Vaginoplasty for Gender Affirmation
Vaginoplasty is an operation for creating both the external (vulva) and internal (vagina) components of the genital anatomy associated with individuals designated female at birth. The penile inversion method is the most commonly-used technique for vaginoplasty. Other techniques include the intestinal vaginoplasty, which is more commonly reserved for those undergoing revision procedures, or for those who lack sufficient genital skin to line a vagina of appropriate dimensions.
Penile inversion vaginoplasty
This technique utilizes the existing anatomy of individuals designated male at birth to create female genitalia. It is often combined with orchiectomy (removal of the testicles), but it can be performed following a previous orchiectomy as well.
The clitoris is made from the tip of the existing anatomy (glans penis). The clitoral hood, labia minora, and vaginal vestibule are made from a portion of the penile skin and the urethra. It is easier to make a clitoral hood in individuals who have not undergone penile circumcision. The urethra is shortened and placed into a more female position. The vaginal lining is made from the penile skin as well as the scrotal skin, which is attached like a pouch to the end of the penile skin and placed within a cavity that is created between the prostate and rectum.
An alternative technique for vaginoplasty which is appropriate for individuals who need to undergo revision vaginoplasty or for those with insufficient penile tissue available for vaginoplasty (such as those who underwent pubertal suppression). Intestinal vaginoplasty uses a segment of either large or small intestine to make the vaginal lining. Operating on the intestines can potentially lead to problems later on, like bowel obstruction or internal hernia, which may require an emergency operation to fix in the future.
Vaginal Space and Rectal or Urethal injury
The creation of the vaginal space is the most difficult and dangerous portion of the operation and can lead to significant bleeding or damage to the rectum or urethra. Damage to the rectum can lead to one of the most dreaded complications of vaginoplasty, rectovaginal fistula, which is an abnormal connection between the rectum and vagina. Rectovaginal fistula must usually be treated with a diverting ileostomy or colostomy, whereby a portion of intestine is brought out through the abdominal wall, and stool is collected in a bag, until the rectovaginal fistula is healed. It is not uncommon for individuals who have been treated for rectovaginal fistula to require a revision vaginoplasty, as their vagina may close while the fistula heals.
Damage to the urethra during vaginoplasty may lead to a urethrovaginal fistula, where in urine can come out of or collect in the vagina during urination. This may cause significant symptoms, or may be without significant symptoms. Fixing a urethrovaginal fistula may be difficult, depending on how much tissue is available.
During vaginoplasty, the prostate remains in place. That means the individual will continue to need prostate exams, which can then be performed through the vagina. Removal of the prostate is too involved a procedure to be performed as a part of vaginoplasty, and could result in problems with the urethra with some of the nerves which provide erogenous sensation.
Because the prostate and seminal vesicles are left in place, some individuals may continue to ejaculate with orgasm after vaginoplasty. If you are ejaculating with orgasm prior to vaginoplasty, you may very well do so afterwards as well.
Removal of the testicles will render an individual infertile. If fertility preservation is desired, sperm should be frozen prior to initiating hormones. Any questions about fertility preservation should be asked of a fertility specialist. Vaginoplasty will not allow for giving birth vaginally; it does not change the dimensions of the pelvis, nor is the vaginal lining particularly elastic. As of the writing of this document, there have been no known cases of uterine transplantation for transwomen.