Metoidioplasty
What exactly does metoidioplasty involve? How to prepare for your operation and what to expect after the operation? Below, you can read about the procedure, the risks of the operation and the period after the operation. The illustrations give you more insight into the surgical procedure itself.
About the metoidioplasty
The metoidioplasty is an operation in which a penis of below-average size is created from your own genitals. In this operation, a scrotum is created at the same time. The operation is only possible when the clitoris has grown sufficiently through the use of hormones.
The small penis can be created with or without a urethral extension. In a metoidioplasty without urethral extension, you urinate from behind the scrotum. Without urethral extension, the vaginal tissue will be preserved. With urethral extension, the urethra usually ends at the tip of the penis. Metoidioplasty with urethral extension is more likely to cause complications than without urethral extension. In addition, the extension does not guarantee the ability to urinate standing up.
(Just to be clear, the metoidioplasty is NOT in preparation for phalloplasty; the two procedures are completely different operations).
In order to be eligible for metoidioplasty, you first need to be well informed and meet a number of criteria. You can read more about preparing for metoidioplasty here. Clarifying information about metoidioplasty can be found in Amsterdam UMC's animation video.
The operation
The metoidioplasty is carried out by a plastic surgeon and, in the case of a urethral extension, a urologist. The operation takes 3 to 4 hours, depending on the technique.
With both techniques (with and without urethral extension), the penis is made by stretching the clitoris and folding the surrounding skin around it. The scrotum is created using the skin and fat from the outer labia and mons pubis. Also, in both cases, a draining tube (catheter) is inserted through the urethra to drain urine.
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.Metoidioplasty without urethral extension
First of all, the clitoris and the inner and outer labia are cut free (a). The clitoris is pulled up to make the penis (b). Then the outer labia and the skin of the mons pubis are brought together and sutured to make the scrotum (b and c). A penis has thus been created with the urethra positioned below the scrotum (d).
Metoidioplasty with urethral extension
In the case of the metoidioplasty with urethral extension, in addition to the urinary catheter, you will also receive a bladder catheter that is inserted through the abdomen, in addition to the urinary catheter. Also in this procedure, the clitoris and inner and outer labia will be cut free (a). The urethra is extended with skin from the inner labia or oral mucosa. The clitoris is pulled up to make the penis (b). Subsequently, the outer labia and the skin of the mons pubis are brought together (b) and sutured to construct the scrotum (c). This creates a penis with urethra and scrotum (d).
NB. An extended urethra is no guarantee of being able to urinate standing up.
Aftercare
After the operation, you will have regular check-ups with the plastic surgeon and urologist. The plastic surgeon will check the appearance and the wounds on the penis. The urologist will continue to monitor your urethra and urinary function after surgery both with and without urethral extension. The urologist will do so using urine samples and questionnaires. If any complications occur, you will need to go to hospital more often. You should care for catheters and wounds as explained by the nurse.
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 4 to 6 weeks. This is to prevent the stitches from dissolving too early and you getting infections in the wound. Brief showers are allowed. You are not allowed to exercise or lift heavy objects for six weeks, as this may cause bleeding or the build-up of excessive fluid. In addition, you will need to wear tight underwear/net briefs for six weeks so that the penis will hang straight down.
You are strongly advised not to smoke for at least three months after the operation. You should care for catheters and wounds as explained by the nurse.
Clarifying information about aftercare, results, and complications can be found in this animation video from Amsterdam UMC.
Complications and risks during and after the operation
Medical complications may arise during or after the procedure, even though the operation was performed correctly. The risk of complications depends on your health and the technique used. A metoidioplasty with urethral extension carries more than 50% risk of complications. For a metoidioplasty without urethral extension, this is 5%.
Problems with wounds
- Haemorrhaging usually occurs immediately after the operation. Depending on how severe the bleeding is, a second operation may be necessary to stop it.
- Wounds may open, for example, because sutures come apart prematurely. You must take good care of the wound, because re-suturing is not possible.
- Particularly around the sutures, wound healing can become impaired. This often happens to smokers, but sometimes also to non-smokers. This type of wound will generally heal by itself, but it can take a long time. Rinse the wounds regularly with lukewarm tap water and pat the area dry.
- Although the procedure is done in a clean and sterile way, there is always a chance of bacteria entering the wound and causing an infection. This can also happen later, once you are at home. Therefore, it is important that you take good care of your wounds. If the skin around the wound becomes warm and red, if the wound starts to fester or if you get a fever, this may be an indication of the wound being infected and you should contact the plastic surgeon.
- 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 blood circulation can already be observed during the operation, in which case the surgeon will improve the circulation. It also may occur after the operation and will usually recovers by itself, but sometimes a repair operation will be necessary.
Urination problems
- Narrowing of the urethra (stenosis) may make it difficult to urinate. Stenoses are treated by regularly stretching the urethra, over a number of weeks or months, which is done at the outpatient clinic or by yourself. Sometimes, surgery will be required. The risk of stenosis in cases without urethra extension is 5%, whereas with urethra extension, this is more than 50%.
- The extended urethra may find an opening to the outside, causing urine to leak out of this opening. This is called a fistula. Sometimes, the opening will heal on its own, but it can also require surgery to correct this situation. Without urethra extension, the risk of a fistula is 5%, whereas with such an extension, this risk is over 50%.
- Even after a successful urethral extension, leakage is common. The outpatient clinic can provide information and give you instructions on how to massage the urine out of the urethra.
Loss of feeling
There is a small risk of nerve damage from the operation, which can make the penis less sensitive or even insensitive. Nerves take months to recover. If they do not recover within a few months, the chances of feeling in the penis returning are slim.
Bowel problems
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.
End result and secondary corrections
End result
The end result will be different for everyone, which is why you cannot request a certain appearance of your penis, in advance of the operation. The length and width are determined by the size of the clitoris.
You will have scars after the operation that are hidden within skin folds and are therefore not immediately noticeable. The production of scar tissue varies from person to person, from skin type to operation technique. Everyone and their skin heals in its own way. Scars will heal less well in overweight people and smokers than in non-smokers with a healthy body weight.
Secondary corrections
There may be various reasons why you are not completely satisfied with the appearance or function of the genitals after the operation. You are advised to wait at least a year for any secondary corrections.
Prosthetics
After genital surgery for masculinisation, prosthetics can be placed. Prosthetic testicles are possible after a metoidioplasty,
Sexuality
Sexuality remains important for many people after the metoidioplasty. Once your penis has healed sufficiently, you will be able to have sex. The guideline is three months after the operation; we advise you to discuss this during the follow-up examinations with the plastic surgeon.
Most people are able to experience sexual arousal and orgasm after a metoidioplasty, both when masturbating and with a partner. Many are satisfied with their sexual life, but this is not true for everyone. Penetration is almost always out of the question, so if that is important to you, metoidioplasty is less suitable for you.
Familiarising yourself
However, your sexual life depends not only on a metoidioplasty, but also on many psychological and biological factors. Becoming familiar with your penis (sexually speaking) and learning to use it 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 7-10-2022
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Phalloplasty
Phalloplasty is a surgery in which a penis is made with tissue from elsewhere in your body. The technique depends on your physical characteristics and desires.
