by the plastic surgeon. First, a urinary catheter is inserted, which is a small drain that is inserted through the urethra. Then an incision is made along the length of the scrotum. Inside this incision the surgeon will make room for the vagina, between the bladder and the intestine.
The penile skin is removed from the shaft of the penis; this skin is still well perfused and sensitive and is subsequently packed into the vaginal cavity and then sutured. In this way, it forms the inside of the new vagina.
Subsequently, the testicles are removed (castration). The clitoris and inner labia are created from the glans and the foreskin. The urethra is freed up and shortened up to the new entrance. Soon, a GIF will be presented below to illustrate the surgical procedure. Untill then, you can watch this animation video about vaginoplasty at Amsterdam UMC.
To allow the skin of the vaginal cavity to heal comfortably and in the correct position, a tampon is inserted that consists of a condom filled with gauze, which is then sutured in place. The tampon remains inserted for 5 days, after which it will be removed by the physician.
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(2) Penile inversion vaginoplasty with skin grafting
Vaginoplasty using skin grafts is performed when the penis is too small to create a vagina of sufficient depth. The surgical technique with skin grafts is very similar to that of penile inversion.
The difference is that, in order to create a vaginal cavity of sufficient depth, the penile skin is extended by a skin graft. The skin graft is taken from the scrotum, groin or lower abdomen. Soon, a GIF will be presented below to illustrate the surgical procedure. Untill then, you can watch this animation video about vaginoplasty at Amsterdam UMC.
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(3) Bowel vaginoplasty
Bowel vaginoplasty is performed in cases where there is insufficient skin for a penile inversion or skin grafting technique. For example, if puberty inhibitors have caused the penis to be underdeveloped or very small, or if previously a vulvoplasty was performed. In this procedure, a piece of the intestine is taken, using laparoscopy, to create the inner lining of the vagina. This operation is performed by a plastic surgeon and gastrointestinal surgeon, who are specialised in such laparoscopic procedures.
The bowel vaginoplasty and penile inversion techniques lead to basically the same result, in terms of appearance. The only difference is in the tissue that is used for the vaginal cavity. When the penile skin is short, the bowel is visible on the outside of the vulva around the entrance to the vagina.
First, three small incisions are made below the navel: one to insert a camera and two to operate through. At the same time, the plastic surgeon starts to insert a urinary catheter (a small tube that is inserted through the urethra). Next, the plastic surgeon will makes an incision along the length of the scrotum. This incision provides access to the pelvic floor and creates a cavity between the rectum and the urethra/bladder.
The gastrointestinal surgeon then removes a piece of intestine of about 15 cm long, which is transferred to the pelvic floor.
The penile skin is removed from the shaft of the penis; this skin is still well perfused and sensitive. Then the testicles are removed (castration). The clitoris and inner labia are created from the glans and the foreskin. The urethra is freed up and shortened up to the new entrance. The piece of bowel is brought out and connected to the skin of the penis. With this operation, it is not necessary to leave a tampon in the vaginal cavity.
Soon, a GIF will be presented below to illustrate the surgical procedure. Untill then, you can watch this animation video about vaginoplasty at Amsterdam UMC.
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Aftercare
Depending on the health institute, you must stay in bed for 1 to 3 days, and you will remain in the health institute for 3 to 5 days. Bed rest is recommended for proper wound healing and decrease of swelling. If a wound drain has been inserted (to drain blood and wound fluids), this will be removed 1 to 3 days after surgery.
The catheter will be removed at the day you will leave the health institute, after which you should be able to pass urine properly within a few hours. After urination, your bladder will be scanned to make sure it is empty. If your bladder is not empty enough, the catheter is replaced and will be removed again after 1 or 2 weeks.
It is often advised to wait until the wounds are completely closed before swimming, taking a bath or going to the sauna. This often takes at least 6 weeks. This is to prevent the stitches from dissolving too early and you getting infections in the wound. Short showers are allowed. You may not exercise or lift heavy objects for six weeks, as this may cause bleeding or excessive fluid production.
You will also be taught how to dilate with the dilator kit that you purchased before the operation.
You will be discharged from hospital as soon as you are able to correctly perform dilation and use a vaginal douche, and can urinate properly.
Hormone use after the operation
After the operation, you will stop taking testosterone blockers. You will only continue taking oestradiol. The hormone treatment following the surgery will be supervised by the endocrinologist.
More information about aftercare following surgery can be found here.
Complications and risks during and after surgery
Problems (complications) may occur during or after the operation, irrespective of whether the procedure was performed correctly. The likelihood of complications depends on your health and the technique used. There is a higher risk of complications with the bowel vaginoplasty than with the penile inversion or skin grafting technique.
- Bleeding: This may occur immediately following the operation. If the bleeding does not stop on its own, a second operation may be necessary.
- Infection: Although surgical procedures are done in a clean and sterile way, there is always a chance of bacteria entering the wound. In the period following the procedure, there is also a risk of infection. That is why it is so important to take good care of the wound.
- Blood suffusion (haematoma): Some blood may accumulate in the surgical area, which may give the area a slightly blue or purple appearance, like a bruise. This will go away by itself after 2 to 4 weeks.
- Fluid retention (oedema or seroma): Fluid may also accumulate in the surgical area. If this starts to feel uncomfortable, the fluid can be removed by your physician.
- Badly healing wound edges (wound dehiscence): After the operation, the wounds may not heal immediately, and the would edges may open up a little. Should this happen, we recommend that you rinse the wound thoroughly with running water and, if necessary, contact your physician.
- Necrosis: If there is insufficient perfusion in part or all of the skin, tissue will die off. This is what is known as wound necrosis. Sometimes, poor circulation can already be observed during the operation, in which case the surgeon will improve the circulation. Smokers have an increased risk of this type of complication. Whether or not another operation is necessary will depend on the severity of the skin loss.
- Bowel problems – constipation: The intestines come to a halt or become blocked, so that the contents can no longer be moved. This may be a symptom of what is called an ileus. Usually, medication can help to restore bowel movement. It is also important to drink enough fluids and to exercise.
- Hypergranulation: Hypergranulation is a common problem. It is benign, but does involve a sizeable loss of fluids or blood. It may also have a certain odour and be painful, but it is easy to treat.
- Bowel problems — perforation: A small hole may appear in the rectum. If this is noticed during the operation, it can be treated immediately. Sometimes, this is discovered at a later stage. A small hole will usually heal by itself. If a perforation of the rectum leads to long-term complaints, another operated will be required.
- Urethra problems: Some weeks or months after surgery, narrowing (i.e. stenosis) of the urethra exit may occur. As a result, some people find it more difficult to urinate: the stream becomes weaker and they have to exert more pressure. Stenoses are treated by regular stretching over several weeks or months; in some cases, surgery may be required.
- Loss of feeling/orgasm: you may loose all or some sensation in your genitals. Whether or not sensation will be restored is uncertain.
- Scarring: The growth in scarring tissue differs per person, skin type and surgical method. People and skin types all heal in their own way. Being overweight or a smoker means that wounds will heal less pretty than in healthy non-smokers. Sometimes, a scar can be corrected (one year or more after the operation).
Possible complications following bowel vaginoplasty
- Bowel problems – wound leakage. With bowel vaginoplasty, it is possible that the sections of intestine that have been joined together do not heal properly and cause leakage, which results in faecal matter entering the abdominal cavity. This soon causes abdominal pain and fever, in the first 2 to 3 days after surgery. This requires urgent surgery to repair the leakage.
NB: In case of serious leakage or a hole in the rectum that will not heal, a stoma may need to be installed temporarily (for a minimum of 3 months).
End result
The final result will not be visible until after six months. Complete healing takes time. The swelling and discolouration will slowly subside. The vagina will form naturally after the operation and will adapt to your body shape. For example, the colour of the scrotum and the amount of fatty tissue determine what the genitals will look like. The end result is different for everyone.
Corrections
Perhaps, after the operation, you are not completely satisfied with the appearance or function of the genitals. You can discuss this with your plastic surgeon or urologist. They will be able to tell you whether an additional operation could lead to improvements.
Corrections may, for example, be a reduction of the inner labia, correction of the clitoral hood, removal of large scars or a correction of the urethra.
In principle, corrections are not performed within 6 months of the first operation. It is advisable to wait at least one year. Whether such corrections will be covered by your health insurance company varies per situation.
Sexuality
Sexuality remains important for many people after vaginoplasty. Once your vagina has healed sufficiently, sex and penetration are possible. Most people are able to experience sexual arousal after a vaginoplasty; 80% are able reach an orgasm.
Sex drive (libido) depends on the hormone testosterone — regardless of gender. As your body no longer produces testosterone after your testicles are removed, this may have an impact on your libido.
However, your sexual life depends not only on genital surgery, but also on many psychological and biological factors. Becoming familiar with your genitals (sexually speaking) and learning to use them in a pleasurable way are important challenges after genital surgery.
It is important that you discover what gives you sexual pleasure and that you discuss this with your potential partner/partners.
This text was edited on 14-10-2022
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Aftercare
What does the recovery period look like after being discharged from the hospital? Here, you can read about the best way to take care of yourself and what you can do to speed up the healing process.
