Transgender Vaginectomy: What You Need to Know

Pros

• Transmasculine or nonbinary patients may find this to be a gender-affirmating procedure.
• Because the vaginal canal is sealed off during vaginectomy, the procedure can prevent prolapse.
• Undergoing vaginectomy removes the risk of vaginal cancer and related health concerns.
• The aesthetic outcome can be quite good. “This surgery tends to heal well. It's usually a straight line closure, and this area of the body tends to recover well overall,” explains Dr. Praful Ramineni, a plastic surgeon in Washington, DC. 

Cons

• The layer of tissue between the back wall of the vagina and the rectum can be very thin, so there’s a chance of injury to the rectum during the procedure.
• A vaginectomy doesn’t always heal well, due to the nature of the tissue involved. Mucosa tissue, like the tissue found in your mouth, doesn’t bond together. If it’s not properly or thoroughly removed—or, in some cases, if it regenerates on its own—this inhibits healing. “If that happens, you can get cysts, or it can create openings, and then it can drain to the outside,” Dr. Ramineni says.
• Even in the best of surgical circumstances, there is a high risk of infection. “This is not a truly clean surgery,” explains Dr. Ramineni. “A vaginal cavity has a lot of bacteria in it, even if you clean everything out.”
• If your provider is redirecting your urethra during your vaginectomy, complications during healing can cause urination challenges.

As we mentioned, a vaginectomy is usually preceded by a hysterectomy. Though there is a case to be made for doing both procedures in one operation, the tissue may be more susceptible to bleeding and tearing. “If you do it in two stages, there’s less swelling and stress along the area,” says Dr. Ramineni. “Most surgeons will wait three to six months for the first surgery to heal and to let a patient’s body recover from blood loss” before performing the vaginectomy procedure. 

Here’s what to expect: 

• First, you’ll be given general anesthesia.
• Then your surgeon will start the procedure by removing the mucosal lining, “which is usually done by either stripping that area away from the edges and taking it off piece by piece, or burning the area to cauterize the edges,” Dr. Ramineni explains. Cauterizing the tissue allows the vaginal canal to adhere to itself and heal. 
• Your surgeon can also remove vulvar tissue, such as the labia majora and labia minora, if desired. However, most patients who also plan on having a scrotoplasty leave their labia majora intact because that tissue can be used to create the scrotum. 
• Finally, they’ll suture the vaginal orifice closed.

Transmasculine patients may choose to subsequently undergo phalloplasty, metoidioplasty, or scrotoplasty, often with testicular implants.

You can have scrotoplasty without vaginectomy, but it can create challenges. “You want a stable, soft tissue platform for the scrotum,” says Dr. Ramineni. 

Leaving a vaginal orifice also increases the risk of poor healing after a scrotoplasty.

It’s not recommended to undergo metoidioplasty without a vaginectomy, if you’re having your provider reconstruct your urethra to redirect urine flow through the neophallus. 

“If you're trying to divert the urine stream, usually you have to borrow some of the tissue in the area, generally from the labia minora,” says Dr. Ramineni. “You want as much tissue support behind this area as possible to prevent the formation of a fistula.”

Patients who heal well will likely be fully healed (or almost there) 6 weeks post-procedure. 

As you recover, avoid stress on your genital area. “When you close things off, you're not only closing the inside, but also the outside portion, which means it may be a little bit tight in that area,” explains Dr. Ramineni. “If you're sitting on it too much, doing a lot of exercise, or stretching that area, you could actually pull those tissues apart.”

The most common complications after a vaginectomy are related to poor wound healing, due to the challenges of operating on the vaginal mucosa and the natural bacteria within the vagina. 

“There's a higher risk of infection, drainage, and poor healing than with other surgeries,” says Dr. Ramineni. “This is a ‘clean contaminated’ surgery.”

Follow your provider’s aftercare instructions, to keep the area as clean as possible and stay alert to signs of infection.