Vaginoplasty for Gender Affirmation

Vaginoplasty is a surgical procedure for feminizing gender affirmation. Fan Liang, M.D., medical director, Johns Hopkins Center for Transgender Health, explains the surgery.

What is vaginoplasty?

Vaginoplasty is surgery to create a vagina. It involves removing the penis, testicles and scrotum.

Vaginoplasty involves rearranging tissue in the genital area to create a vaginal canal (or opening) and vulva (external genitalia), including the labia. To create the vaginal canal, the surgeon uses a combination of the skin surrounding the existing penis along with the scrotal skin. Depending on how much skin is available in the genital area, the surgeon may need to use a skin graft from the abdomen or thigh to construct a full vaginal canal.

How many stages are included in the procedure?

Vaginoplasty is typically a one-stage procedure. Some patients have their testicles removed (orchiectomy) before vaginoplasty, but this is not required. In fact, having the orchiectomy before your vaginoplasty can increase the risk of needing skin grafts.

Do I need to have hair removal before vaginoplasty? When should I start?

Yes, you will need to have permanent hair removal before surgery. The surgical team will provide you with a template during your consultation for the areas that require hair removal. Patients are advised to start hair removal as soon as possible, since it can take three to six months to complete the process.

Will I need any additional surgery after vaginoplasty?

You may need additional surgical procedures to revise the appearance of the new vagina and vulva. Later revisions can improve aesthetic appearance, but these are not typically covered by insurance.

Sometimes, patients experience complications related to vaginoplasty. These can include narrowing of the vaginal canal or a fistula (an abnormal connection between the new vagina and the rectum or bladder). These complications are typically treated with another surgery.

How long is vaginoplasty surgery?

Most surgeries last between seven and 10 hours.

Recovery After Vaginoplasty

After surgery, you will be admitted to the hospital for about five or six days. You will spend most of this time in bed recovering. As you get closer to discharge, you will begin sitting and walking around. Your care team will monitor your pain, and make sure you are healing appropriately and able to go to the bathroom and walk.

On average, it can take six to eight weeks to recover from a vaginoplasty. Every patient’s recovery is different, but proper home hygiene and postoperative care will give you the best chance for a faster recovery.

Will I have a catheter?

While you are in the hospital, you will have a Foley catheter in the urethra that will be taken out before you go home.

Will I have surgical drains?

Yes, your surgeon will place a drain while you are in the operating room, which will be removed before you leave.

What type of hygiene is required after vaginoplasty?

Starting eight days after surgery, you will begin douching (cleansing the vaginal canal). When douching, you must use a nonscented vaginal douche. You should douche at least once a week, depending on the amount of vaginal discharge you are experiencing. If you notice you are having a lot of vaginal discharge, you can increase your douching schedule.

It is also very important to keep the external genital area dry. If the area is looking very red and wet, like you were soaking in a tub too long, you can place an absorbent pad between the outer lips (labia) to wick away excess moisture.

Can I shower after vaginoplasty surgery?

Yes. It is very important to clean the area to prevent infections. You can gently wash the area with soap and water. Never scrub or allow water to be sprayed directly at the surgical site.

Is going to the bathroom different?

It is important to remember for the rest of your life that when wiping with toilet paper or washing the genital area, always wipe front to back. This helps keep your vagina clean and prevents infection from the anal region.

You may notice some spraying when you urinate. This is common and can be addressed with physical therapy to help strengthen the pelvic floor. A physical therapist can help you with exercises, which may help improve urination over time.

Is the vagina created by vaginoplasty sexually functional?

Yes. You must avoid any form of sexual activity for 12 weeks after surgery. Sexual activity during your recovery period can delay wound healing and cause complications. Twelve weeks after surgery, the vagina can be used for receptive intercourse. Additionally, the clitoris may have sensation.

How long does it take for sensation to come back?

Sensation is not guaranteed after vaginoplasty, but it is important to remember that this aspect of healing is different for every patient undergoing this procedure. Nerve function can return as early as three weeks after surgery. Sometimes this process takes a year or longer.

What is the average depth of a vagina after vaginoplasty?

The depth depends on patient preferences and anatomy. On average, the constructed vaginal canal is between 4 and 6 inches deep. Vaginal depth is dependent on the amount of skin available in the genital area before your vaginoplasty. This varies among individuals, and some patients may need skin grafts. Some patients may request a no-depth or minimal-depth vaginal canal, which is also possible.

What is dilation after vaginoplasty?

Part of the healing process after vaginoplasty involves dilation — inserting a medical grade dilator into the vagina to keep your vaginal canal open as it heals. The hospital may provide you with a set of different sized dilators to use.

A doctor or therapist from your care team will show you how to dilate. This can be difficult at first, but professionals will work with you and your comfort level to help you get accustomed to this aspect of your healing process. You will begin dilating with the smallest dilator in the dilator pack. You continue to use this dilator until cleared to advance to the next size by your care team.

During the first few weeks after surgery, you must dilate twice a day for at least 15 minutes. It is very important that you continue dilating, especially during your immediate postoperative period, to prevent losing vaginal depth and width. Patients continue to use a dilator for as long as the care team recommends. Some patients may need to dilate their whole lives.

Is dilation after vaginoplasty painful?

Dilation should not be a painful process. At first, you may feel discomfort as you learn the easiest angles and techniques for your body. If you feel severe pain at any time during dilation, it is important to stop, adjust the dilator, and reposition your body so you are more comfortable. It is also important to use lubricant when you dilate. A pelvic floor therapist can work with you to help you get used to this aspect of recovery.