General Information
What is gender-affirming bottom surgery?
Some patients with gender dysphoria desire removal of male genitalia (penis, testes, scrotum) and construction of female genitalia (clitoris, labia, vagina).
Goals of this surgery include gender affirmation, maintenance or enhancement of sexual and urinary function, increased comfort and safety in public settings, and receptive vaginal intercourse.
Types of bottom surgery include:
Orchiectomy +/- scrotectomy - removal of the testicles with or without removal of the scrotum.
Undergoing orchiectomy DOES NOT affect future vaginoplasty/vulvoplasty options, however removal of the scrotum does limit options for vaginal canal creation.
Minimal depth vaginoplasty / vulvoplasty - creation of external female genitalia without creation of a vaginal canal.
Robotic peritoneal flap vaginoplasty (RPFV) - creation of external female genitalia with a full depth vaginal canal that is augmented by peritoneum.
Penile inversion vaginoplasty - creation of external female genitalia and use of the penile skin alone to create a vaginal canal.
Colon vaginoplasty - creation of external female genitalia and creation of a vaginal canal with colon.
Personalized surgery (ie: phallus-preserving vaginoplasty) - offered on a case-by-case basis. Discuss with your surgeon.
What is minimal depth vaginoplasty (vulvoplasty)?
Vulvoplasty is a procedure done for create external female genitalia.
The clitoris is created out of the glans (head) of the penis.
The erectile bodies within the penile shaft are removed.
The penile skin is used to create labia minora.
The urethra is shortened to the level of the skin so you will urinate sitting down.
The testicles are removed. Please let us know if you are interested in fertility preservation, as removal of the testicles will make you infertile.
The scrotum is used to create the labia majora.
No dilation requirement.
No hair removal requirement.
Preparing for Surgery
What must be done or ready prior to my surgery?
Most insurances require two letters of support - one from your hormone provider (endocrinologist or PCP) and one from your mental health provider.
These letters must be dated within 1 year of your surgery date.
Double check your insurance requirements here or reach out to your insurance carrier directly.
Plans differ in terms of letter and hormone requirements. Make sure you follow their guidelines in order to avoid delays with scheduling surgery
BMI <35.
Nicotine test must be negative – this is done typically done about 8 weeks prior to your scheduled surgery.
You do not need to stop your hormones.
Establish care with a pelvic floor physical therapist.
General readiness and preparation
Appropriate expectations regarding external appearance.
Financially ready to take at least 6 weeks off work. 8-12 weeks is preferable, if possible. Check with your employer about short-term disability or medical leave.
Consistent and scheduled access to mental health care.
Housing stability and sufficient social support.
What will my hospital stay be like?
This surgery requires at least 5 days in the hospital.
Days 0-4 are focused on ambulation and pain control.
On day 4, the catheter will be removed from the bladder and the dressing will come off the vulva.
Discharge usually occurs on day 5.
Letters of Support
As per the guidelines set forth by the World Professional Association for Transgender Health (WPATH) in the Standards of Care (SOC) version 8, you will require 2 letters of support prior to your gender affirmation surgery. If you are undergoing vaginoplasty, vulvoplasty, phalloplasty, or orchiectomy, you need 1 letter of support from your mental health providers and an additional letter from your hormone provider (endocrinologist or PCP).
WPATH's SOC 8 serves as a comprehensive resource for healthcare professionals, ensuring that transgender and gender nonconforming individuals receive competent and compassionate care. In line with these guidelines, your readiness for gender affirmation surgery is typically assessed through the evaluation of referral letters from qualified mental health professionals as well as your hormone provider (if necessary). These letters should come from professionals who are knowledgeable about gender identity and experienced in providing mental health support to transgender individuals.
Surgery cannot be scheduled until all letters have been received and meet the requirements outlined in this document. Letters that do not follow the format below will be returned for completion. Please show this document to the provider(s) writing your referral.
RECOMMENDED CONTENT FOR MENTAL HEALTH LETTERS:
1. Description of the provider’s qualifications as well as the duration of their relationship with the patient. Include types of evaluation and therapy to date.
2. The patient’s general identifying characteristics.
3. Results of a psychosocial assessment, including all psychiatric diagnoses and accompanying psychiatric medications.
4. An explanation that the criteria for surgery have been met, and a brief description of the clinical rationale for supporting the patient’s request for surgery. Criteria include:
Confirmation of the patient's persistent gender dysphoria diagnosis.
Documentation of the patient’s capacity to provide informed consent.
If significant mental health concerns are present, they must be well-controlled.
5. Assessment of the patient’s understanding of the potential benefits and risks of gender-affirming surgery.
6. Evaluation of the patient’s overall mental health and ability to cope with the surgery and recovery process.
FOR HORMONE PROVIDERS:
1. Description of the provider’s qualifications as well as their duration of their relationship with the patient.
2. Duration and dosage of current hormone medications.
3. Confirmation that the patient has been on hormones for at least 6 months.
OTHER HELPFUL TIPS FOR LETTER WRITERS:
Each letter needs to specifically state the type of surgery that the patient is requesting (ie: vaginoplasty or orchiectomy).
Letters must be dated within 12 months of surgery date.
The letter must be signed. Insurance companies will not accept electronic signatures.
Each provider needs to submit a separate letter. One letter signed by multiple providers will only count as one letter.
Send your letters via MyChart so they can be uploaded into your chart.
Post-Operative Instructions
Wound Care
Shower using a mild foaming cleanser or gentle soap. Wash between all folds and creases. Gently pat incisions dry.
No baths or submersion in other bodies of water until all incisions are completely healed, usually around 4-6 weeks.
Remember to wipe from front to back after urinating or defecating.
Medications
Take Tylenol (acetaminophen) every 6 hours.
Take Motrin (ibuprofen) every 6 hours.
Tylenol and Motrin should alternate:
For example: Tylenol 12MN/6AM/12noon/6PM and Motrin 3AM/9AM/3PM/9PM.
Take Neurontin (gabapentin) every 8 hours for the duration prescribed (3 days) - this also helps with pain and is not a narcotic.
Only use the narcotic medication (oxycodone) for pain NOT relieved by the Tylenol, Motrin and Neurontin. An occasional sharp pain does not qualify as severe pain.
It is important not to become constipated.
Use gentle laxatives (Sennakot, Dulcolax or Miralax) as prescribed. You should hold the medications if stool is loose.
Constipation/straining can cause vaginal bleeding.
Do NOT use suppositories or enemas.
You may continue your estrogen at the same dose you were taking prior to surgery. Please see or speak with your hormone provider regarding resuming the hormone blockers (Aldactone).
Resume your home medications unless specifically advised otherwise.
Activity
Walking is good for you. Walk around every hour while you are awake. Balance activity with rest.
No more than one flight of stairs at a time. Take stairs slowly and carefully.
No lifting more than 10lbs for 6 weeks.
Avoid pushing, pulling or straining for 6 weeks.
No gym or strenuous physical activity for 6 weeks.
Diet
Resume pre-op diet.
Eat more fiber to prevent constipation. Foods like fruits, vegetables and whole grains have a lot of fiber.
Drink lots of water - aim for 2L a day.
Avoid excessive alcohol intake.
If You Are Sent Home with a Urinary Catheter
Empty the urinary drainage bag frequently during the day. Please keep the leg bag attached to your leg. Do NOT allow the bag to hang freely, as this will pull down on the catheter and cause pain.
Change to bedside drainage bag (larger bag) at night. The night bag holds more urine, and allows you to sleep through the night without having to get up to empty the bag.
Wash hands before and after manipulating the catheter.
You can shower with your catheter and drainage bag.
Increasing your activity may cause your urine to turn intermittently pink or bloody, which is normal.
Patients who have catheters often have the sensation of needing to urinate, even though the urine is draining through the catheter. This sensation is known as bladder spasms. If this sensation is especially painful for you, please contact the office and we can prescribe an additional medication.