What is Vaginoplasty?

Vaginoplasty is a major surgical procedure used to create a (neo-)vagina where either one didn't exist before (such as in the case of male to female (MTF) sexual or gender reassignment patients) or, when absolutely necessary as an adjunct to vaginal agenesis or vaginal stenosis therapy.

Despite the significant difference in the conditions, the surgical procedures followed for vaginal agenesis sufferers are essentially the same as for MTF sexual reassignment surgery (SRS, sometimes abbreviated to GRS standing for Gender Reassignment Surgery). As such this text will primarily focus on the larger interest group, namely MTF SRS patients, with significant differences in the treatments being pointed out as and when they are relevant.

It should be noted that all reputable SRS surgeons will almost certainly be conforming to the requirements laid out within the Standards of Care issued from time to time by the Harry Benjamin International Gender Dysphoria Association (HBIGDA now called WPATH). Currently the most recent edition of these (Version 6) was issued on 20th February 2001. These Standards of Care are very comprehensive and generally useful reading for all those diagnosed with Gender Dysphoria. As far as SRS is concerned, amongst other things, the surgeon will require to see two letters from appropriately skilled and qualified psychologists confirming that in their professional opinion this fundamental, irreversible and life altering surgery is likely to be in the best interest of the patient.

There are essentially two main ways in which vaginoplasty is carried out: using a split-thickness skin-graft (the McIndoe technique) and, recto-sigmoid colon vaginoplasty. Subsequent care following both procedures is much the same involving significant periods of neo-vaginal dilation using a set of high quality vaginal dilators.

Skin-graft Vaginoplasty

The most commonly performed vaginoplasty procedure is to create the neo-vagina with a split-thickness skin-graft. In vaginal agenesis cases, the donor skin required is typically removed from the abdomen, top of a thigh or buttock. For an MTF SRS patient, skin from the penis is primarily used (penile inversion) usually combined with skin from the scrotum (testicle sack), although in some MTF cases where there is insufficient penile and scrotal skin to produce a satisfactory neo-vagina (perhaps where circumcision or an orchiectomy [castration] has previously been carried out), a skin-graft will also be taken. It should be noted that the donor sites from where grafts originate can be prone to scarring which can be unsightly and painful later, so care needs to be taken by the therapist, especially with regards post-operative care to ensure that this is minimised.

Regardless of the precise form of skin-graft vaginoplasty being employed it is essential that any skin donor sites and, in the case of MTF SRS, the relevant genital area, is completely and permanently cleared of hair well before the operation. This is not a particularly pleasant process, but nevertheless needs to be done comprehensively, even though most surgeons will endeavour to cauterise any stray hair follicles from the back of the skin-graft before implanting it. Anyone who doubts the necessity and importance of taking the initiative on this should consider the consequences of incomplete hair clearance, namely having hair within their neo-vagina which quite probably cannot subsequently be removed. Although recently it has been suggested that laser hair removal is adequate for this, it is generally not recommended by most surgeons, since, despite the marketing hype, laser hair removal appears not to be permanent. As such, electrolysis, even if slower and slightly more painful remains the preferred technique as it is permanent. However, the removal process should be started well in advance of any surgery date to ensure no re-growth is ever likely to occur. Genital electrolysis quite often will cost slightly more per hour than, say, facial, and typically requires between 25 and 45 hours.

The basic procedure for a penile inversion vaginoplasty is essentially the same as that used in the skin-graft vaginoplasty, so the former, slightly more complex version will be described, from which the reader should easily be able to deduce which parts of the operation would not apply in the latter case.

Preparation Prior to Surgery

Usually the night before the operation, the digestive tract, especially the colon will be cleared and cleaned. Different surgeons use different techniques to achieve this. Some simply administer one or more tablets, while others prefer that the patient drinks a fairly substantial amount of a special fluid (typically about one gallon). In either case, the object is to ensure the colon is completely clear of any material prior to the operation starting. This is not only to ensure that if the bowel was entered, it would be relatively clean, but also to ensure that after the operation, the patient will not need to excrete any solids for the period the vaginoplasty initially needs to heal. Indeed, many surgeons will insist that their patients have only a liquid diet for the first few days following the operation in order to further facilitate healing.

Then, the genital areas not already permanently cleared of hair as indicated above, will be shaved.

Vaginoplasty Surgical Procedure

The vaginoplasty procedure is broadly as follows, although each surgeon?s technique will vary slightly:

Once the anaesthetic has been administered (usually a general anaesthetic although some surgeons do prefer to use epidural anaesthesia), the urethra is catheterised and an incision is made to open the area at the base of the penis following which the urethra is freed and possibly shortened.

Some surgeons retain this small section of the urethra removed and later incorporate this into the vulva as a lining to the area between the urethral opening and the clitoris. This adds a more ?authentic? finish to the skin texture in this area and some patients have reported is also responsible for an amount of vaginal lubrication, but this is not likely not be significant.

Then the corpus cavernous are identified and removed (failure to do this correctly can result in undesirable, possibly restricting, swellings within the vaginal area at times of arousal), and a bilateral orchiectomy (castration) is performed.

A vaginal cavity is then prepared, taking care not to damage or perforate the delicate colon which runs nearby as this would result in the creation of a fistula, the healing of which can considerably increase the recovery period.

The penile skin which was removed earlier will then be formed into a closed tube, and if needed further tissue will be added in order to produce a vaginal cavity of acceptable length and diameter. This incremental skin will be obtained from donor sites such as the scrotum or the abdomen, where the entire skin-graft would perhaps have been sourced in the case of a vaginal agenesis patient.

Then, once the vaginal cavity has been successfully prepared, this tube will be turned inside out and inserted to form the neo-vagina. Skin from the scrotum and the areas surrounding the entrance to the neo-vagina will then be formed into the labia minora and labia majora, and the shortened urethra will be sown in place between the vaginal opening and the location of the clitoris.

The neo-clitoris itself will then be created from a portion of the glans, or other area of the penis if preferred by the surgeon, and then positioned above the entrance to the vagina (over the urethral opening).

So, in most vaginoplasty (penile inversion) procedures, the skin from both the penis and scrotum is used for making the lining of the neo-vagina as well as forming the external genital features of the vulva. Furthermore, a small part of the tip of the penis, or glans, is used by many surgeons to form the neo-clitoris. Some use a small section from the front or top, while others use a small part from the rear of the glans. However, some surgeons prefer to create the clitoris from one of the nerve packages which runs up the penis, and imbed the glans within the vagina, believing that this slightly more complex procedure leads to increased sensitivity.

After all this work is complete, the incisions will all finally be closed and a relatively pliable stent (effectively another name for a dilator) will be placed into the neo-vagina to ensure it retains its shape during the initial post-operative healing phase.

Typically several days of bed rest will follow for the patient, during which a variety of methods are likely to be employed to ensure blood continues to circulate as required through the legs and hence reduce the likelihood of deep vein thrombosis.

One significant variation to the 'typical' procedure described above is that of incorporating the penile graft into the vaginal cavity some days after the initial vaginoplasty operation has been performed. It is believed by some that this ?two stage? procedure increases the probability of the neo-vaginal graft surviving; however incidences of graft morbidity do not appear to be common these days.

Furthermore, whilst many surgeons complete the entire vaginoplasty procedure during a single operation, however a significant number prefer to perform a second operation (labiaplasty) typically some three months later, in order to form the labia after the swelling from the first operation has subsided and any new blood supplies required have been established by the body. This approach, although requiring a second anaesthetic has the advantage of allowing the labia perhaps to be better formed, and for the work performed during the first procedure to be comprehensively checked, and, if necessary revised.

Risks and Recuperation

Overall, there are various risks to this surgery, which include as with most invasive procedures bleeding and infection. However, more specific to vaginoplasty are the risks of post operative vaginal stenosis and pulmonary embolism from deep vein thrombosis (DVT). To minimise the latter, during the extended periods of post operative bed rest which many surgeons advocate (typically 5 - 7 days), various forms of intermittent leg compression are often employed, together with the possible administration of a prophylactic anticoagulant, although such drugs are usually only used after the operation has been completed.

During the recuperation period immediately following the surgery, the patient will only be allowed a limited intake milk products and fibres and indeed may be restricted to an entirely liquid diet in order to reduce any strain on the colon and the new formed neo-vagina. Needless to say, the wound should be cleaned frequently to reduce the possibility of infection.

The catheter will usually be removed some 4 - 5 days after the surgery and it should perhaps be pointed out that once the vaginoplasty is complete, it is not unusual for the patient to experience some spraying during urination, however, this usually resolves itself as the genital swelling subsides. Also, particularly for MTF SRS patients, the urine stream often exits pointing a bit more forward than would be the case with a genetic female. To some degree this is a natural consequence of the new vaginal geography and tends not to be a major issue, although it might take a bit of getting used to.

Colon Vaginoplasty

The second procedure quite often employed is the newer and somewhat more invasive technique called recto-sigmoid colon vaginoplasty where a section of the sigmoid colon is used to create the neo-vagina (i.e. the ?s? shaped part of the large intestine above the rectum which terminates at one end with the anus) as opposed to a skin-graft.

Apart from this important difference the actual surgical procedure itself is in many respects the same as that of the skin-graft vaginoplasty. Sometimes this procedure is employed in cases where the split-thickness skin-graft technique (penile inversion) has not yielded a satisfactory result.

However, it is much more complex operation usually involving full access into the abdomen. This will result in relatively extensive lateral scarring, although some would argue that such scars are less disfiguring than those resulting from an extensive skin-graft having been taken. To further mitigate this and other more involved disadvantages, some surgeons have recently been advocating a laparoscopic approach to this operation which does not involve such extensive scarring as the more conventional procedure. As such all of the vaginoplasty operation is performed laparoscopically, namely requiring only a small incision in the abdomen, retrieving the resection specimen through the anus.

Reported benefits of recto-sigmoid colon vaginoplasty include self-lubrication and a deep neo-vagina (as much as 8" or 200 mm, is not uncommon). However, the operation is more involved and will necessitate a longer period of recuperation in hospital. Furthermore, the natural secretions from the colon graft can be a bit smelly and maybe excessive, especially in the first 12 - 18 months following surgery. In addition, the colon graft is quite a deep red colour and therefore care needs to be taken by the surgeon to ensure that the graft is connected to the vaginal skin a little way up the neo-vagina in order to ensure that this somewhat unnatural redness is not unduly visible.

One possible surgical complication arising specifically from colon vaginoplasty is diversion colitis which is an inflammation of the colon which can occur following a colostomy (i.e. the need for a stoma to be put in position or a temporary redirection of excrement from the body to allow the colon to heal).

However, it has also been suggested that recto-sigmoid colon vaginoplasty results in a lower risk of shrinkage to the neo-vagina compared with skin-graft methods. This would consequently result in a slightly reduced amount of vaginal dilation being necessary to ensure the vagina remains open post surgery.However, regardless of the precise operative procedure followed, post operative care following vaginoplasty is of considerable importance. Vaginal dilation is a fundamentally important part of this aftercare. The surgical stitches will usually be removed by the surgeon about one week following the surgery, at which time it is likely that the vaginal packing or stent which was inserted during the latter stages of the surgery will be removed and dilation will start.

Post-Operative Procedure

Approximately 5-7 days after the vaginoplasty has been performed, the surgeon is likely to remove the stent which was put into the neo-vagina during the final phase of the operation. This is usually a coil of some cotton-like material, packed quite tightly in position. Once removed the neo-vagina will be cleaned and inspected. Once it is clear that all is well and that healing is progressing as expected, the surgeon will select a dilator from a set, lubricate it and insert it into the neo-vagina. The fit will be checked, and if necessary a slightly larger diameter dilator will be tried. Once it has been established which size of dilator is most appropriate at that time, the patient will be shown how to dilate on their own. This is a nerve-racking process at first, but soon becomes second nature. Gradually, as the post operative swelling subsides, it will be possible for the patient to insert a dilator of a larger diameter. This process will continue until the desired diameter for the neo-vagina has been achieved.

During the early dilation session, the surgeon will also indicate to what depth the neo-vagina should be delighted, and with what pressure the dilator should be held in position. It is very important that the patient carefully listens to and remembers this information as using too much or too little pressure could lead to problems later.

Unfortunately, dilation in the weeks immediately following surgery is not terribly pleasant; in fact it is often quite uncomfortable. However, during these formative times for the neo-vagina, it is essential that the patient dilates as often and as for long as is recommended by their surgeon, and this could be as much as four to six times a day for at least 45 minutes. However, after a while, this intensity may be reduced and dilation becomes a not unpleasant process, and significantly less invasive with regards lifestyle. It will need to be continued by most who have a neo-vagina for the rest of their lives during which they intend to maintain the capability to participate in sexual relations. Indeed, long periods of not dilating can result in shrinkage of the neo-vagina, I terms of both diameter and length. With care and perseverance and a little discomfort, this loss can usually be recovered. But it is recommended that the surgeon who carried out the initial procedure is consulted in such circumstances.

As the neo-vagina heals, there is likely to be a certain amount of vaginal discharge. This is normal, but can be distressing when some of the medical adhesives are expelled, perhaps in large pieces, as the healing process advances. But during this time it is essential that any concerns of the patient are relayed promptly to the surgeon for consideration. Later, these discharges will diminish, but certainly in the case of a skin-graft neo-vagina, there are no, or very few, natural secretions to clean the neo-vagina (unlike within a genetic vagina), it is therefore important for the patient to douche regularly and keep the vaginal area clean. This will reduce the likelihood of contracting infections, not least of the urinary tract.

Sexual Intercourse

With all types of vaginoplasty, assuming normal healing has followed the surgery sexual intercourse can be attempted, subject to the surgeon's recommendations, some 6-8 weeks later. However, the longer the wait the better, and three months might well be a more appropriate amount of time to wait. But, hormones, which should have been stopped some 6 weeks prior to surgery, can normally be resumed some 1-2 weeks after surgery.

Many people who have had a vaginoplasty operation and particularly male to female sex reassignment patients worry about whether their vagina is large enough to accommodate a normal penis. In fact, this is usually not a problem. The average penis is about 130 mm long when erect (some two thirds of this when not erect), and not all of this will be inserted into the vagina during intercourse, and depending on the positions of the partners, considerably less than the total length might be inserted.

Vaginas within genetic females are on average about 110 mm long, i.e. slightly shorter than the average male, although a natural vagina is little stretchier than a typical neo-vagina, especially those created using a skin-graft surgical procedure. Nevertheless, on average, the male average penis will be slightly longer than the average vagina, and this is not a restriction for normal sexual intercourse.

There are several factors which restrict the length of a neo-vagina, the most important of which is the physiology of the person concerned. There is only a certain amount of room within which to form the vaginal cavity and in terms of length; this is essentially restricted to the distance between the location of the vaginal entrance and the proximity of the colon.

Most MTF sexual reassignment and other vaginoplasty patients have vaginas of about 125 mm in length on average, some slightly more and some slightly less. Furthermore, with patience, and good dilators a vaginal diameter of close to 38 mm can also be obtained. This is more than adequate for most male sexual partners, and the usual positions. However, it should be borne in mind that immediately after surgery the area surrounding the vaginal entrance will be quite swollen and therefore any measurements taken at that time are likely to be misleading.

Finally, it is important that all vaginoplasty patients get to know their neo-vagina. There are two main ways to do this, first, by looking at it with a mirror, and second by feeling it. This may seem a bit strange at first but everyone should know how their body normally looks and feels in order to recognise when something is not quite right. However, when feeling in a neo-vagina, it is best to put a small amount of lubricant on one's finger. Generally speaking, neo-vaginas feel much the same as natural vaginas.