From now until sometime in Spring 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 scrotoplasty.
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 Scrotoplasty?
Scrotoplasty is the creation of a scrotum, which is the pouch of skin at the base of and behind the penis. For people with testicles, the scrotum is where balls hang out. It is sometimes done to change the size of an existing scrotum. In gender affirming surgery, it creates a scrotum. The individual can choose to get implants that look and feel like testicles at a later date. If a phalloplasty with pumpable erection implants is planned, one prosthetic testicle will be placed. The other testicle space will house the pump for the penile implant.
Gender affirming scrotoplasty often uses the outer labia to create the new scrotum. If there is not enough tissue available to create the size desired, scrotoplasty can be done in two steps, with a tissue expander. A tissue expander is put into the scrotum at a smaller size. Over time, saline can be added to the expander, which encourages the skin to grow to fit around it. When the scrotum is large enough, the tissue expander is removed, and more permanent implants are put in. See two pictures of scrotoplasties with implants done by The Crane Center.
Scrotoplasty can be done as a part of bottom surgery including phalloplasty or metoidioplasty, or as a later procedure after several months of healing.
Scrotoplasty is not required with phalloplasty, and may be chosen as a part of a vaginal-preserving phalloplasty. Scrotoplasty may be done along with metoidioplasty, too. If urethral lengthening is not chosen as a part of your gender affirming procedures, the urethra will be behind the scrotum, towards the back of the body.
If planning scrotoplasty as a part of phalloplasty, the timing might look something like this:
A typical “3-stage” approach for a radial forearm free flap phalloplasty with urethral lengthening, scrotoplasty, hysterectomy, vaginectomy, and penile implants performed by Johns Hopkins:
- Stage 1 – create the penis from the forearm skin graft
- hospital stay of four to five days
- time off from work may be up to 8 weeks
- five to six months for healing
- regular visits with occupational therapy for 6-8 weeks is not uncommon
- Stage 2 – connects old urethra to new urethra, vaginectomy, scrotoplasty, glansplasty
- hospital stay of up to a couple of days
- time off from work may be up to four weeks
- up to a year for healing
- Stage 3 – testicle implants and erectile device implants
- overnight hospital stay
- time off from work may be up to eight weeks
“Single-stage” phalloplasty combines stages 1 and 2. Phallo.net has a great diagram and description of staging options.
When: Expected Prep and Recovery For Scrotoplasty
Scrotoplasty, if done alone, can be done without an overnight hospital stay. Expect 7-10 days of soreness, bruising, and swelling. Sexual activity and vigorous exercise should be avoided for up to 8 weeks. Saddle activities such as bicycling can be done after healing.
Hair removal is not needed for scrotoplasty.
If scrotoplasty is being done along with other gender affirming procedures, there may be more extensive prep needed, and prep specific to each procedure may be needed. There may be multiple surgery dates with prep needed before each surgery, and healing afterwards.
How: Common Surgeon and Insurance Requirements
Like other gender affirming surgeries, you will likely need a letter from a mental health provider for your surgeon, along with a letter from your surgeon and/or hormone provider for insurance. Some organizations may still require two letters. They may also 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 surgeons would like a full year or more of testosterone use prior to a scrotoplasty.
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. If you have diabetes, your blood sugars will need to be well-controlled. Your surgeon or hormone provider will do a wellness exam prior to surgery to ensure that your health is optimized and you have the best chances for good healing and recovery.
Don’t know what your insurance covers? We’ve published several blogs on navigating insurance and we also provide care navigation appointments.
Why: Some Things To Think About
For each surgery in this series, we’ve talked about Form and Function.
What do you want your genitals to look and feel like?
If having a scrotum and testicles is part of your desired gender journey, scrotoplasty may be your choice.
While a scrotoplasty with or without implants does not perform a biological function, it can house the pump for erectile implants, and that’s a fun function, indeed.
Where: Surgeons Who Offer Scrotoplasty
Very many surgeons offer scrotoplasty, as they are also done for other reasons. You may have an overall better experience with providers who are explicitly gender affirming. Finding the right surgeon for you may be more or less difficult due to insurance and financial restrictions. Your hormone provider or primary care provider may be able to refer you to someone they know and trust.
Some other directories of surgeons include the following. Any surgeon who provides phalloplasty will likely also provide scrotoplasty.
- WPATH Provider Directory
- OutCare Health
- The r/TransSurgeries wiki on Reddit
We recommend talking to others in your communities to get recommendations, too.
Download our Questions To Ask Your Surgeon handout: