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Choosing to Have a Metoidioplasty

For transmasculine individuals seeking bottom surgery as part of their gender affirming process, metoidioplasty is one of the surgical options we offer. We understand that choosing to undergo this procedure is a big step for your gender affirming journey.

Our team of plastic surgeons and urologists will be there every step of the way to support you. It is our goal to make sure you feel comfortable and confident with your decision and satisfied with your results.

What Is Metoidioplasty?

Metoidioplasty is a gender affirming genital surgery for patients who want to create a small penis using their existing genital tissue.

The following procedures are generally performed as part of a metoidioplasty surgery:

  • Clitoral release — The tissues that hold the hormonally enlarged clitoris are divided. This allows the clitoris and its shaft to rotate outward.
  • Urethral elongation — The urethra is lengthened (tube that carries urine out of the body from your bladder) to move the opening to the tip of the newly created penis, using vaginal tissues from the labia minora. Sometimes, a graft will be taken from the lining of your mouth or cheek.
  • Vaginal mucosectomy & vaginal closure — The vaginal canal lining is removed and the canal is closed with absorbable sutures (stitches). This allows the tissues to heal together.
  • Scrotoplasty — A scrotum will be created rom the vaginal tissues of the labia majora. Testicular implants may also be placed at a later date. Both of these are optional.

WPATH Standards of Care

Our providers follow the WPATH SOC, which require TWO letters from qualified mental health care professionals prior to your surgery.

Criteria for Metoidioplasty

  1. Persistent, well documented gender dysphoria;
  2. Capacity to make a fully informed decision and to consent for treatment;
  3. Age of majority, which is 18 years old in the USA;
  4. If significant medical or mental health concerns are present, they must be well controlled;
  5. 12 continuous months of hormone therapy as appropriate to the patient’s gender goals;
  6. 12 continuous months of living in a gender role that is congruent with their gender identity.

We recommend that you regularly visit with a mental health professional or other medical professional. However, this is not deemed to be essential when considering if metoidioplasty is right for you.

What to Expect at Your First Appointment

At your initial consultations, you will meet with our urology and plastic surgery teams to discuss your goals for bottom surgery. One of our team's physician assistants or residents may be in this meeting. As a teaching hospital, it is our duty to train the next generation of surgeons to care for our transgender patients. 

Together, we will work with you to create a plan that best meets your goals. Patients who undergo metoidioplasty typically want to:

  • remove their current genitalia.
  • construct external genitalia and secondary sexual characteristics, which will look like a small penis and scrotum.
  • urinate while standing (an estimated 85 percent of patients can urinate while standing after metoidioplasty).
  • preserve their protective and erogenous sensations (clitoral nerves are not cut or connected to new nerves during metoidioplasty).
  • avoid large surgical scars in easily visible locations (such as the arms or legs).
  • have the option of a phalloplasty in the future, if desired.

During your first appointment, we will ask you questions about your:

  • goals,
  • gender transition story,
  • medical history,
  • family medical history,
  • current medications,
  • allergies, if any,
  • sexual history,
  • living situation & support network,
  • drugs and alcohol use, if any, and
  • your general health.

We will then go over a presentation with you that details every step of metoidioplasty.

Physical Exam

We will perform an external and internal physical exam of your genital area.  We understand that this may seem intimidating and uncomfortable. However, we will do everything we can to respect your privacy and ease your concerns. We will give you a detailed real-time breakdown of the exam so that you know what to expect without any surprises. 

Once the physical examination is complete, we will:

  • discuss the surgical options that fit your goals.
  • give you a packet and checklist to help you organize the next steps of your journey.
  • set up appointments and referrals, physical therapists, and fertility specialist, if interested.
  • introduce you to our schedulers who will assist you with insurance authorizations.

How to Prepare for Your Surgery

A patient will generally need to have a hysterectomy (removal of the uterus) and usually the ovaries and fallopian tubes. This will need to be done at least two to three months in advance of your metoidioplasty.

We encourage all of our patients to eat a well-balanced, protein-rich diet in the weeks leading up to surgery. Good nutrition, particularly eating protein, is essential to the healing process. Some people may wish to supplement their diet with a standard multivitamin. You may even want to consider meeting with a nutritionist before surgery. We are happy to refer you to one. 

Keep in mind that patients with a body mass index (BMI*) >35 are at a higher risk for wound healing problems and complications after surgery.  However, we understand that BMI is not a perfect measure of your overall health. We will discuss how your weight may affect you and the potential benefits of losing weight before surgery. If our team decides that weight loss is the best pre-surgical option for you, we will refer you to our weight management program.

Before surgery, you may also need to stop certain medications, particularly blood thinners or herbal supplements. As our surgery team goes over your list of current medications, we will be able to identify which ones you need to discontinue. You typically will not need to stop taking your hormones before your metoidioplasty.

Week Before Surgery

You should get rest, eat well, and exercise as you normally do.

If you have had previous scar contractures (thick, tight scars that prevent movement) after surgery, we may ask that you purchase vacuum tubes to use in the weeks following surgery. These tubes are applied over the metoidioplasty and help maintain the length as incisions heal and contract.

Day Before Surgery

You will give yourself a "bowel prep" to clean out your intestines. This is a precaution we take in case of an injury to the rectum during the vaginal mucosectomy and closure. If a rectum injury occurs, there will be less contamination if your bowels are cleaned out. 

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Metoidioplasty Risks & Side Effects

Gender affirming bottom surgery is a big surgery with many potential complications such as:

  • pain;
  • bleeding;
  • infection;
  • urethral fistula (a hole in the urinary channel leading to leakage of urine from an area it normally should not come out);
  • urethral stricture (a scar that can block urine flow);
  • abnormal urine stream such as spraying, leakage, or unusual angle;
  • potential changes in erogenous (sensitive to sexual stimulation) or touch sensations;
  • retained lining of the vaginal canal or fluid collections in the closed vaginal canal can occur, which may or may not have symptoms. However, these problems may require revision surgeries.
  • bowel injury during vaginectomy. This is a rare occurrence, but a colostomy (diverting the bowels to an opening in the the abdominal skin to allow in order to allow the bowel injury to heal) may be required.

If you wish to have a scrotoplasty, the scrotum may have delayed wound healing that requires dressing changes.

In most cases, we place the testicular prostheses (silicone testicles) into the scrotum at a later date to reduce the rate of complications. Testicular prostheses are a foreign body, which means you may be susceptible to infections or breakdown of the overlying skin. In these cases, you may need to take antibiotics to treat the infection or have the testicular prostheses removed.

Metoidioplasty: After Surgery

You should expect to be in the hospital for two to three days. We will prescribe you:

  • antibiotics to take for the first week to prevent infection,
  • pain medications,
  • anti-nausea medication,
  • a stool softener for constipation, a common side effect of taking some pain medications.

If we prescribe you any narcotic pain medications, we will help you minimize or wean yourself off of them as soon as possible. 

You will need to apply antibiotic ointment to your incisions and change the dry gauze dressings each day for the first two weeks. We will also schedule you for a weekly follow-up with our urology or plastic surgery team for up to four weeks after surgery.

You will have a catheter (a long, thin tube) passing through your elongated urethra into your bladder.  This will allow you to urinate and protect the elongated urethra as it heals. The catheter will drain to a leg bag for approximately four weeks after surgery/ We will remove it in the urology clinic. 

All scars contract (tighten) during the healing process. This contracture can shorten your metoidioplasty length.  At three to four weeks post-op, a vacuum device is sometimes used to help maintain the length of your metoidioplasty during healing. In some cases, this may be used for up to six months.

Revision Surgery Options

Our team wants you to be happy with your results. We will perform revision surgery based on follow-up discussions with you. Revision surgery may take place with our plastics team, urology team, or both, depending on the issue. We do offer BLISCare insurance to all patients undergoing gender affirming surgery. This generally covers any complications of surgery within the first 12 months. However, not all dissatisfied patients will have a complication. Sometimes, the issue of concern is cosmetic.  In these cases, you will discuss your concerns with your surgeons and decide on a plan. You may be required to pay for revisions that are cosmetic, but within the norms of expected surgical outcomes.