From now until sometime in early 2023, we’ll be writing about gender affirming procedures. We’re starting with bottom surgeries and will end with office visit procedures such as fillers and botox. This week, we’re discussing phallus-preserving vulvovaginoplasty.
Content advisory: we will be using anatomical terms and discussing surgical procedures in this article and this series. External sites that we link to may contain graphic images.
What is phallus-preserving vulvovaginoplasty?
That’s an awful lot of words! You may have seen “PPV” as an acronym.
Traditionally, it has been assumed that an individual who wants vaginoplasty would also want penectomy (link when that blog is available.) But that doesn’t have to happen! We are thrilled that surgical techniques are catching up to the many ways in which humans envision their bodies. A phallus-preserving vulvovaginoplasty is the creation of a vulva and vagina without penectomy. For people who want to keep the P and get the V. Embrace the power of “AND”!
A vulva isn’t required, either! Individuals can choose to have phallus-preserving vaginoplasty (you may also see it called “penile preservation vaginoplasty.” But, wait, there’s more! Orchiectomy and scrotectomy are also not required (although if the testes and scrotum are present, there may be less room for the vagina.)
Phallus-preserving vulvovaginoplasty can’t be done using the surgical techniques employed in penile inversion vaginoplasty, where penile and scrotal (and sometimes other tissues) tissues are used to create a vulva and line the vagina. If the individual desires both vulvoplasty and vaginoplasty, scrotal skin or a skin graft form another part of the body may be needed to create the vulva.
In PPT – peritoneal pull-through – vaginoplasty, penile tissue is not used. An incision in the perineum is created and a vaginal cavity is created between the rectum and prostate. Peritoneal tissue – this is the tissue that lines the abdominal cavity – is used to create the vaginal lining. Some benefits of PPT vaginoplasty (which we will be discussing later in this series) are:
- no need for skin graft
- tissue is pink
- tissue is “serous”: it secretes a clear fluid, so is (somewhat) self-lubricating
- may be able to achieve more depth
- no potential hair growth on vaginal lining
- (pertinent to this blog) the penis can be kept
This isn’t a complete list, of course, and is not a discussion of risks – your surgeon should go over those in detail with you.
When: Expected Prep and Recovery for Phallus-Preserving Vulvovaginoplasty
Prep for penile preservation vaginoplasty or vulvovaginoplasty is similar to other bottom surgeries. Some surgeons require hair removal on the external genitals. More information at Your Bottom Line: Preparing for Bottom Surgery .
Recovery is also similar to other bottom surgeries. Patients will stay in the hospital for a couple of days post-op. Average time off from work is four to six weeks. Lifting and activity restrictions will apply for up to eight weeks, and significant restrictions will apply for the first month. Activity restrictions may depend on whether or not other procedures were done along with the vaginoplasty. Your surgeon may want you to stay in the area for a month after vaginoplasty, so you may need to arrange housing.
How: Common Surgeon and Insurance Requirements to Access
Like other lower surgeries, you will likely need two letters from a mental health provider for your surgeon, along with a letter from your surgeon and/or hormone provider for insurance. They may require hormone use for a certain period of time or want documentation for why hormones were not part of your journey. The current WPATH SOC 8 recommendation is six months of hormone use unless hormones are not desired or are medically not appropriate. Some insurance policies may require that you document your support and housing plans during recovery. If you’re a smoker, most surgeons will require you to stop smoking for a few months before surgery, and you’ll need to be in generally good health.
Why: Some Things To Think About When Choosing Penile-Preserving Vaginoplasty
Urination: the urethra isn’t commonly moved during phallus-preserving vaginoplasty, but the structures around it are changed significantly. How you pee may change, as may how you experience bladder-fullness and the urge to urinate.
Sex: how you have sex may change. This may be, of course, exactly what you want. How you experience arousal, erotic sensation, and orgasm may significantly change. The new vagina will likely be pressure-sensitive, but not touch-sensitive internally.
Dilation: although PPT vaginoplasty maintenance requires less dilation than penile-inversion vaginoplasty, some may still be required to maintain depth and width.
Lubrication: the peritoneal membrane self-lubricates. This lubrication may be constant: panty liners may become a household staple.
Recovery: PPT is a significant surgery and has added risks compared to penile inversion vaginoplasty as the abdominal cavity is involved. As with other bottom surgeries, working with a physical therapist specializing in the pelvic floor is recommended, both before and after surgery.
Orchiectomy and Scrotomectomy: the testicles and scrotum may be kept, although this reduces the amount of tissue available for vulvoplasty, and the total amount of real estate available for the vaginal opening.
Who: Surgeons Who Offer Penile-Preserving Vaginoplasty:
These are the surgeons we know about – we are sure there are more! If you know of one, please let us know, too. These are the United States surgeons or surgical practices that we know of who offer PPV. This list is for informational purposes and is not intended to be a recommendation or referral.
Download our Expected Time Off From Work for Gender Affirming Surgeries handout: