PRE-OP FREQUENTLY ASKED QUESTIONS:​

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Pre-op age requirements?

• Patients must be18 years old in order to undergo surgery.

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Pre-op insurance requirements?

• Insurance companies generally follow WPATH guidelines. WPATH guidelines currently require 2 letters from providers, one can be your primary care or hormone specialist and the other from a mental health specialist.

• However, many insurance companies follow the previous WPATH recommendations of 3 letters: 1 from your hormone specialist and 2 mental health letters from 2 separate mental health providers. For more details on the letter requirements, please go under our new patient tab and choose the letter option.

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California sterilization state law requirements:

• Non-Federally funded (not Medi-cal or Medicaid) patients, must be 18 years old to undergo elective sterilization surgery (orchiectomy, removal of the testes). Exceptions to this rule include the following: under 18 years of age and have entered into a valid marriage OR is on active duty with the U.S. armed services OR received a declaration or emancipation OR is at least 15 years of age, live apart from your parents or guardians, and manage your own financial affairs.

• Federally funded (have Medi-cal or Medicaid) patients, must be 21 years of age to undergo elective sterilization surgery (orchiectomy, removal of the testes).

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Hair removal requirements? 

• Hair removal is required prior to undergoing most forms of vaginoplasty procedures. This can be done with either laser hair removal or electrolysis. Hair removal can take 6-12 months depending on genetics and response of hair follicles.

• What hair needs to be removed? Please see our surgery specific hair removal guides. These can be download and taken with you to your local hair removal specialist.

• Insurance coverage for hair removal? We provide a letter with our initial consult for patients to submit to their insurance to facilitate coverage, if insurance covers hair removal. If you have not had a surgical consultation and would like to start on hair removal, ask your hormone or primary care specialist to write a letter stating that hair removal is medically necessary for surgery.

• Starting hair removal prior to your initial consultation may facilitate shorter wait times for surgery. If the 6-12 months of hair removal is already completed and you have the appropriate letters stated above, surgery can sometimes be scheduled within 3 months.

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How long do I have to be in the area?

• We require patients stay in the Bay Area for 4 weeks. A pre-op visit can be up to 1 week prior to surgery and then 3 weekly post-operative visits are required. Everyone needs to be seen in person pre-operatively. This cannot be done over the phone. A physical exam is needed. 

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Does my place of recovery have any distance requirements?

• All surgical patients must stay in the Bay Area for a total of 3 weeks post-surgery.

• We require that you stay in San Francisco County and within 30 traffic minutes from our office for the first 2 weeks post-surgery.

• For your final week in the Bay Area, you may stay within 30 driving miles from our office location and are not required to stay in San Francisco County.

• Justification: The first 2 weeks after surgery is the time when some emergencies can happen. If 911 is called, they will take you to the closest emergency room which may not be equipped to see our post-operative patients and where we may not have facility privileges to treat patients.

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Why do I only have 2 nights in the hospital and I have to stay longer in the area but other providers have patients stay 5 days in the hospital and they get to leave shortly after?

• Luckily, more insurances are covering vaginoplasties. There are regional differences in what is covered and is considered standard of care as far as hospital stays.

• We have a lot more restrictions for preoperative and post operative recovery than some other places. This is due to our experience with the recovery of vaginoplasty. This procedure is one of the biggest procedures you can have, mostly from a maintenance and recovery aspect.

• The recovery is physically, mentally, emotionally and socioeconomically more involved than a lot of other surgeries. However, this recovery is mostly outpatient. Remember California is the home and birth place of managed care and tends to lead the nation in care. Shorter stays in the hospital are geared for need for IV medications and initial monitoring after surgery, but also balancing the need to protect you from hospital infections and unnecessary interventions. Recovery monitoring after the first 3 days/2 nights is mostly reassurance. We provide more access and visits immediately after surgery (first 3 weeks) with text/emails/phone calls to in-person visits, and access with emails, phone calls, in person, telehealth visits scheduled every 3 months for the rest of the year. Unscheduled visits, emails and phone calls are promptly responded to within one business day, if not sooner depending on the situation.

• East Coast tends to take longer to follow the current trends in hospital stays.

• Note that traditionally this surgery was cash pay and performed by plastic surgeons who owned their surgery centers. Patients stayed for the week in the hospital/clinic then were discharged to go home after their initial post operative instructions were given. Most patients then traveled home and did not have local support for their surgery. This is a set up for more issues and complications.

• Please note, if there is a medical issue or complication, this may mean a longer stay than 2 nights.

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Traveling: Why am I so swollen after my short flight?

• Even a short flight can cause swelling. We recommend ice packs, Motrin and rest after any flight.

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Support Person:

• Your support person is required to be in the area from the day you are discharged from the medical facility until after your 3-week post operative visit. 

• There can be a team of support people, but there must be someone continuously available and no gaps in coverage. You must have someone with you 24/7 throughout the duration of your stay in San Francisco.

• Your support person does not have to have a medical background.

• Your support person will be responsible for making sure you get from the medical facility to your place of recovery, that you are fed, taking your meds, emptying your foley/urine bag the first week, ensuring you are getting to your appointments, and available to call if there is an emergency.

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Is there a BMI (body mass index) cutoff for vaginoplasty?

• Yes, we require patients to have a BMI between 19 and 35 for surgery. If you are not sure what your BMI is, you can input your height and weight from any BMI website. 

• This is a safety precaution for anesthesia, post-op recovery, infection, aesthetics and scarring, ability to physically dilate/maintain/keep area hygienic and to minimize complications.

• If your BMI is outside these limits at your pre-op appointment, surgery may need to be canceled or delayed.

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Hormone Dosage?

• We have evaluated the WPATH SOC8 and currently available hormone studies. Preliminarily, the risk of clots and issues does not seem to be increased in low risk individuals continuing their current dosage. As of 1/15/2023, we will no longer be requiring low risk individuals to decrease their estrogen preoperatively. 

• Please bring your own estrogen supplies for your stay here.

• Note we will not be prescribing any estrogen while you are in the hospital but you can resume the day of discharge from the hospital.

• If you have a higher risk of blood clots, you will have to stop your estrogen 6 weeks prior to surgery and resume 2 weeks after. We will let you know based on your medical history if this applies to you.

• Progesterone does not have to be discontinued.

• If you are taking any testosterone supplements, these do not need to be discontinued.

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Why is it important to have an active relationship with a mental health provider?

• Pre-Operative: The World Professional Association for Transgender Health requires assessment prior to an irreversible surgery like those involving sterilization procedures.

• Post-Operatively: No matter what the surgery, there is a post-operative blues condition that occurs for everyone. The bigger the surgery, the bigger the blues. On average it occurs 2-3 months after a big surgery. This will manifest in inability to concentrate, fatigue and depression. It is important to have a mental health provider visit scheduled about 2 months after surgery or for when these symptoms start to manifest as occurrence can be variable. The episode lasts approximately 2-4 weeks but is different for everyone. It is important to have a provider that knows you in order to be able to guide you through this experience. 

• It is also helpful to let your support system know ahead of time about the above symptoms, in order to signal you to make your appointment with your mental health provider.

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Affidavit letters for Gender Affirmation?

• Can I get a letter saying I’ve had my surgery, so I can get legal documents changed to reflect my true gender?  Yes, letters from our office verifying you have undergone vaginoplasty surgery can be requested after your surgery. These letters are usually required to be notarized by a Notary Public. Please allow 14 business days from date of request to receive your documents. Physician declaration letters or other documents requiring notarization will incur the cost of the services rendered by a notary republic.

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POST-OP FREQUENTLY ASKED QUESTIONS:

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Why is my perineum opening up?

• Very commonly, after your bandages have been removed, the skin has a lot of rebound swelling. This can cause tension on the perineum which is the area at the bottom of the vagina that connects the vagina and anus. Separation will happen more than 50% of the time, so don't be nervous if this area opens up. This is one of those expected aspects of your recovery and healing process. This area will take time to heal and we want it to heal naturally. If we put this area back together immediately, there is an increased risk of infection, which can lead to prolonged healing, more scarring, and discomfort.  You should continue to cleanse the area using a squirt or spray bottle with one of our recommended cleansing solutions (Dakin’s Solution or 1 cup water with 1 Tbsp of Hydrogen Peroxide). This should be done twice daily and after every trip to the restroom.

• Swelling typically is maxed at post op week 2 (recommendation is to limit walking to 2 blocks 3 times/day). If someone is walking more than 4 blocks 3 times/day on the 3rd post operative week (e.g. going on a long hike), then swelling can increase further. Continuing ice packs, non-steroidal anti-inflammatory meds like ibuprofen (as long as you can take this medication), and over the counter arnica can also help with swelling.

• Air travel and prolonged car rides will also increase swelling in the immediate postoperative period. Once your travel has been completed, please go home, lay down, apply ice packs, non-steroidal anti-inflammatory meds like ibuprofen (as long as you can take this medication), and over the counter arnica.

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My catheter is not emptying; what should I do?

• If you notice your catheter is not emptying for more than 1-2 hours, it is often positional. Make sure the collection bag is to gravity and try different positions (standing, side lying, etc).  If these are unsuccessful, please reach out to our office as you may need to go to the nearest Emergency Room to have the catheter flushed (ideally CPMC Davies Campus or Saint Francis Memorial Hospital).

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Is it ok that I have small blood clots in my catheter/tubing?

• Very commonly, small flecks or clots of blood appear in the catheter, especially toward the end of the week.

• Also it is common to feel urethral irritation and burning with a catheter in place.

• The catheter irritates your urethral lining, which can cause both of the above.

• The antibiotics that are prescribed will cover any possible urinary tract infection, but please contact our office if you have a fever of 101.0F or greater.

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Is it ok if some urine is squeezing out around the catheter?

• It is ok and a good sign that some urine squeezes out when your bladder is contracting. This means the urethral swelling may be decreasing and the next bladder trial has a better chance of succeeding.

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My dressing is gapping open and stuff is falling out, what should I do?

• Gapping of the surface covering is common in creases like the perineum​, bottom crack and groin. You can try over the counter paper or medical tape to see if this helps. Usually the dressing gaps open again with movement. Please try to keep the area clean and hold/press your dressing against your skin while having bowel movements. Wipe from front to back after bowel movements. If some stool gets into edge of dressing, do not dig underneath the dressing, just clean the outside as much as you can. Stool cannot get onto your incisions or in your vagina. We will need the remaining dressing to stay in place until your scheduled post op visit.

• If there is some gauze sticking out: you can push the gauze back into place, but if it still hangs out or gets dirty, then trim. But do not pull on the gauze.

• The gauze that may fall out is outside of the vagina and not the vaginal packing which is separate and the vaginal packing stays well inside.

• You will also notice a black sponge underneath the dressing. This is not blood, the sponge is black.

• Swelling starts to increase under the dressing towards the end of the week- usually Saturday and Sunday you will notice an increase in pressure and pain on the outside. Continue to ice and take your pain regimen.

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Why am I bleeding?

• If you are having blood soaking through your first-week dressing or filling the wound vacuum canister, please contact our office. If you call after office hours, please go to the nearest Emergency Room (ideally CPMC Davies Campus or Saint Francis Memorial Hospital).

• If you are having bleeding after the first week, make sure you are dilating the vagina and not the urethra. If you are dilating correctly and soaking more than two pads in an hour, please contact our office.

• If you are bleeding after the second to third month, it is commonly from benign scar tissue called granulation tissue. Granulation tissue is common during the first year of healing. It is vascular tissue and can resemble a bloody polyp or flat red/pink tissue. It may resolve on its own, but seeing your surgeon can help expedite healing. We either excise or cauterize the area. Sometimes applying Medi-Honey or Clobetasol cream over the affected area helps over the course of 1-2 months. 

• Please refer to the picture on Common Post Op Issues for Examples of Normal and Abnormal Bleeding.

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What is a normal and abnormal amount of bleeding?

• Please refer to the picture on Common Post Op Issues for Examples of Normal and Abnormal Bleeding.

• Immediately Post Operatively: In the first two weeks, a small amount of bleeding onto the dressings or pads is expected.

• First 3 months: Intermittent bleeding can occur postoperatively as part of healing within the first 3 months after surgery. Please make sure you are dilating the vagina and not the urethra. Also check for signs of a bladder infection (see FAQs and Videos on Bladder Health/ Gyn 101).

• Within the first year after surgery, occasional bleeding or dark brown discharge can be seen on pads. This is usually due to granulation tissue which commonly occurs within the first year after surgery. While scary, it's benign bleeding. This will be taken care of on your post-operative visits at 3, 6, 9, and 12 months. If unable to return to our office, please see a local provider like a gynecologist. Again, please make sure you are not accidentally dilating your urethra and also check for signs of a bladder infection (see FAQs and Videos on Bladder Health/ Gyn 101)

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What are the pads that I should buy for post vaginoplasty recovery?

• 2 types:

• First is a feminine pad geared for vaginal bleeding. You will need maxi-pads for heavy bleeding initially then with time you can move to the daily underwear liners when discharge lightens up - somewhere between 2-3 months.

• Immediately post-operatively it will be nice to have a pad to protect your bedsheets. They are usually called medical "chucks" pads but exactly the same & less expensive are puppy pee pads. 

 

How often should I change my pads? 

• Whenever you go to the restroom

• Whenever they are covered with discharge

• Whenever they start having an odor

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What brand pads should I buy?

• Does not matter, as long as it's economical and does the job

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How do I clean my incisions post-operatively?

• Common solution of dilute hydrogen peroxide: obtain hydrogen peroxide from store and dilute 1 tablespoon of hydrogen peroxide in 1 cup of tap water

• Spray or Squirt bottle: place solution in bottle and spray or squirt minimum 3x/day or whenever you use the restroom. Pat dry.

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Bowel Movements, what is up with the change?

• After vaginoplasty surgery, a lot of patients have questions about bowel movements - how to have one, what to expect, what is and is not normal.  So here is some information that you will hopefully find helpful.

• At the end of your surgery, we put a whole bunch of packing material inside the vagina, and this puts a lot of pressure on the rectum.  After surgery, the nerves down there are really confused, so sometimes this pressure can feel like needing to have a bowel movement.  But for many patients, their first bowel movement isn’t until many days after surgery, and in really rare cases not until the packing comes out the following week.  

• The most important thing to know for bowel movements after surgery is that we don’t want you to push or strain or bare down or hold your breath.  Ideally you will just relax your bottom muscles and things will flow out.  It’s common to see changes in the texture or color of your stool or even a little bit of blood if there is dripping down from the bottom of the dressing.  Heavy bright red bleeding from the anus would not be expected and we would want to hear about that as soon as possible. You also may feel some popping during a bowel movement, this is normal post-operatively and you have not damaged anything. Sometimes sitting on a normal toilet seat can be uncomfortable because those seats are designed to kind of pull the butt cheeks apart, so some patients find sitting on just one cheek is more comfortable, or even just picking up the seat all together and sitting on the rim of the toilet.  When you’re finished going to the bathroom, we want you to be really gentle when cleaning up and once the outside bandage is off you will be instructed to spray the area with a dilute hydrogen peroxide solution and gently dab the area dry.

• Both constipation and diarrhea are really common after surgery.  Constipation tends to be more uncomfortable and can lead to straining - which again we want to avoid - so you will be given stool softeners while in the hospital to prevent this.  At home, we recommend daily Miralax for at least the first week and for as long as you are taking narcotic pain medication.  You can also add once or twice a day Colace and things like Smooth Move Tea or Prune Juice if the Miralax isn’t enough.  And drinking lots of water is also really important. 

• On the flip side, some patients have diarrhea after surgery, sometimes because of the stool softeners and also the antibiotics you are receiving.  And unfortunately stooling accidents are also common.  It’s okay if some stool stains the bottom of your dressing.  There’s no way for poop to get into your dressing or into the vagina.  Overall it’s preferable to err on the side of a little diarrhea over constipation, but if you’re having a lot of diarrhea it’s okay to take less of the stool softeners.  If you’ve stopped all of your stool softeners and still have uncontrollable frequent diarrhea, you can try a dose of Imodium but please use this with caution as it can really back you up.  

• Common to have bloody stools for first few weeks after surgery.

• There will be a lot of new sensations and experiences after vaginoplasty surgery, and having bowel movements is definitely one of them!

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How do I douche?

• There are many over the counter brands - it doesn't matter which one as long as it is unscented. Follow their instructions.

• Generally, you insert the nozzle just in the opening of the vaginal and squirt the bottle.

• Alternatively, once you get comfortable, there are many home kits you can use. Google options. Insert the nozzle or end of the catheter/tube into the vagina and squirt the solution.

 

What solution do I use to douche?

• There are many brands or over the counter versions - it doesn't matter which one as long as it is unscented.

• Home solutions involve vinegar, apple cider, or diluter hydrogen peroxide (1 table spoon in 1 cup of water).

• All of these solutions are acidic which help flush out bacteria that build up with skin grafted vaginal lining.

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Why do I need to douche? I heard douching was bad.

• For neovaginas vs natal vaginas, there is less lubrication and self-cleaning oven effect, and natal acidic pH which keeps the flora in check.

• Neo vaginas tend to be more basic with a pH of 7 vs natal vaginas with an optimal pH of 4.4

• To compensate for the above, douching is needed to flush out skin cells, dried up lube, and overgrowth of bacteria that like to hang out in basic pH vagina, which is why douches are acidic.

 

How often do I douche?

• First week post op - douche every day

• Second week post op - douche every other day

• Third week and ongoing - 1-2x/week minimum

• If you start having a fishy odor - commonly this is from bacterial overgrowth and you can increase your douching regimen to cleanse out the overgrowth and re-acidify your vagina

 

Why am I numb and also having sharp zinging pains throughout my pelvis, vulva and clitoris?

• Nerves can initially be numb or super sensitive.  Though they heal very slowly, while they are "waking up" they can produce sharp zingy pains anywhere you have had surgery. This does not mean something has gone wrong, this is part of the normal nerve healing process.

• Nerves regenerate and heal very slowly, typically it can take up to one year post operatively to see what the final results of sensation are, and sometimes even up to eighteen months.

• Risks of surgery are that certain areas remain numb or with decreased sensation, these are typically the actual scar sites or incision sites. For instance, scars where you have had a cut or accident before feel a little different than the surrounding skin once the area heals.

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Post Operative Period 1-4 months

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Why is Dilating becoming harder?

• Remember that depth is more important than width or size of the dilator. If it is starting to hurt, go down in size and increase in frequency until you can go back up to the larger sized dilator. This may take several weeks to months. 

• Between month 2-4 after surgery, the body goes through a healing process that stiffens the muscles, ligaments and scar tissue around the vagina. Patients commonly have a period of time when dilating becomes more difficult. We recommend taking more time, going down in size of dilator (if you have increased size), dilate more frequently from at least 3x/day to 4-5x/day. Once dilation becomes easier, you can decrease to your baseline number of times of dilation and increase your dilator size.

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Why do I feel suture poking out and or tender hard red spots?

• ​All sutures will be eventually absorbed or the body will push them out. Sutures dissolve at varying times from 10 days to 4 months. The sutures used in areas of most tension (along clitoral hood, labia minora and the perineum near the bottom of the vaginal opening) will have delayed absorption of up to 4 months. Typically, at 3 months after surgery, these suture knots are causing redness and tenderness points which will heal with time.

• If the areas of redness and tenderness are getting bigger, more tender, have any discharge, or you experience a fever - please contact our office for evaluation for possible infection. If unable to come into our office due to distance, please be evaluated locally for possible infection.

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I had the peritoneal flap procedure and I am having continuous vaginal discharge that moistens my underwear, is this normal?

• Discharge: One of the differences between a penile inversion vaginoplasty and a peritoneal pull through vaginoplasty is that the peritoneal lining produces a little bit of a watery discharge which skin grafting does not do.  This discharge can be clear or white or yellowish, but is usually thin and odorless.  The amount of discharge is quite variable - some patients have just a little bit and others have to wear underwear liners every day to catch that extra moisture to prevent their underwear and pants from getting wet.  And because this is a relatively newer procedure, we don’t yet have data to say how likely it is that the discharge will be a little or a lot. 

• All vaginoplasty patients have discharge of variable colors during the first 3 months.  By about the 3 month mark you will have a better sense of what’s normal for you.  And if the discharge ever changes - especially if it becomes thick or develops an odor - that could be a sign of an infection so you should increase your douching to twice a day for a couple of weeks and if it persists, go see your primary doctor or gynecologist for evaluation.

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Post Operative Period 1-12 months

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When should I be able to orgasm?

• There is a range of as little as a few months to as long as a year for having a clitoral orgasm. On average, most patients tend to have their first clitoral orgasm around 9 months. Remember, nerves take longest to heal, so be patient and if at first you do not succeed, try, try again.

• G-spot orgasm: post-operatively the other erogenous zone is the prostate, which is approximately 4 cm inside the vagina on the top wall. Patients can also experience an orgasm with stimulation of this area. This also may take time but can happen sooner than the clitoral orgasm. Range is as little as a few weeks to as long as a year.

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How do I go about having an orgasm?

• Unfortunately there is not one set of instructions that would work for everyone. This is an experimentation type of process because everyone is different and also as the nerves heal, different stimulations may feel better. Be patient during the first year since it does take time for the nerves to heal, as well as time for you to learn your body and what you like stimulus-wise.

• There are 2 erogenous spots: the clitoris and the G-spot (where the prostate is located) approximately 4cm inside the vagina on the top/anterior/bladder side of the vagina. Gently rubbing these spots separately or together will help you find your way to an orgasm.

• Experimenting with either touching these spots directly, gently at first since these areas may be extremely sensitive (or numb depending when you are trying during your first year of nerve regeneration), or gently touching, rubbing massaging the areas around the clitoris and the G-spot may work for you.

• Be patient, experiment, have fun.

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Why do I have a sudden resistance to dilating?

• Please make sure you are not dilating the urethra

• At your first office visit after vaginoplasty surgery, we will remove the packing from the vagina and teach you how to dilate.  We have a few other videos on our website that talk about dilating in detail, but one thing we wanted to emphasize is that it’s very important that the dilator isn’t going into the urethra.  This could cause damage to urethra and lead to bladder infections, and more importantly means that the vagina is not being dilated and could start to scar closed.  As a quick anatomy review, we have a picture on our website as well detailing anatomy, the urethra is where the urine comes out and is located below the clitoris and above the vaginal opening. 

• Signs that you might be trying to dilate the urethra would be - the dilator all of sudden only goes a little ways in and won’t go in any more, or new sharp pain with trying to put the dilator in, a sudden abrupt difference in tightness of the dilating regimen, or sometimes bleeding with urination after dilating.  If you ever experience any of these things and are concerned that you may be dilating your urethra, remove the dilator, pause, take a deep breath and relax, and then try to re-insert the dilator at a lower angle. Sometimes you can use a finger to guide the dilator below the urethra if you can feel the urethral opening.

• Never try to force anything if you are unsure. Rewatch the videos and readjust your angles. If things still don’t seem right and you aren’t sure you’re dilating correctly, please reach out to us ASAP.

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General Questions:​

• Do different linings have issues with tearing?  As long as nothing sharp is being inserted into your vagina, including piercings, then it does not matter what the lining is: natal vaginal mucosa, skin grafting, tunica vaginalis, peritoneal lining, colon, or other. These linings should not tear with insertion of non-sharp items and normal pressure at apex.

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