Sex reassignment and plastic surgery with Dr. Pierre, Brassard, Montreal, Canada

Here are some guidelines and information that I have learned over the years after 1500 SRS in regards with M. to F. SRS. They should be read with an opened mind. They will certainly be improved for accuracy .Anyone who cares genuinely for an SRS patient will realize that we have still much to learn and that the patients should be praised for the courage they show during a long and difficult journey. Fortunately most will be relieved after surgery and live an happier life. I welcome questions, observations and calls if you are caring for a patient of mine.

Appearance

In most patients the vulva looks swollen and bruised and the bruising can extend to the groins and upper thighs. There is either  a crust ,a piece of gauze and/or blood clot on the small lips. The clitoris is invisible, it is hidden between the small lips and behind the hood. It becomes visible after 4 to 6 weeks. There can be a small dehiscence at the posterior entrance (fourchette) where the tension on the incisions is greatest. The opening of the urethra (meatus) is difficult to find visually ,it is located immediately above the entrance of the vagina. The inner lips will start at the hood and continue downward to the meatus of the urethra. They can be quite swollen and asymmetric during the first month .The bright red inner lining is urethral mucosa will become pink in time ( 1 year).

Swelling

It is considerable for months. One will see that it goes slowly away for a good year. It is surprising to observe that the vulva changes so significantly for 9 to 12 months. The details of the vulva will refine over that period of time. Some asymmetry can become evident but it will gradually improve back to the immediate postop symmetry.

Stitches

There are 2 types of sutures (vicryl and monocryl) that are used. All are resorbable. Some take 21 days to resorb others will take 60 days. Knots and strings can be seen along the process. The knots should be left alone and the strings gently pulled and cut. They can also be ignored if they are not annoying because they will resorb on their own.

Bleeding

Bleeding in small amounts is usual for 2 to 4 weeks after surgery. It should never be enough to drip and make clots. In that case there is a bleeder that needs to be addressed. Local pressure should be the first reflex for 10 minutes. Slow daily bleeding is secondary to unhealed surfaces inside or outside. Most surfaces will heal quickly during the first month thus reducing the bleeding. Granulated areas that are friable can cause chronic bleeding.

Skin slough

Because most of the lining inside the vagina is made of grafted skin, it is common to see pieces of “dead skin” coming out of the vagina. What is actually seen is superficial layers of graft peeling off.If they hang loose they can be cut off without pulling. Contraction, reepithelialisation and healing of this will happen in time. It is not possible for the lining of the vagina to come out, although patients may fear it.

Urination

The urinary catheter is removed on the 6th day postop. At first urination can be in one stream and quickly become one big spray. This is normal and seen in all patients and can last 2 to 4 months. Beyond that period, if still present, it can be caused by an irregularity at the meatus. This will be addressed surgically only one year postop.

Urinary tract infection

Because the vaginoplasty causes limited nerve damage around the prostate, sphincters and bladder it alters the normal physiology of urination. Added to that is the fact that the urethra is shorter and thus germs are closer to the bladder making patients prone to bladder infection. Keeping  urine clear and proper urine testing pre and post treatment are indicated. In general patients will develop bladder infections in the few months after their surgery. The proneness to this problem tends to disappear after 2 to 4 months.

Granulation tissue

The granulation tissue is a normal finding in the M to F patient. It occurs most often at the posterior entrance of the vagina (fourchette).If kept clean and flat it will heal in time. It can be of variable extent and is caused at the fourchette by tension at the incision. One way to reduce tension is to make sure that while sitting there is no upward traction of the buttocks. Simply a patient should sit straight and not slide on the chair…If the granulation tissue becomes thick or pedicled it cannot heal on its own and needs the application of AgNO3 (silver nitrate) which is available to any doctor or nurse. The AgNO3 will cauterize it .This treatment may need to be repeated every 2 weeks until it is healed. We think that thick granulation tissue is caused by  germs and  also needs some kind of topical antibiotic like sodium fusidate cream. Granulation tissue may appear anywhere in the center of the vulva and should be addressed the same way.

Ointment

In general patients will use polysporin on the incisions after surgery. It should be discontinued after dilation day number 10.Beyond that the ointment tends to irritate the skin.

Discharge

Colored discharge is part of healing in some patients. During the first 2 months patients will douche and bathe twice a day to have proper hygiene. Color and odor will be controlled well with the hygiene measures that patients learned at the convalescence house. Increasing pain, with changed color and full odor are signs of acute vaginosis and should be treated accordingly (cultures, systemic antibiotics, close follow-up on the treatment efficacy).In general patients should obtain within their 2 months of douching a clear return of  the douching solution (absence of blood and discharge) and stop douching after 2 months .Discharge and/or blood beyond 2 months is tolerated somewhat for another 2 months after which it should be considered a low grade infection .Visual examination of the cavity is to be considered. If granulation tissue is found in the cavity is found it should be treated with AgNO3 every 3 to 4 weeks and metronidazole gel 1%.The gel should be used sparingly with the applicator or as a lubricant during dilations until discharge has subsided ( sometimes for weeks…). Oral Metronidazole 500mg twice daily for two weeks usually is given at the beginning of the treatment. Douching with normal saline solution helps clean the cavity without causing a change in the vaginal flora.

Intercourse

It is generally accepted that 2 months after the surgery will be enough for sufficient healing for “reasonable” intercourse. Discharge and/or blood after intercourse is a sign of inner lining break and should be protected (see “discharge”).

Personal hygiene

Patients learn how to care for themselves at the Asclépiade recovery center. Our trained staff show every step of the way how to dilate, douche ,take care of incision lines .Patients should bathe twice a day and douche every day for two months .After that they can go back to one bath a day and stop douching.

Hair removal

Three months should elapse before any hair removal is done near the surgical site.

Sports

In general patients can start light sport activities after 6 weeks and increase very slowly the intensity.

Orgasm

The onset of orgasm vary tremendously. Some rare patients will experience their first orgasm the second week after their surgery. Others will have to wait two years. An orgasm can be accompanied with ejaculation. In general there is a decrease in sexual drive and libido for a few months after surgery. For a good part of patients sex is not a priority.

Examination by P.C.Physician

Vaginal canal

There is no need to examine the vaginal canal during the first year if there is no discharge or bleeding. At one year postop a visual examination of the cavity can be done to verify the integrity of the inner lining. Hair can be found inside on occasions and can be pulled. Sometimes they fall and accumulate inside at he dome. If in great numbers they will need to be cauterized. CO2 laser is never an option in the cavity.

Prostate

It should be examined through the vagina and it will be found at the antero-inferior portion of the vaginal canal.

Recto-vaginal fistula

A RV fistula can occur after S.R.S. in one patient in 400.It will show up during the first 6 weeks after surgery. The first symptoms will be gas expulsion through the vagina and gas through the anal canal will no longer be. Feces and/or fecal material will be found on the dilator or exiting through the vagina. The patient will be apyretic and will not present with pain. A definitive diagnosis is crucial and should be confirmed without any doubt by a visual examination and confirmed and localized by X-Ray .The patient surgeon needs to be advised and should participate in the investigation and care. In principle, care for a fistula starts quickly after confirmation by stopping the dilation regimen, fistula repair after 6 months and vagina reconstruction after 12 months. In general colostomies are unnecessary and should be kept as a treatment of last resort.

Protracted pain

Pain is usually well controlled with infrequent narcotics and anti-inflammatory during the second and third week postop. Beyond that protracted pain is caused by unhealed raw areas at the entrance of the vagina which can be helped with topical lidocaine gel. If there is no sign of raw areas and the pain is intense ,a deep infection can explain the symptoms .Infection and necrosis of the corpus cavernosum stump is possible. Enzymes rich pus can cause the irritation .A culture and wide spectrum antibiotics should be prescribed.

CT-SCAN anomaly

Rarely patients will have an investigation and a CT-SCAN is done .The alarming response from the radiologist can be describing an unidentified mass above the pubic bone with or without a loculation of fluid. It can be interpreted as a tumor ,cyst or abscess. It is, in reality ,the folded neurovascular pedicle of the clitoris(Buck’s fascia, blood vessels and nerves)! It does not explain a fever in a patient, It should NOT be explored surgically needless to say.

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