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Patient Information |
Neo-Vaginal Surgery
by
Dr Peter Haertsch
F.R.A.C.S. F.R.C.S.E.
http://www.haertsch.com.au/outer.html
June 2002
Introduction
The following has been written for you, the patient preparing for surgery. It has been written in conjunction with Dr Haertsch and with the assistance of medical specialists working in related fields. You may find some of the information covers issues that you are already comfortable with, however please read it carefully to ensure that you have not missed anything that may assist your recovery. It will be valuable to read it a number of times and you should take it with you into the hospital as a reference. Should problems or concerns arise that are not discussed here, please do not hesitate to contact Dr Haertsch or his support staff.
In preparation for this surgery you have seen two psychiatrists who agree that it is reasonable for you to pursue this surgery. You may also have been diagnosed as having a condition described as gender dysphoria, a gender identity disorder or transsexualism. It is acknowledged however that many individuals whom doctors have described as having one of these conditions have chosen not to pursue surgery, and have made instead lifestyle changes to manage their situation.
The surgery that you are preparing for, also called genital, sex or gender reassignment surgery is not considered by the medical and health care professionals who are providing this service to you as a cure for gender dysphoria, gender identity disorders or transsexualism. This is elective surgery and no iron clad guarantee can be given as to the outcome.
Both hormonal and surgical reassignment are viewed as treatments to assist patients. Such patients demonstrate a commitment to manage their lives, and the distress they have experienced, through a permanent change of gender role and a change of their genital‑sex status. The surgical goal is to comfort and assist the patient to achieve an improvement in their quality of life.
If you are unclear, confused or uncomfortable about any of the above issues, we strongly recommend that you reschedule your surgical date and seek further counselling.
This surgery will affect how your gender is defined for legal purposes in some circumstances. Federal and State laws may not be consistent and laws will differ from country to country.
Outcomes & Expectations
The object of the exercise in male to female reassignment surgery is to give you the external genitalia which have the appearance of being female and to give you a functioning vagina.
Because of the differing amounts of tissue available to reconstruct the external genitalia, there will be a spectrum of appearances ranging from being similar to biological genitalia and quite convincing, to being obviously a surgical result. This appearance will be related not only to the availability of skin tissue, but also healing without complication. The two stage procedure which will be discussed with you, is able to achieve a more pleasing appearance. You will be shown a series of photographs depicting the varying appearances. Labia minora (the inner lips above the entrance to the vagina) are the most difficult to reconstruct and no guarantee can be given as to the final result.
The aim of vaginal reconstruction is to give you a functioning vagina which is somewhere in the vicinity of 13cms in depth and in circumference.
Again, the given anatomy of the individual who has a narrow pelvis, will compromise the ability to construct a vagina with the above circumference and in those who have a lower pelvic floor, achieving adequate length will be difficult. Both these problems will not really be apparent until the time of surgery and there is no investigation, radiological or otherwise, which can be carried out to determine this.
Given the physical constraints, i.e. the availability of suitable tissue and suitable quantity of tissue, the end result also depends on the healing process. As with any reconstructive process, healing is directly affected by blood supply which can be compromised and result in the death of some of the body's tissues around the surgical site. As a direct consequence of this there will be delayed healing, more scarring and possibly an inferior result.
Potential Surgical Problems
The Clitoris
This is made from a small portion of the glans penis which during surgery is isolated only on it's blood supply and nerves. This portion of the head of the penis is orientated in an anterior/posterior position and buried to some extent to simulate a female clitoris in appearance. It will never be exactly the same as a female clitoris.
According to whether or not there are problems with the blood supply, the clitoris may in fact die altogether, or end up hyposensitive. This is a rare occurrence. If there is to be a problem with sensitivity, it is most likely that the clitoris will be hypersensitive initially but this, in our experience, usually settles down over a period of several months.
Manual stimulation of the clitoris or surrounding area normally will allow you to achieve orgasm and in doing so, there will be some ejaculate emanate from the urethra. The ability to climax is a complex process and no guarantee can be given in this respect. For more information on this please see the section in this booklet titled 'Sexual Function".
The Urethra
During surgery the purpose of repositioning the urethra is to allow for a straight stream and allow you to sit down to pass urine as a female would normally do. This result is sometimes not achieved because of various problems.
The first problem is a caruncle, which is a small fleshy projection developing somewhere on the urethral opening. This is easily treated by surgical excision.
Because the urethral opening is circular, occasionally there can be some stenosis, or narrowing of the opening when the scar matures. This can result in some difficulties passing urine. It will mean that you will have to strain to some extent to empty your bladder and you may feel that you are not emptying your bladder completely. This situation will lead to the development of urinary infection. The most common way of dealing with this problem, is to dilate the urethral opening and the most practical way to do this is to use a shortened golf tee. Secondary surgery for urethral stenosis is a rare event and stenosis effectively treated by dilation with a golf tee usually settles down as the scar totally matures. (This procedure should not be attempted without first receiving instruction and direction from the surgeon).
Because the urethra goes through the urethral bulb which is erectile tissue (the tissue in a penis that swells during erection), it is not always possible to remove sufficient erectile tissue without destroying the blood supply to the urethra. Loss of blood supply to the urethra would result in the death of this tissue, therefore erectile tissue cannot be completely removed. This remaining erectile tissue can, in some instances when you are stimulated, become quite turgid and form an uncomfortable ball in the anterior vaginal wall. Secondary surgery can reduce this at a later date. The risk of this problem occurring is less than 10%.
When a two stage procedure is used, there is no urethral scar. Problems with urinary retention after surgery because of swelling and later scar contracture are vastly reduced.
The Vagina
The preferred method of lining the vagina is inverted penile skin and there is usually sufficient skin if you have not been circumcised.
The vaginal introitus (entrance) has to be between the urethra and the anus and if the inverted penile skin flap cannot be repositioned sufficiently, then to avoid an introitus that is too far anterior, a small posterior mostly hair bearing flap from the front of the anus will have to be used. This win allow the vaginal introitus to be situated where it should normally be. This flap gives a rather squarish appearance to the introitus and is occasionally bulky, however at secondary surgery the flap can be debulked without risk of interfering with its blood supply.
If you don't have enough penile skin to adequately line the neo vagina, then the surgeon will have to resort to either a skin graft which can be split thickness graft or a full thickness graft, or else a colovaginoplasty.
With split skin grafts there are problems associated with a painful donor site on the back of the thigh which may even become hypertrophic, that is raised and red, but this is a low risk, especially if your heritage is Caucasian.
Skin tissue that is grafted can never be guaranteed to always take whether it is a full thickness or a split skin graft. The complication rate for grafts used during this surgery is approximately 30%. Of this about a third require re-operation to form another vagina because of vaginal shrinking related to graft failure or the inability to dilate. For this reason, Dr Haertsch will not perform this surgery unless it is specifically demanded by the patient.
Full thickness grafts are obtained by doing an abdominoplasty at the same operation and using the skin of the lower abdomen. The removal of skin for a full thickness graft will leave an extensive permanent scar and there is a risk that it may keloid. There can sometimes be concerns as to the exact repositioning of the umbilicus or navel. Because these grafts are extremely thick and are therefore associated with poor take, Dr Haertsch will not perform this operation unless specifically requested.
A full thickness graft using scrotal skin appears to be the desired method of skin grafting the neo vagina. It can only be used if there is sufficient laxity of the scrotal skin and, quite often, because it is hairy, patients will be asked to have the area depilated by way of electrolysis or laser prior to surgery. Any remaining hair follicles may be removed at the time of surgery by diathermy, however there can be no guarantee that there will be no remaining hair follicles and therefore some hair growth.
Colovaginoplasty is also available if insufficient penile skin tissue is available to create the vagina. This involves using the right side of the colon (large bowel) with an associated appendectomy if not already done. Colovaginoplasty has no problems in direct relation to the depth of the vagina, however because of the nature of the surgery and the precarious blood supply of the colon, the risk of necrosis (death of some bodily tissue) is there, albeit not high.
Associated with a colovaginoplasty is the fact that you will have an abdominal scar, which will vary in it's length depending on your physical condition. Any abdominal operation carries with it the risk of further problems later on, in relation to adhesions.
The right side of the colon is used because there are less problems after full healing has occurred with discharge when dilating or after having intercourse, than if other parts of the bowel are used. However there may still be some problems associated with discharge and hygiene pads are recommended as the appropriate way to manage this problem should it occur.
Remember whilst the aim of this surgery is to give you a functioning vagina, there can be no guarantees and at worst you could end up with a non‑functioning vagina.
Labia Minora
There is never in any patient, sufficient quantities of thin skin to form the inner lips of the vagina, which are the mirror image of those of a biological female. The labia minora of a reassigned patient are always thicker and shorter.
The main problem with the labia minora is healing at the attachment to the entrance to the vagina and this will leave ulceration on one or either side of the opening. This will slowly heal and the end result will not be really any better or worse than if this complication had not occurred. Scrupulous hygiene is necessary to ensure healing, should this problem occur and daily salt baths must continue.
The most satisfactory and convincing labia minora can be constructed by way of a second procedure involving extra cost, separated from the first by a period of 3 months. You will be shown photographs which will demonstrate a range of appearances that can be achieved.
Labia Majora
These are the outer lips of the vagina and are mostly responsible for the external appearance of the genitalia. After the primary surgery most patients have external genitalia that looks for all intents and purposes female. Occasionally because of the cleft produced by pulling the inverted penile skin backwards, secondary surgery is required on the labia majora, to reduce the cleft and make it more feminine. This can simply be done under a local anaesthetic in the rooms at Epping and is by no means major surgery. Less than 5% of patients have required this revisional procedure.
Recto‑Vaginal Fistula
This is a major potential complication of this surgery, although not life threatening. It is a hole between the rectum and the vagina and thus allows faeces to enter the vagina. In our hands the risk of a recto‑vaginal fistula is less than 1%. The risk of recto‑vaginal fistula is much higher when only a split skin graft is used for the lining of the neo‑vagina. It usually occurs as a direct consequence of inadvertent injury to the rectal wall during the dissection to create the vagina. The rectal wall can be damaged for a variety of reasons, and on each occasion a patient has her bowels prepared in the event that this inadvertent damage occurs. With satisfactory bowel preparation, the surgery can continue following repair of the injury by an experienced colorectal surgeon.
Once the inadvertent perforation of the rectum is identified and repaired, that should be the end of it. However if it were to develop into a fistula as a result of insufficient healing of the repaired wound, then you would require a temporary diverting colostomy to be performed once the fistula is diagnosed. In usual circumstances, this would be within 48 hours of removing the vaginal pack, some five days after the surgery. This temporary colostomy will be required for about 3 months during which time the fistula will heal and then the colostomy closed by the surgeon. After this time a review of the depth of the vagina can take place and if depth has been lost as a result of the above complication, this can be discussed and any further surgical intervention considered.
In theory when a colovaginoplasty has been performed patients should not be at risk of fistula as described above.
Those patients who have had a colovaginoplasty (the neo‑vagina is created from an isolated piece of colon) performed may discharge faecal material for a short period of time after surgery. The quantity and duration will vary from patient to patient, but will depend to a large extent on how effective the bowel preparation has been. This discharge should it occur, may be delayed and only become evident some months after surgery.
Material discharged may look like faeces, or it may in fact be much darker and have a malodorous smell. The discharge may commence as early as a week or two following surgery and may persist for as long as a couple of months.
In the event of this occurring, and the smell being a problem, we would suggest that you use a gentle, weak Betadine douche on a daily basis until such time as the matter resolves. Should this be necessary please contact your pharmacist to obtain the above and gain directions for safe use and appropriate dilution of the Betadine solution.
Whilst you may interpret the passage of this faecal material as possible evidence of a fistula, it is extremely unlikely that such a complication will occur when a colovaginoplasty has been performed. It is imperative however that you contact Dr Haertsch in relation to these concerns.
When a colovaginoplasty has been performed, it is more likely that any leakage from a rectal tear, should it occur, would find its way onto the skin around the entrance to the vagina.
Preparation
Before you leave for the hospital it is important that you are as prepared as possible for your return home. There are some general areas that you need to organise and some special items to purchase. Please remember that the less you leave to be done on your return the better. This is because you will need to minimise your activities to help your body's healing process and also because you will be tired and very uncomfortable from the effects of surgery and the anaesthetic.
The amount of general preparation needed will depend on your living arrangements when you leave hospital. If you are on your own and/or have travelled from interstate, then you will need to be more organised. Try to arrange accommodation with a bath and organise things to that you don't have to go out for a few days or until you are comfortable. You will need a number of items to prepare for surgery. These are the following:
Salt
When you return home you will need to have salt baths every day for a few weeks. These are important to help the operation site/s heal and help to reduce the risk of infection. You will need quite a lot of salt (a couple of cups full in each bath), so a couple of two kilo bags should be enough at least to start with. Cooking salt from the supermarket is quite adequate or even butcher's salt will serve the purpose. Table and epsom salts, while effective, are usually only available in smaller quantities and at a greater cost.
Pads
When you leave hospital there will still be some discharge and light bleeding from your vagina. It's a good idea to buy some pads from a chemist or supermarket. Most brands come in different sizes and are quite adequate for your needs. Around two packets of super size and one of regular should do to begin with, more can be purchased if required later. Remember always to dispose of soiled pads carefully into a closed bin or bag.
The following items should be brought into hospital with you :
Lubricant
To help with your dilating after surgery, you will need some lubricant. The best lubricant to get is one from the pharmacist e.g. KY jelly. These lubricants are free from additives and are the safest to use at first when you are still recovering after surgery. During this time do not try dilating with other creams and ointments as they may interfere with your recovery.
Condoms
These are to use as covers for the dilator once you commence dilation as an extra hygiene aid during the healing process. It would be helpful to purchase 2 or 3 dozen to start with.
Mirror
You will need a mirror preferably with a handle or stand to take with you into the hospital. It will be helpful during dilation exercises and to check for cleanliness when you commence your own peri‑toilets (washing around your vagina). A mirror approximately 10‑20cm x 10‑20cm is a useful size.
Panties
After surgery you will be uncomfortable and will have some stitches along both sides of the inner folds of your groin. Because of this it is important to wear comfortable fitting panties and ensure that they are made of cotton, as nylon may irritate the healing area. Five or six pairs would be useful because they may become easily soiled from the wound in hospital.
General
Try not to take too much with you into hospital as the less you have to carry out the better. If you have never been admitted to hospital before as a patient and you are concerned about what amenities and services are available, then it may be wise to contact them prior to your admission.
Bowel Preparation
Bowel Preparation for Colovaginoplasty
Please cease any iron tablets, aspirin or arthritis medication one week prior to the procedure but continue all other usual medications until the day of the procedure.
Purchase one packet of PICOPREP from a chemist on the weekend prior to surgery.
Two days prior to the procedure: fight diet only. No fried or fatty foods, red meat or high fibre cereals, make sure to drink plenty of fluids.
One day prior to the procedure: CLEAR FLUIDS ONLY. No solid foods or milk products. You may drink fruit juice, strained soup or broths, soft drinks or cordials.
Take the PICOPREP ‑ follow the instructions on the pack. In usual circumstances this will commence after your admission to Westside Hospital.
Continue to take plenty of fluids to avoid dehydration. At least one glass of fluid every waking hour is required. Continue clear fluids until midnight.
Bowel Preparation for Standard Procedure
Two days prior to the procedure: Light diet only. No fried or fatty foods, red meat or high fibre cereals. Make sure to drink plenty of fluids.
One day prior to the procedure: CLEAR FLUIDS ONLY. No solid foods or milk products. You may drink fruit juice, strained soup or broths, soft drinks or cordials.
About the Surgery
The surgeon will have seen you on several occasions pre‑operatively during which time he has monitored your progress as far as adhering to the assessment criteria and ensured that you have had appropriate blood studies performed.
Prior to admission you will have discussed the nature of this surgery in detail and you will have been advised as to which method of lining the neovagina will be appropriate. Complications will be discussed, in particular the risk of recto‑vaginal fistula (a break or tear in the vaginal wall into the rectal passage).
Post‑operatively Dr Haertsch will see you as many times as is necessary for the first 12 months at no cost to you and if there is any additional surgery required, as there sometimes is, then he will discuss this with you. He is at all times available to talk to you about any problem you have.
During the consult prior to surgery you have had the opportunity to discuss any final details and ask any further questions you may have. Instructions will have been given to you about the time of hospital admission, preoperative bowel preparation as well as details of the pre‑operative shaving.
You will be given a script for medication at this time to have filled at the chemist and to be taken with you to the hospital.
Admission to Westside Private Hospital will be on Sunday, when you will be asked to continue on a liquid diet.
Surgery will be on Monday afternoon. In the morning before surgery you will be given a disposable enema to clean out the lower bowel of any solid matter. At this time you will be reminded that you must shave all the hair from the pubic and scrotal area just prior to surgery.
Immediately after surgery you will notice a number of things. Firstly there will be some stitches causing puckering over the pubic area. Do not be concerned as these will be removed on Wednesday and the puckering will disappear. Occasionally a sore will develop around the stitches but this will heal in time.
You will also notice you have an indwelling catheter which is draining the urine and this will remain until Friday. There will be two plastic vacuum drains exiting from the pubic area. At the same time you will feel a large pack or gauze packing in the new vagina held in by two large stitches. It is usual for there to be a reasonable amount of oozing and some swelling after surgery. As surgery is a traumatic experience for the body, bruising can also occur.
Tuesday and Wednesday tend to be the most uncomfortable days and you will be kept rested in bed with the foot of the bed elevated. Dr Haertsch will visit on Wednesday, the drains and the stitch in the pubic area are usually removed at this time.
You will also be advised at this time if it is appropriate to begin to get up and commence limited mobilisation. Be very careful when you begin to walk around. Take things slowly as you may feel weak and faint as a result of the surgery. Even if you feel strong at this stage it is important to be very gentle in activity.
If penile skin or a skin graft has been used for the surgery then you are allowed to have a normal diet immediately after the surgery. Normacol granules will be given to help keep you bowel motions soft. If you at any time feel constipated please inform the nursing staff.
If you have had a colovaginoplasty and a tube has been inserted down your nose into your stomach, then this will probably be removed at this time. You will then be recommenced on a fluid diet.
Early on Friday morning Dr Haertsch will visit and remove the catheter, the stiches holding the packing will be removed and the new vagina cleaned and inspected. After the packing has been removed it will be necessary to begin dilating. This will be explained to you on Friday and you will have brought the dilators supplied with you into hospital.
Some people have difficulty passing urine after the catheter is removed. It is not uncommon for the stream to be poorly directed and this is related to the swelling from surgery. It will improve as the swelling subsides over the next couple of weeks.
Occasionally post‑operative problems occur with urination however they can be resolved with medial assistance and will require your cooperation. If it is necessary to put the catheter back into your urethra, it win mean an extra 2‑3 days in hospital. This occurs in less than 10% of patients and it should not affect the eventual outcome of surgery.
Provided there is no problem with urination and you are otherwise comfortable you will be free to go home. Most patients leave hospital either on the Friday evening or on Saturday morning.
If at any time following your discharge you are uncertain or unhappy about any aspect of your progress do not hesitate to call Dr Haertsch or his support staff. You will be advised in due course when it is reasonable to become sexually active. Usually under normal circumstances if everything occurs uneventfully then this will be around 6‑8 weeks after surgery.
If a skin graft is required to line the vagina then there will be some differences in your care. The graft will be taken from the back of your thigh and a thick dressing and bandage will cover it after your operation.
This will be replaced on the Friday after surgery and you will go home with a clear plastic dressing that can be safely removed after a few days. The donor site on your thigh may be very uncomfortable after surgery although this will settle quickly. This will leave a red patch similar to a bum or graze and it will take many months to fade.
If the dressing that you go home with does not stay on properly and comes off after a short time, the wound can be left open and exposed to the salt baths. If this remains too uncomfortable or the area does not dry out, then an appointment can be made at Dr Haertsch's Epping office to have it redressed by the clinic nursing staff.
Going home from hospital
Leaving hospital can be an experience in itself. Having spent a whole week in an unfamiliar environment it may be very reassuring to get home. Others may feel they were safer in hospital and are anxious about leaving. Remember medical assistance can always be arranged on your return home should post‑operative problems arise.
Be careful in the car when you leave as sitting will still be uncomfortable. When you get home remember that you only have two important goals for the next few weeks. These are taking care of your new vagina and recovering from the general effects of surgery. Don't try to be too active too fast. You will still need plenty of rest.
Salt Baths
You will need to begin salt baths a soon as possible after discharge from hospital. If you have a dressing in place from a skin graft this may be difficult until the dressing is removed. Use about one or two cups in each bath of warm water. Use enough water to cover your pubic area when you are immersed. Bath once a day for about 20 minutes.
Discharge
Initially you may have a fair amount of discharge from your vagina. This will consist mostly of blood, loose skin tissue from around the surgical site and lubricant from your pack or dilator. The smell of this may be unpleasant to begin with but should improve as you recover. The discharge will slowly decrease over the next few weeks. It is not unusual for some irregularities in the amount, colour or smell of this discharge, however if you feel that something is wrong don't hesitate to seek medical advice.
Bleeding
You will go home from hospital with most of your stitches in place, they will dissolve in time. It may be that some of these are traumatised during your daily activities and a small amount of bleeding result. This will not harm the outcome of your surgery and provided the bleeding is light and stops after a few pad changes there is no need to be alarmed.
Hygiene
During the first weeks of recovery you must wash the vaginal and groin area clean after each time you go to the toilet either to pass urine or open your bowels and after each dilation.
Toileting
Your bowel habits may be a concern for some time. Constipation after surgery is not uncommon and may be related to the effects of medication given to you for pain, change of eating habits in hospital or reduced activity.
You have been given Granucol (also called Normacol) in hospital to help your bowel motions and it may be wise to purchase some from a chemist to take for a few weeks after surgery. Also try to drink plenty of fluids and select foods that are high in fibre e.g. brown bread, fruit, etc.
You may find that your stream of urine is poorly directed after the catheter is removed in hospital. This is due to swelling and will improve in time. Until then try to keep the area as clean as possible.
One method which is very effective is to keep a jug or plastic container next to the toilet. When you go to the toilet, fill the jug with warm water and add a small handful of salt. After going to the toilet, pour the water slowly over your vagina (leaning backwards helps) before patting the area dry carefully.
If on your return home you experience an increasing difficulty passing urine, then seek medical advice. Do not try to manage this by reducing your fluid intake.
Some patients will feel like they are passing urine too often after surgery. If this occurs don't be alarmed as this will improve in time. If it occurs try to strengthen your bladder muscles by slowly increasing the time between visits to the toilet to pass urine. This will involve "holding off' for an extra half hour or for as long as comfortably possible each time. If this problem persists you may need to speak to your doctor about exercises to strengthen these muscles.
Pain Relief and Sleeping
People experience different levels of discomfort following surgery. This is because pain is a very personal experience and it is up to you, when you go home, to decide if and when you can manage without pain relief tablets.
If you are having difficulty sleeping, are too anxious from pain to move about or finding dilating too difficult, then some medication will be important to avoid problems during your recovery. Only take tablets as often and in the quantities prescribed. Your body is very weak at the moment from the effects of surgery and care needs to be taken.
Taking pain tablets regularly however will help. This works by keeping an even amount of the medication in your blood stream. If your pain is not manageable then seek medical advice.
Sleeping may be a problem for a short while due to discomfort. Taking regular pain relief tablets should help, however if not a sedative may be necessary. Taking mild sedatives for a week or two after surgery will be less stressful on your body than prolonged sleeplessness. A doctor’s prescription will be required for sedatives.
Anxiety
Hopefully your recovery will go by without any problems and the main feelings that you will have to deal with will be feelings of tiredness and discomfort. It is possibly however that events go less than perfectly or are different to what you anticipated.
Because you will be tired and uncomfortable from the effects of surgery, you may have less emotional strength to cope if problems do arise. It is not unusual to feel angry, frustrated or anxious in this situation. If you do feel this way, one way to deal with these feelings is to talk about them with family, friends or care‑givers. It may be unwise to bottle them up inside, as this could adversely affect your recovery.
Dilating
You will be shown how to place the pack or dilator into your vagina while in hospital. The important thing to remember is that the skin tissue around your new vagina has been traumatised by surgery and is going through a healing process.
Try to relax as much as possible when inserting a pack or dilator. It is okay if this process takes some time and it is not unusual for full insertion to take several minutes to achieve comfortably. Be careful to make sure that you have the dilator inserted to the full depth shown to you.
Ensuring that your bowels and bladder are empty before dilating will make the process less uncomfortable and using a mirror to guide you initially will also help.
When using a dilator, once full insertion is achieved it should be held in position for about 20 minutes. This should be repeated as instructed for the first week until you return to visit Dr Haertsch. This is an opportunity to cheek with Dr Haertsch which size dilator you should continue with. After this visit provided everything is healing well, dilation can be reduced in frequency slowly over the next few weeks and months. Remember however that even when you have completely recovered you will need to continue dilating.
After a year or two when things have settled down get into the habit of dilating fully at least once a week. Failure to do this will eventually result in loss of depth, making sexual intercourse difficult and eventually impossible.
If at any time you feel that your vagina is tightening, it may be that dilating more frequently is required. If this does not resolve the problem or the dilating is becoming increasingly difficult, or painful, then seek medical advice. If your local doctor cannot assist you it may be necessary to get in touch with Dr Haertsch.
During dilating you will require the use of a lubricant. Until your vagina is completely healed ensure that you use a surgical lubricant (free of additives that are potential irritants). You will require a lubricant when dilating in the future and also should you participate in sexual intercourse. Some patients who have had a colovaginoplasty find that their vagina is self lubricating and they are then able to dispense with the use of a lubricant.
Sexual Function
At first after surgery sexuality may be the furthest thing from your mind. It may take several weeks or even months to feel comfortable exploring these feelings. After your surgery sexual function will be related to a number of different factors. Sexuality is both part of and an expression of our personalities. It is also influenced by our experiences and our environment. The capacity to function sexually will be influenced both by these and by physical factors. Some important considerations will include:
Previous sexual function.
If prior to this surgery and while on oestrogen therapy you have had difficulty achieving orgasm or have had a loss of sexdrive, then it is likely that these problems will continue after surgery.
Medication.
Taking anti‑androgens (Aldactone and Androcur) may reduce sex‑drive and in particular this is a common effect of Androcur. If you are on this medication and have noticed a reduction or loss of sex‑drive during this time, then it is unlikely to return after surgery, while still on the medication.
Surgical factors.
After surgery most of your sensitivity will be centred on and around your clitoral area. While every effort is made to maintain the nerve tissue and as a result of the sensitivity of what was previously the penile shaft to achieve this, there are risks involved. Specifically nerve damage can occur as a result of surgery, resulting in diminished sensitivity, over‑sensitivity or even loss of sensitivity in a small number of cases. These will affect the ability to achieve orgasm (if orgasm was achieved through penile stimulation) after surgery.
Vaginal depth and width.
Functional intercourse can be looked at from the point of view of pleasing the partner or from receiving pleasure. Surgery should create depth and width capable of comfortably accommodating an average size penis. However a larger penis may make sex uncomfortable or even painful. If you are not able to relax your pelvic muscles during intercourse, then sex could become painful. It may take time to learn to relax and dilating prior to intercourse may help. If you do not maintain sufficient depth and width with dilating after surgery, then intercourse may become difficult and eventually impossible. Poor depth and width postoperatively can be related to surgical complications and if this occurs it may be necessary to carry out further surgery to correct this.
Vaginal stimulation.
Receiving pleasure vaginally is another question. For some, intercourse is not pleasurable even with sufficient depth and relaxation, as is the case with some biological women. For many it remains mildly pleasurable while the main stimulation is achieved around the clitoral area.
If vaginal orgasm is achievable after surgery then the physical basis for it will most likely be when the (prostate) gland behind the anterior surface of the vaginal vault is stimulated. This gland will be affected in time by the hormone therapy and stimulation may decrease. Sometimes orgasm is an emotional experience and can be felt without any particular physical process taking place. Also pleasure is a very personal experience and expectations may differ between individuals.
Lubrication.
Although some moisture will continue to be present inside your vagina after it has healed, it may not be sufficient to maintain intercourse and a lubricant will usually be required. Some fluids may be released upon orgasm and if so this will occur above the entrance of the vagina at the urethral opening.
Time and experience.
It may take some time after surgery to readjust to the changes you have experienced both physically and emotionally. Many women take several years after they have become sexually active to become comfortable and confident with their sexuality.
Body image.
Our sexuality is affected by how we feel about our bodies. It is the intention of the surgery to assist individuals who feel uncomfortable with their male genitals. Many people who have had this surgery report an improvement in their body image.
Hygiene & health
During Recovery
Your skin is part of the immune system that your body uses to defend itself against disease. When you have surgery the skin is broken and so until you have completely healed, you will be at some risk of developing local infection.
What this means in regard to your situation is that you must maintain high standards of cleanliness around your operation site/s for a few weeks after surgery until you have completely healed. You must take particular care in relation to bathing, cleaning your vagina and toileting. Do not wipe after toileting from your anal area towards your vagina.
When cleaning your vagina it's okay to splash water over it, soak it in the salt bath, pat it clean and dry, but do not douche unless instructed otherwise during your recovery. If you wish to practise this form of female hygiene after your recovery then please discuss the matter with Dr Haertsch.
After Recovery
Your genitals are now female and are subject to many of the same infections and diseases as other women. You can get trichomonas infections, yeast infections and if sexually active you are at risk of many other sexually transmitted diseases. In respect to HIV (the AIDS virus) you should assume that the practice of safe sex is as essential to you and your continued health as it is for anyone else engaging in sexual activity. With some sexually transmitted diseases the symptoms are far easier to detect on male genitals as they may become visible as sores or pustules. However they can be harder to detect on the female anatomy and if you have put yourself at risk, then it is advisable to discuss this with your doctor.
You will also be at increased risk of contracting urinary tract infections. The female urethra (the passage leading from your bladder to where you pass urine) is much shorter than a males. It is easier for bacteria to travel from the opening up to the bladder and cause infection. The main symptoms of infection are painful or increased frequency of urination, in severe cases blood may be noticed in the urine. This will require antibiotic treatment from your doctor.
There are some important things that you can do to keep the risk as low as possible. Firstly maintain a high standard of cleanliness around your genital area (light sanitary pads are available from the chemist if you continue to have slight discharge).
Try to remember to empty your bladder before and after sex if required. Lastly adequate fluid intake will keep your urinary system in good health. This is about 2‑3 litres a day.
Douching
This is no longer recommended as a form of feminine hygiene by many health agencies. If your vagina develops a bad odour then it would be appropriate to first have an examination by a medical practitioner. You should only commence douching on medical advice.
If there are no medical problems then a product called "Aci‑gel" may be of assistance. It should be applied 2‑3 times a week as instructed. This is available from your pharmacist without prescription. Once the odour is under control, then a quarter to a third of an applicator twice a week will help the vagina to maintain a healthy acid balance.
Medication
Prior to surgery you will have been on hormone therapy for some time. During the operation your testes are removed and this will result in irreversible sterility. You will no longer produce sufficient sex hormones and these are necessary for the absorption of calcium, to keep bones healthy. If you do not continue hormone therapy or take inadequate or inconsistent doses, the brittle bone disease osteoporosis can occur within a few years of surgery. This matter and the appropriate medication for you after surgery should be discussed with the doctor who prescribes your hormone replacement.
Conclusion
By the time you have had surgery you will have seen a number of doctors. Your general practitioner will be able to assist you with many of your health concerns in the future.
If you are in further need of surgical review or having difficulty adjusting to your new circumstances and require referral for counselling following surgery, please do not hesitate to get in contact with Dr Haertsch.
