Vaginoplasty
Legend
What is vaginoplasty?
Vaginoplasty is a gender-confirming surgery for transgender women in which a vagina is created using their own tissue. The vagina can be created using various techniques, and the choice of technique depends on physical characteristics and personal preferences.
After vaginoplasty, you will need to maintain the vaginal cavity through dilation and internal irrigation to preserve the functionality of the vagina.
During vaginoplasty, the testicles are removed. Removal of the testicles can lead to a decrease in libido and will result in permanent infertility.
What is vulvoplasty?
Vulvoplasty is a surgery in which a shallow vagina (without depth) is created using the patient’s own genital tissue. Externally (on the outside), a shallow vagina looks the same as a vaginoplasty. The recovery time for vulvoplasty is shorter than for vaginoplasty. Since the vulva does not have any depth, there is generally no need to irrigate or dilate the vulva.
As with vaginoplasty, the testicles are removed, which can result in a reduction in libido and permanent infertility.
Vulvoplasty creates a shallow vagina. Externally, it resembles a normal vagina with a clitoris and labia, but the inside is only about 1 cm deep.
Differences from vaginoplasty:
- Recovery time: vulvoplasty has a faster recovery time than vaginoplasty (either penile inversion or colon vaginoplasty).
- No need for dilation or irrigation: since the vulva has no depth, dilation or irrigation is not necessary. Only the wound is irrigated until it is closed after the surgery.
Pelvic floor physiotherapy
It is advisable to consult a pelvic floor physiotherapist before vaginoplasty surgery. The physiotherapist will teach you how to actively and consciously relax the pelvic floor muscles. Sometimes, the pelvic floor muscles are unconsciously tensed, making it difficult to relax them intentionally. It is important to have conscious control over the pelvic floor muscles to facilitate urination and defecation. Furthermore, relaxing the pelvic floor muscles post-surgery is crucial for dilation (keeping the vaginal cavity open) and promoting wound healing.
Preparation for surgery
For safe surgery and the best results, it is essential that you do not smoke and have a healthy weight with a BMI >18 and ≤30. Your testosterone levels should also have decreased sufficiently (<2 nmol/L). It is important that the genital area is permanently hair-free.
All the preconditions and further explanations are set out in our brochure, which will be given to you before the surgery. The brochure also includes information about items you may need to purchase in preparation for the post-surgery period, such as a dilation set.
Suggested purchases
To prepare for the post-surgery period, you may want to buy the following items:
- Cotton sanitary pads, without chemicals. Preferably a store brand or brands such as Kotex.
- Loose (baggy) underwear or a mesh garment.
- Extra towels and clean bedding for home. We recommend old bedding due to potential stains from fluid and blood loss.
- Paracetamol. If necessary, ibuprofen (in which case you will also need stomach protectors).
The surgery and surgical techniques
We perform several surgical techniques at our Gender Clinic. The surgery typically lasts 1 to 3 hours, depending on the technique used. The hospital stay is 3-5 nights.
Penile inversion vaginoplasty
Penile inversion vaginoplasty can be performed if the penile skin is of sufficient length and size (an average-sized penis will typically be sufficient). In this technique, the vagina is created from the skin and underlying tissue of the penis.
Vaginoplasty with skin graft
Vaginoplasty with skin grafts is performed if the penis is too small to create a vagina with sufficient depth. This technique uses skin grafts, such as pieces from the scrotum, groin, or lower abdomen. These skin areas usually provide ample tissue.
Vulvoplasty
Vulvoplasty creates a shallow vagina from the skin and tissue of the penis. No vaginal cavity is created. The surgery is performed by a plastic surgeon.
During the surgery, the surgeon first inserts a urinary catheter via the urethra. A catheter is a tube through which the urine is drained. The testicles are then removed.
Next, a small incision is made in the perineal muscle to shape the vulva to look like a real vulva, but the incision is not deep.
The surgeon then detaches the skin of the penis from the underlying tissue, leaving only the part near the pubic bone intact. The glans and foreskin of the penis are used to create the clitoris and the labia minora. Using the existing nerve pathways and blood vessels preserves sensation in those areas.
The urethra is freed and shortened to the new vaginal opening and sutured in place. The erectile tissue is also removed.
The skin of the penis is then shortened, folded over, and sutured in place to resemble a vagina (but without the depth). The remaining penile skin is used to form the labia majora.
About the surgery
Even when the surgery is performed correctly, unintended medical issues (complications) can arise, such as post-operative bleeding, necrotic tissue, and urinary problems. The risk of complications depends on your health and the technique used.
Possible complications
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Pain |
Necrotic tissue (necrosis) |
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Wound dehiscence (open wounds) |
Postoperative bleeding |
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Infection |
Urethral stricture (stenosis) |
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Granulation tissue (hypergranulation) |
Difficult urination (catheterisation) |
Day before surgery:
Do not eat or drink after 12:00 AM, unless instructed otherwise. You can drink a small amount of water up to 6 hours before the surgery.
Do not wear underwear or socks under the surgical gown. Remove jewellery, piercings, and dentures or dental plates. If you wear a wig, it must be removed.
Day of admission:
On the day of surgery, you will be admitted to our clinic. Blood tests will be performed. The plastic surgeon will meet with you, and you will receive a blood thinner injection to prevent thrombosis. This will be administered daily during your hospital stay. You will also begin taking a laxative.
Post-surgery (in our clinic):
After surgery, you must stay in bed for one day. You may sit upright and lie on your side with a pillow between your legs. A nurse will assist with personal care. Your blood will be tested, and your wound will be irrigated twice daily by the nurse.
Two to three days after surgery, you may begin mobilising: you can go to the toilet and try to take a shower.
Do you have wound drains? Then it will be assessed whether they can be removed.
After four days, you can try to manage your personal hygiene and wound care independently.
After five days, the urinary catheter will be removed, as well as any vaginal packing (tampon) that was inserted.
Afterward, an examination of the vagina will be performed using a speculum (commonly called a "duckbill").
After the catheter is removed, you must be able to urinate adequately. To assess this, a bladder scan will be performed to check whether your bladder is emptying properly.
If you are unable to sufficiently empty your bladder, the catheter will be reinserted. In that case, it will typically be removed again after approximately two weeks.
If you have undergone penile inversion vaginoplasty:
You will receive instructions on how to keep the neovagina open (dilation) and how to rinse the vaginal cavity internally (vaginal irrigation).
At discharge
Once you are able to adequately rinse and dilate the vagina, and are able to urinate without difficulty, you will normally be discharged. Your doctor will make this decision.
Follow-up care
Two to three weeks after surgery, you will have a follow-up appointment with a physician or physician assistant.
You will be given supplies for vaginal irrigation. You will also be given prescriptions for any medication needed, which you can collect at your own pharmacy.
Shortened hospital stay with return visit
Under certain conditions, a shortened hospital stay is possible. Your plastic surgeon will discuss this with you prior to surgery.
- On day 2, you may start mobilising.
- On day 3, you may be discharged.
- On day 5, you will return for unpacking and your first dilation.
After vaginoplasty, the neovagina requires a great deal of care and attention. Pain and discomfort are still to be expected.
Key Points
Rinse the surgical area twice daily using lukewarm water in the shower, and gently pat dry.
The stitches
The stitches are dissolvable and will break down over time (weeks to months).
Sometimes, the stitches may come loose and the wound edges may part slightly. This is known as wound dehiscence. It often occurs near the vaginal or vulvar entrance, where the skin is moist and under tension.
These wounds usually heal on their own after a few weeks.
Fluid and blood around the wound
As long as the wounds are open, they may leak wound fluid, sometimes mixed with (old) blood. This will stop once healing is complete.
You may use sanitary pads to absorb the fluid — replace them regularly. Allow the area to air dry if at all possible.
If you see a yellow layer on the wound, do not rinse it off! This is not pus, but protein deposits that promote healing.
Necrotic tissue and unpleasant odour
Small pieces of skin from the labia or vagina may die and detach, which can produce a foul smell. These areas will form wounds that will also heal naturally.
Keep the area clean as described above. Do not worry — necrosis does not spread in this case.
Even if you have wound issues, it is important to stay mobile and continue dilating.
Secondary corrections
You may feel dissatisfied with the aesthetic or functional results of the vaginoplasty. Discuss this with your plastic surgeon.
They will inform you if there is a corrective procedure that might improve the outcome.
Depending on the extent of the revision, it may be done under local anaesthesia or require general anaesthesia.
Revisions are not generally performed within six months of the initial surgery.
Once you’re home, it’s important to follow certain instructions to aid recovery.
Full recovery takes several weeks — typically around six.
You must care for the wounds yourself.
- Do not lift heavy objects or engage in intensive exercise for the first six weeks. Gentle movement and walking are encouraged to support recovery.
- Cycling will not be possible for the first three months. You will feel when it’s appropriate to resume.
- Sit preferably on a hard chair, as this provides counterpressure, reducing swelling and improving circulation.
- Short showers are fine, but no baths, swimming, or saunas until the wounds have fully healed.
- Wait with sexual activity until the wounds have fully healed. Get to know your new genitalia before engaging in sexual contact with others.
Pain management and medication
- Painkillers – Paracetamol (acetaminophen) will often be sufficient (maximum 4 x 1000 mg per day).
For best effect, take it at regular intervals.
If this is not enough, you will be given a prescription for stronger pain relief. - Prescriptions – You can collect these at your own pharmacy.
- Hormones – You may continue using oestrogens as before surgery.
You may stop taking testosterone blockers.
Urination
Urination may sting or burn after the catheter is removed.
The urine stream may initially spray or be directed more forward — this improves as swelling subsides and healing progresses.
Bowel movements
It may take a few days for bowel movements to return to normal.
To avoid constipation, drink at least 1.5 litres of fluid daily and eat a fibre-rich diet.
If this is not sufficient, your GP can prescribe fibre supplements.
Sexuality
Sexuality remains important for many after vaginoplasty or vulvoplasty.
Penetrative sex will be possible once the wound has healed sufficiently (caution: not after vulvoplasty).
Most patients experience sexual arousal, and 80% are able to reach orgasm.
Questions about penetrative ability or sensitivity can be discussed with your plastic surgeon.
Resuming hormones
As a general rule, you will have continued taking your hormones around the time of surgery.
If you paused them temporarily, you can resume oestrogens once you’re mobile again, at the same dosage as before.
You will no longer need to take testosterone blockers.
Your endocrinologist will want to see you three months post-op to check your hormone levels.
If you are not given an appointment, please schedule one yourself.
