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 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 vulvovaginoplasty?
Vulvovaginoplasty is the creation of a vulva and a vagina.
People often use “vulva” and “vagina” interchangeably, or, most frequently, use the word “vagina” when they mean “vulva.” The same thing applies to bottom surgeries. Because it is possible to get a vulvoplasty without vaginoplasty (sometimes called a “zero depth vaginoplasty,” and to get vaginoplasty without vulvoplasty, we wanted to blog a bit about it.
The Vulva
In terms of body parts, “vulva” describes a set of external parts that can be for peeing, pleasure, and reproduction. This set includes the labia minora (the inner lips,) the labia majora (the outer lips,) the mons (the mound in front that is lower than the belly, sits on top of the pubic bone, and is where the labia majora meet,) the clitoris and its structures, the urethral opening (where pee comes out of the body,) and the opening of the vagina. The area between the clitoris and the perineum is called the vestibule.
It can be surprisingly hard to find a copyright-free diagram of the vulva that isn’t accompanied by potentially problematic text. We found one, and you can click through to see it here.
The Vagina
The vagina is a tube. Functionally, it allows some things into the body and lets other things out of the body. It often gets used in sexual activity (but doesn’t have to be!) and less often in reproductive activity.
A vulvovaginoplasty is a combination of separate surgical procedures that create a clitoris and clitoral hood, inner and outer labia, move the urethral opening, and create a vaginal opening and a vagina. The vagina may be “minimal” or “full” depth. Like a lot of bottom surgeries, you can customize (we discuss penile-preservation vaginoplasty, where the penis is kept when a vagina is constructed here.)
Existing tissues are used to create the new genitals. There are a few different techinques for vulvovaginoplasty. The main ones are:
PIV – penile inversion vaginoplasty
- A vaginal canal is created between the prostate and rectum. A penectomy and scrotectomy are done, and the tissues of the penis and scrotum are used to create the lining of the vaginal canal and the structures of the vulva.
- Depth of the vagina is limited by penis size. Some surgeons will also use additional tissues from the cheek or scrotum to line the vagina.
- We like these images from the Mayo Clinic for a visual description of how existing anatomy is used in a PIV
- We also like this color-coded set of images (1 – from a published article)
Peritoneal Pull-Through (PPT) vaginoplasty
- A vaginal canal is created between the prostate and rectum. Peritoneal tissue from the abdomen is used to line the vaginal canal.
- Tissues from the penis can be used to create the vulva.
- Vaginas created by PPT may be self-lubricating and can achieve more depth than PIV vaginoplasty.
- PPT is the technique used in penile-preserving vaginoplasty.
Rectosigmoid vaginoplasty
- A vaginal canal space is created between the prostate and rectum. A section of the sigmoid colon is separated from the colon and used to line the vaginal canal. The colon is re-attached to itself.
- Tissues from the penis can be used to create the vulva.
- Vaginas created by rectosigmoid vaginoplasty are self-lubricating and can achieve more depth than PIV vaginoplasty.
Some providers use a combination of techniques.
Other procedures that may happen during or in preparation for vulvovaginoplasty include:
- orchiectomy and/or scrotectomy
- clitoroplasty
- monsplasty
When: Expected Prep and Recovery for Vulvovaginoplasty
OHSU provides an excellent booklet on planning for vulvovaginoplasty.
Hair removal will be required for any skin that is used to create the vaginal canal. Your surgeon will provide information about what areas need to have hair removed
- MTFSurgery.net’s discussion on hair removal
- MozaicCare’s PIV hair removal handout
- MozaicCare’s PPT hair removal handout
We provide a longer look at prep and recovery here. OHSU offers a recovery plan worksheet and a detailed discussion in their booklet.
If you’re a smoker, your surgeon will require that you stop smoking a few months before surgery. If you have diabetes, your blood sugars will need to be well-controlled before surgery. You’ll need to arrange transportation, housing, a caretaker, and time off from work.
Many surgeons will recommend that you see a physical therapist who specializes in pelvic floors before surgery. More and more are recommending PT after bottom surgery, as well. Your anatomy changes a lot during surgery, and keeps changing during the healing process. A physical therapist can help you identify and learn how your new anatomy works.
Recovery is also similar to other bottom surgeries. Patients will stay in the hospital for up to a week after surgery, and will stay in bed for several days. The average time off from work is four to eight weeks. Lifting and activity restrictions will apply for up to eight weeks, and significant restrictions will apply for the first month. Your surgeon may want you to stay in the area for a month, so you may need to arrange housing.
How: Common Surgeon and Insurance Requirements
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. 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.
Why: Some Things To Think About
Form: What do you want your genitals to look like?
Function: How do you want your genitals to work?
Urination: the urethra and the structures around it are moved and changed significantly during vulvovaginoplasty. How you pee, will change and how you experience bladder-fullness and the urge to urinate may change, too.
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. Your new vagina will likely be pressure-sensitive, but not touch-sensitive internally. Discuss how much touch and erotic sensation you want to preserve before surgery – it may help you decide what kind of vaginoplasty to have.
Penetration: you may want to have penetrative sex using your vagina. The types of penetration you want may influence what kind of vaginoplasty to have. If you don’t want penetration, you can also opt for a “minimal” depth or “zero depth” vaginoplasty, which may mean a less complex surgery and shorter healing time.
Dilation: although PPT and rectosigmoid vaginoplasty maintenance require less dilation than penile-inversion vaginoplasty, some may still be required to maintain depth and width.
Lubrication: self-lubrication is possible with peritoneal and rectosigmoid vaginoplasty. This lubrication may be constant: panty liners may become a household staple.
Douching: douching can help maintain vaginal pH and help remove dead skin cells, old lube, and any other substances in the vagina. PIV requires douching indefinitely. PPT and rectosigmoid vaginoplasty may need less frequent douches.
Recovery: PPT and rectosigmoid vaginoplasties are more complex, involve more body systems, and have added risks compared to penile inversion vaginoplasty. 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 tissues of the scrotum and the lining of around the testicles may be used in building a vulva and vagina. It is possible to have a vaginoplasty without removing the testicles and scrotum, but there may be less room available for a vagina and fewer tissues available to create the vulva.
Where: Surgeons Who Offer Vulvovaginoplasty
There are many surgeons in the United States and the world who offer vulvovaginoplasty surgeries. Finding and choosing the right one for you can be an intricate process, and your choice may be narrowed due to insurance and financial restrictions.
We have a limited database of surgeons by procedure on our Gender Affirming Surgery page. It was designed for our internal use, so it contains medical terminology. Use with caution.
Some other directories of surgeons include
- TransHealthCare.org
- findplasticsurgery.org
- WPATH Provider Directory
- OutCare Health
- mtfsurgery.net
- The r/TransSurgeries wiki on Reddit
We recommend talking to others in your communities to gather recommendations, too.
Download our Questions To Ask Your Surgeon handout:
Citations:
- Bruce LK, Morris MP, Swanson M, Kuzon WM, Morrison SD. Post Penile Inversion Vaginoplasty Clinical Examination: Considerations and Techniques. Plast Reconstr Surg Glob Open. 2022 May 20;10(5):e4338. doi: 10.1097/GOX.0000000000004338. PMID: 35620498; PMCID: PMC9126509.
