Transfeminine Bottom Surgery

Gender affirmation surgery (also known as gender affirming surgery or gender reassignment surgery) for a transfemine person is sometimes called "bottom surgery."

There are three surgeries that can help a patient surgically transition from being a man to a woman. They are:

  1. vaginoplasty,
  2. vulvoplasty, and
  3. orchiectomy.

Vaginoplasty

During a vaginoplasty surgery, a surgeon creates both an outer and inner vagina by using skin and tissue from a penis. 

  • Your surgeon will use skin from the penis and scrotum to build the inner and outer labia of the vagina
  • Your surgeon will create a new opening for the urethra (so you can urinate)
  • Your surgeon will use tissue from your foreskin to build the new opening of the vagina (also called the introitus).

Vaginoplasty Procedure

During most vaginoplasties, your surgeon will use a skin graft to create a new vaginal canal (the inside wall of the vagina). To do this, your surgeon will take skin from your scrotum and thin it so it works well as a skin graft. 

If there’s not enough skin from your scrotum to make your new vagina, then your surgeon can take extra skin from the sides of your abdomen where there won’t be a very noticeable scar.

To make your new vaginal canal, your surgeon will create a space between your rectum and bladder. Once your skin graft is inserted, your surgeon will place gauze or spongy material inside the new vaginal canal for 5 days. The gauze puts pressure on the skin graft so it grows like it should into the surrounding vaginal tissue. 

Vaginoplasty & Orgasms

Many transfeminine people wonder if they’ll still be able to have orgasms after having a vaginoplasty.

Your surgeon will use skin from your penis to create a clitoris. This clitoris still has feeling, and most transgender women can have orgasm through clitoral stimulation. 

How Long Will I Be in the Hospital After Vaginoplasty?

Patients are in the hospital for 5 days and mostly rest in bed. Resting will help your skin graft grow into the surrounding tissue in your vaginal canal. 

Your surgeon will also place a compressive bandage on the outside of your vagina. After the outer and inner bandages are removed, most patients feel fine and can leave the hospital.

When Should I Start to Dilate my Vagina After Vaginoplasty?   

Each patient’s situation is different, but we recommend waiting 2 weeks after your surgery before you start dilating your vagina. Waiting two weeks will let your vagina heal.

Your surgeon will give you vaginal dilators to use at home. You should dilate your vagina 2-3 times each day for the first 6 months after your surgery.

Read this instruction sheet on how to dilate your vagina after having a vaginoplasty.

Preparing for Vaginoplasty Surgery  

There are several things that patients need to do before having a vaginoplasty. 

Have Electrolysis: The first thing you’ll need to do is have electrolysis hair removal on your scrotum and lower penile skin. Your vaginoplasty surgeon will use this skin to create your new vaginal canal. If hair were to grow inside your new vagina, it would create hygiene problems.

Quit Smoking: If you’re a smoker, it’s very important for you to quit. Smoking, vaping, or using any nicotine products decreases blood flow to the area around your genitals and will make it harder for you to heal after your surgery. 

If you’re a recent smoker, we will give you a nicotine urine test to make sure you’ve been able to quit completely. Nicotine takes about a month to wash out of your system before the test results will be negative. 

See if you need to lose weight: If you’re obese, it may be important for you to lose weight before you have surgery. Although there’s no weight cut off, the surgery will be much easier if you’re able to lose weight before the surgery. You may also have better results and outcomes after surgery if you lose weight.

For some people, vaginoplasty or vulvoplasty may not be possible because of their body shape and weight.

Physical Therapy for Vaginoplasty

Both before and after having a vaginoplasty, your surgeon will recommend that you start seeing a physical therapist. Physical therapy can help you prepare for this surgery.

Vulvoplasty

The vulva is the outside part of the vagina. A vulvoplasty is a type of surgery that uses skin and tissue from a penis to create all of the outside parts of a vagina (except for the vaginal canal). 

The steps of a vulvoplasty are the same as a vaginoplasty. During a vulvoplasty, your surgeon will:

  • create a clitoris out of the glans (or head) of the penis,
  • create an inner and outer labia from skin on the penis and scrotum,
  • create the opening of the urethra so you can urinate, and
  • create the introitus (opening of the vagina).

The only thing that’s different between a full vaginoplasty and a vulvoplasty is the internal part of the vaginal canal.

  • Vaginoplasty creates a vaginal canal.
  • Vulvoplasty creates all the parts of a vagina except for the vaginal canal.

After vulvoplasty, this means you won’t be able to have intercourse or insert a penis into your vagina. 

How Do I Choose Between a Vulvoplasty vs. Vaginoplasty?

A vulvoplasty has a much easier recovery. For example, you won’t need to dilate (or stretch) your vagina.

Another reason to consider vulvoplasty instead of vaginoplasty is because of medical problems or complications. One serious complication after vaginoplasty is called rectal injury. In some cases, a rectal injury can create a hole between your rectum and vagina.

But your chances of developing a rectal injury are much lower if you have a vulvoplasty instead of a vaginoplasty.

Sex & Vaginal Intercourse

Some patients know that they’re not interested in having vaginal intercourse. For these patients, a vulvoplasty may be a better choice.

After a vulvoplasty, you can still have orgasms through clitoral stimulation, just like with vaginoplasty. During a vulvoplasty, your surgeon will create a clitoris from the glans or head of the penis. 

How Long Will I Be in the Hospital After Vulvoplasty?

Patients usually are in the hospital for 3 days after having a vulvoplasty. Your surgical team will give you a compressive dressing that reduces inflammation (swelling) after your surgery.

Most patients rest in bed while they’re healing since the dressing is uncomfortable to walk with. 

After your dressing is removed, you can leave the hospital, usually right at about 3 days.

Orchiectomy

Many transgender patients choose to start their surgical transition process with an orchiectomy. Orchiectomy is a procedure where a surgeon removes the testicles.

For transfeminine patients, having an orchiectomy may also make your hormone regimen simpler later on. That’s because after the testicles are removed, the amount of testosterone (or male hormone) that your body makes drops to almost zero.

By dropping the amount of testosterone that’s produced by your body, you may be able to take less estrogen. 

Taking less estrogen may also lower your chances of developing blood clots and other health problems that may be associated with high doses of estrogens.

Hormones can be complex. It’s best to talk with your doctor who’s prescribing your hormones before you have an orchiectomy so that you understand exactly how your hormone therapy will change after surgery. 

Orchiectomy Procedure

Orchiectomy is a simple procedure and can be done under general or local anesthesia.

Your surgeon will make an incision (or cut) about an inch long in the middle of the scrotum. Then your surgeon will clamp your spermatic cord and tie some strong stitches around it to prevent bleeding. After that, your surgeon will cut your spermatic cord and remove your testicles. Your surgeon will then close your incision with absorbable stitches that will dissolve on their own.

Inside an operating room, the procedure takes about 20 minutes. You will be under general anesthesia so you won’t feel any pain. 

An orchiectomy can also be performed inside a urology clinic and will take about 20 minutes. If you would like to use local anesthesia instead of general anesthesia, your surgeon will give you some relaxing medicines before the procedure as long as you have a ride home afterward. 

Local anesthesia numbs your testicles and scrotum before your testicles are removed. Some patients feel a little discomfort when they’re getting the anesthesia injection.

Orchiectomy Recovery

You will have some bruising in your scrotum area after the surgery.  Complications are mostly related to bleeding inside the scrotum. 

The medical term for blood that accumulates (or pools) in the scrotum is a “hematoma.” But less than five percent of patients get hematoma after having an orchiectomy.

Like any surgery, you may have pain around your cut or where your testicles were removed. But this is also rare.

Even though orchiectomy is a small surgery, it’s considered “bottom surgery” by the World Professional Association for Transgender Health. For these reasons, patients must meet the criteria for surgery (see below).

Before Surgery

Any trans patient who wants to have orchiectomy, vaginoplasty, or vulvoplasty must meet the rules and standards (criteria) that are listed in a document called the “Standards of Care”.

These standards are published by the World Professional Association for Transgender Health (WPATH).  

We follow WPATH’s guidelines for transgender surgery. We feel these guidelines help make sure that patients are mentally and emotionally prepared for surgery, and also help us make sure that you have the best possible outcomes after surgery.  

World Professional Association for Transgender Health (WPATH) Criteria for Genital Surgery

To have transfeminine gender affirmation surgery, you will need two referrals from mental health professionals.

Orchiectomy in Transfeminine Patients 

Trans patients who want to have an orchiectomy must meet the following criteria:

  1. Persistent, well documented gender dysphoria;
  2. Capacity to make a fully informed decision and to consent for treatment;
  3. be the age of majority in a given country;
  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 (unless the patient has a medical contraindication or is otherwise unable or unwilling to take hormones).

Vulvoplasty or Vaginoplasty in Transfeminine Patients

Trans patients who want to have a vulvoplasty or vaginoplasty must meet the following criteria:

  1. Persistent, well documented gender dysphoria;
  2. Capacity to make a fully informed decision and to consent for treatment;
  3. be the age of majority in a given country;
  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 (unless the patient has a medical contraindication or is otherwise unable or unwilling to take hormones);
  6. 12 continuous months of living in a gender role that is congruent with their gender identity.

Mental Health Assessment

We also perform genital and breast/chest surgeries as medically necessary treatments for gender dysphoria only after the patient has been assessed by qualified mental health professionals.

The surgical team at University of Utah Health will perform these surgeries once there is written documentation that this a mental health assessment has occurred, and that the patient has met the criteria for a specific surgical treatment.

By following these procedures, mental health professionals, surgeons, and of course patients, share responsibility for the decision to make irreversible changes to the body.

Letters From Two Mental Health Providers

WPATH requires that all transgender patients who would like to have genital surgeries need two referral letters from licensed mental health providers. The mental health providers writing your letters should have a master’s degree or higher.

WPATH recommends that your referral letters for surgery include the following information:

  1. The client’s (your) general identifying characteristics
  2. Results of your psychosocial assessment, including any diagnoses
  3. How long your mental health professional has had a relationship with the client (you), including the type of evaluation and therapy or counseling to date
  4. An explanation that the patient meets the criteria for surgery, and a brief description of the clinical rationale for supporting the patient’s request for surgery
  5. A statement proving you as the patient are giving informed consent and consent to these surgeries
  6. A statement that the mental health professional is available for coordination of care and is willing to have a phone call with the surgeon to make sure your care is coordinated

Insurance Coverage

It is important that you talk to your insurance provider and ask them if transgender/gender dysphoria is an exclusion or benefit under your plan. We will need prior authorization from your insurance company before we begin any services or treatments for your gender transition. Insurance companies use the prior authorization process to ensure that your surgery is covered. This process can take up to six months depending on your insurance provider. Our team will keep you in the loop as we receive status updates. However, you can always call your insurance for updates too.

For any questions about the prior authorization process, please call us at 801-213-2195, option 1. If you reach our voicemail, please leave your:

  • name,
  • phone number, and
  • date of birth.

If our providers are not in-network, ask your insurance company if you would qualify for a gap exception. A gap exception can sometimes be granted as a covered service if there are no other in-network providers in the area who offer that service. Check our insurance information to verify whether University of Utah Health is in your network of coverage.

Please note that we are actively working with all of the payers in Utah to advocate for medically necessary care as a covered benefit. 

We Want Your Feedback

We are constantly evolving as a program and welcome any feedback from the community that will help us meet our mission to provide safe, gender-affirmative care at University of Utah Health. Please email us at transgenderhealth@hsc.utah.edu.