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Urogynecologic Care of the Transgender Patient

  • Urogynecology (S Pulliam and N Kohli, Section Editors)
  • Published:
Current Obstetrics and Gynecology Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

This paper aims to review the current data that exist on the urogynecologic needs of the transgender patient and to relay important clinical pearls that may be useful to assist providers in caring for this patient population.

Recent Findings

In one study, 7.5% of transgender women who had undergone vaginoplasty surgery had a stage 2 or greater prolapse; 3.8% required surgery to repair their prolapse; 47% reported voiding dysfunction; 25 and 17% reported urinary urgency and urge incontinence, respectively; and 23% had stress incontinence. In a large cohort of patients who had undergone vaginoplasty, the overall incidence of rectoneovaginal fistula was 1.2% (95% CI 0.6, 2.1) and revision surgery was more likely to be associated with the development of a fistula. The complications most associated with phalloplasty procedures performed in female-to-male patients are urethrocutaneous fistulae (22 to 75%) and urethral stricturing (25 to 58%).

Summary

Data on pelvic floor disorders as they relate to transgender patients is sparse; however, as we begin to see more and more of these patients in academic centers, their medical needs are being studied and the literature on this patient population is slowly becoming more robust.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Horbach SE, Bouman MB, Smit JM, Ozer M, Buncamper ME, Mullender MG. Outcome of vaginoplasty in male-to-female transgenders: a systematic review of surgical techniques. J Sex Med. 2015;12(6):1499–512.

    Article  PubMed  Google Scholar 

  2. Wangjiraniran B, Selvaggi G, Chokrungvaranont P, Jindarak S, Khobunsongserm S, Tiewtranon P. Male-to-female vaginoplasty: Preecha’s surgical technique. J Plast Surg Hand Surg. 2015;49(3):153–9.

    Article  PubMed  Google Scholar 

  3. Selvaggi G, Ceulemans P, De Cuypere G, VanLanduyt K, Blondeel P, Hamdi M, et al. Gender identity disorder: general overview and surgical treatment for vaginoplasty in male-to-female transsexuals. Plast Reconstr Surg. 2005;116(6):135e–45e.

    Article  PubMed  Google Scholar 

  4. Perovic SV, Stanojevic DS, Djordjevic ML. Vaginoplasty in male transsexuals using penile skin and a urethral flap. BJU Int. 2000;86(7):843–50.

    Article  CAS  PubMed  Google Scholar 

  5. Bouman MB, van der Sluis WB, Buncamper ME, Ozer M, Mullender MG, Meijerink WJ. Primary total laparoscopic sigmoid vaginoplasty in transgender women with penoscrotal hypoplasia: a prospective cohort study of surgical outcomes and follow-up of 42 patients. Plast Reconstr Surg. 2016;138(4):614e–23e.

    Article  CAS  PubMed  Google Scholar 

  6. Bouman M, van Zeijl MCT, Buncamper ME, Meijerink WJHJ, van Bodegraven AA, Mullender MG. Intestinal vaginoplasty revisited: a review of surgical techniques, complications, and sexual function. J Sex Med. 2014;11(7):1835–47.

    Article  PubMed  Google Scholar 

  7. Bouman MB, Buncamper ME, van der Sluis WB, Meijerink WJ. Total laparoscopic sigmoid vaginoplasty. Fertil Steril. 2016;106(7):e22–3.

    Article  PubMed  Google Scholar 

  8. Kuhn A, Santi A, Birkhauser M. Vaginal prolapse, pelvic floor function, and related symptoms 16 years after sex reassignment surgery in transsexuals. Fertil Steril. 2011;95(7):2379–82.

    Article  PubMed  Google Scholar 

  9. Hirata E, Fujiwara H, Hayashi S, et al. Intergender differences in histological architecture of the fascia pelvis pareitalis: a cadaveric study. Clin Anat. 2011;24(4):469–77.

    Article  PubMed  Google Scholar 

  10. Bucci S, Mazzon G, Liguori G, et al. Neovaginal prolapse in male-to-female transsexuals: an 18-year-long experience. Biomed Res Int. 2014;6:1–5.

    Article  Google Scholar 

  11. Nichols D. Sacrospinous fixation for massive eversion of vagina. Am J Obstet Gynecol. 1982;142:901–4.

    Article  CAS  PubMed  Google Scholar 

  12. Stanojevic DS, Djordjevic ML, Milosevic A, et al. Sacropsinous ligament fixation for neovaginal prolapse prevention in male-to-female surgery. Urology. 2007;70:767–71.

    Article  PubMed  Google Scholar 

  13. Loverro G, Bettocchi C, Battaglia M, et al. Repair of vaginal prolapse following penoscrotal flap vaginoplasty in male-to-female transsexual. Gynecol Obstet Investig. 2002;53:234–6.

    Article  Google Scholar 

  14. Frederick RW, Leach GE. Abdominal sacral colpopexy for repair of neovaginal prolapse in male-to-female transsexuals. Urology. 2004;64(3):580–1.

    Article  PubMed  Google Scholar 

  15. Henninger V, Reisenauer C, Brucker SY, Rall K. Laparoscopic nerve-preserving colposacropexy for surgical management of neovaginal prolapse. J Pediatr Adolesc Gynecol. 2015;28(5):153–5.

    Article  Google Scholar 

  16. Christopoulos P, Cutner A, Vashist A, Creighton SM. Laparoscopic sacrocolpopexy to treat prolapse of the neovagina created by vaginal dilation in Rokitansky syndrome. J Pediatr Adolesc Gynecol. 2011;24(2):e33–4.

    Article  PubMed  Google Scholar 

  17. Condous G, Jones R, Lam AM. Male-to-female transsexualism: laparoscopic pelvic floor repair of prolapsed neovagina. Aust N Z J Obstet Gynaecol. 2006;46(3):254–6.

    Article  PubMed  Google Scholar 

  18. Nowier A, Esmat M, Hamza RT. Surgical and functional outcomes of sigmoid vaginoplasty among patients with variants of disorders of sex development. Int Braz J Urol. 2012;38:380–6.

    Article  CAS  PubMed  Google Scholar 

  19. Djordjevic ML, Stanojevic DS, Bizic MR. Rectosigmoid vaginoplasty: clinical experience and outcomes in 86 cases. J Sex Med. 2011;8:3487–94.

    Article  PubMed  Google Scholar 

  20. Rawat J, Ahmed I, Pandey A, Khan TR, Singh S, Wakhlu A, et al. Vaginal agenesis: experience with sigmoid colon neovaginoplasty. J Indian Assoc Pediatr Surg. 2010;15:19–22.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Lima M, Ruggeri G, Randi B, Dòmini M, Gargano T, La Pergola E, et al. Vaginal replacement in the pediatric age group: a 34-year experience of intestinal vaginoplasty in children and young girls. J Pediatr Surg. 2010;45:2087–91.

    Article  PubMed  Google Scholar 

  22. Khen-Dunlop N, Lortat-Jacob S, Thibaud E, Clément-Ziza M, Lyonnet S, Nihoul-Fekete C. Rokitansky syndrome: clinical experience and results of sigmoid vaginoplasty in 23 young girls. J Urol. 2007;177:1107–11.

    Article  PubMed  Google Scholar 

  23. Imparato E, Alfei A, Aspesi G, Meus AL, Spinillo A. Long-term results of sigmoid vaginoplasty in a consecutive series of 62 patients. Int Urogynecol J Pelvic Floor Dysfunct. 2007;18:1465–9.

    Article  PubMed  Google Scholar 

  24. Parsons JK, Gearhart SL, Gearhart JP. Vaginal reconstruction utilizing sigmoid colon: complications and long-term results. J Pediatr Surg. 2002;37:629–33.

    Article  PubMed  Google Scholar 

  25. Hensle TW, Reiley EA. Vaginal replacement in children and young adults. J Urol. 1998;159:1035–8.

    Article  CAS  PubMed  Google Scholar 

  26. Swenson CW, DeLancey JO, Schimpf MO. Left-sided sacrospinous ligament suspension for treating recurrent sigmoid neovagina prolapse. Int Urogynecol J. 2014;25:1593–5.

    Article  PubMed  Google Scholar 

  27. Zhu L, Chen N, Lang J. Vault prolapse of sigmoid neovagina 26 years after vaginoplasty in Mayer-Rokitansky-Küster-Hauser syndrome: a case report. Int Urogynecol J. 2013;24:179–80.

    Article  PubMed  Google Scholar 

  28. Delotte J, Ferron G, Lim YKT, Querleu D. First laparoscopic repair of neovaginal prolapse following ileocecal reconstruction after resection of vaginal carcinoma. J Laparoendosc Adv Surg Tech A. 2009;19:67–9.

    Article  PubMed  Google Scholar 

  29. Yokomizo R, Murakami T, Naitou H, Yamada A. Treatment for prolapse of the sigmoid neovagina in Mayer-Rokitansky-Kuster-Hauser syndrome. Obstet Gynecol. 2002;100:1085–7.

    PubMed  Google Scholar 

  30. Matsui H, Seki K, Sekiya S. Prolapse of the neovagina in Mayer-Rokitansky-Kuster-Hauser syndrome. A case report. J Reprod Med. 1999;44:548–50.

    CAS  PubMed  Google Scholar 

  31. Freundt I, Toolenaar TA, Jeekel H, Drogendijk AC, Huikeshoven FJ. Prolapse of the sigmoid neovagina: report of three cases. Obstet Gynecol. 1994;83:876–9.

    CAS  PubMed  Google Scholar 

  32. Peyromaure M, Villet R, Jung JL, Szwarc G. Prolapse of neovagina after anterior pelvic exenteration for urethral cancer. Prog Urol. 2000;10:456–60.

    CAS  PubMed  Google Scholar 

  33. Hensle TW, Reiley EA. Vaginal replacement in children and young adults. J Urol. 1998;159:1035–8.

    Article  CAS  PubMed  Google Scholar 

  34. Kuhn A, Hiltebrand R, Birkhauser M. Do transsexuals have micturition disorders? Eur J Obstet Gynecol. 2007;131:226–30.

    Article  Google Scholar 

  35. Fitzpatrick C, Swierzweski SJ, McGuire EJ. Periurethral collagen for urinary incontinence after gender reassignment surgery. Urology. 1993;42(4):458–60.

    Article  CAS  PubMed  Google Scholar 

  36. •• Van der Sluis WB, Bouman MB, Buncamper ME, Pigot GLS, Mullender MG, Meijerink WJHJ. Clinical characteristics and management of neovaginal fistulas after vaginoplasty in transgender women. Obstet Gynecol. 2016;127(6):1118–26. This is a very large study looking at the incidence of rectoneovagial fistula in transgender women who underwent vaginoplasty surgery. The study provides us with a lot of important data regarding this rare but very morbid complication

    Article  PubMed  Google Scholar 

  37. • Obedin-Maliver J, Light A, de Haan G, Jackson RA. Feasibility of vaginal hysterectomy for female-to-male transgender men. Obstet Gynecol. 2017;129(3):457–63. This is a recent analysis looking at female-to-male patients who have undergone hysterectomy and assessing the feasibility of performing hysterectomy vaginally for these patients

    Article  PubMed  Google Scholar 

  38. Stojanovic B, Djordjevic ML. Anatomy of the clitoris and its impact on neophalloplasty (metoidioplasty) in female transgenders. Clin Anat. 2015;28:368–75.

    Article  PubMed  Google Scholar 

  39. Selvaggi G, Bellringer J. Gender reassignment surgery: an overview. Nat Rev Urol. 2011;8:274–82.

    Article  PubMed  Google Scholar 

  40. Morrison SD, Son J, Song J, et al. Modication of the tube-in-tube pedicled anterolateral thigh flap for total phalloplasty: the mushroom flaap. Ann Plast Surg. 2014;72:22–6.

    Article  Google Scholar 

  41. Frey JD, Poudrier G, Chiodo MV, Hazen A. An update on genital reconstruction options for the female-to-male transgender patient: a review of the literature. Plast Reconstr Surg. 2017;139(3):728–37.

    Article  CAS  PubMed  Google Scholar 

  42. Zhang Y, Lu L, Zhang W, Jiang H, Zhu X. A simple and effective method for phalloplasty in female-to-male transsexuals. Plast Reconstr Surg. 2010;126(5):264e–265e.

  43. Aköz T, Kargi E. Phalloplasty in a female-to-male transsexual using a double-pedicle composite groin flap. Ann Plast Surg. 2002;48:423–7.

    Article  PubMed  Google Scholar 

  44. Hage JJ, De Graaf FH. Addressing the ideal requirements by free flap phalloplasty: some reflections on refinements of technique. Microsurgery. 1993;14:592–8.

    Article  CAS  PubMed  Google Scholar 

  45. Perovic SV, Djinovic R, Bumbasirevic M, Djordjevic M, Vukovic P. Total phalloplasty using a musculocutaneous latissimus dorsi flap. BJU. 2007;100(4):899–905.

    Article  Google Scholar 

  46. The World Professional Association for Transgender Health. Standards of care for the health of transsexual, transgender, and gender nonconforming people. 2011. Available at: http://www.wpath.org/site_page.cfm?pk_association_webpage_menu=1351&pk_association_webpage=3926. Accessed 30 Jan 2017.

  47. Rashid M, Sarwar SR. Avulsion injuries of the male external genitalia: classification and reconstruction with the customised radial forearm free flap. Br J Plast Surg. 2005;58(5):585–92.

    Article  PubMed  Google Scholar 

  48. Rohrmann D, Jakse G. Urethroplasty in female-to-male transsexuals. Eur Urol. 2003;44(5):611–4.

    Article  PubMed  Google Scholar 

  49. Leriche A, Timsit MO, Morel-Journel N, et al. Long-term outcome of forearm flee-flap phalloplasty in the treatment of transsexualism. BJU Int. 2008;101(10):1297–300.

    Article  PubMed  Google Scholar 

  50. Kim SK, Moon JB, Heo J, et al. A new method of urethroplasty for prevention of fistula in female-to-male gender reassignment surgery. Ann Plast Surg. 2010;64(6):759–64.

    Article  CAS  PubMed  Google Scholar 

  51. Fang RH, Kao YS, Ma S, et al. Phalloplasty in female-to-male transsexuals using free radial osteocutaneous flap: a series of 22 cases. Br J Plast Surg. 1999;52(3):217–22.

    Article  CAS  PubMed  Google Scholar 

  52. Nikolavsky D, Yamaguchi Y, Levine JP, Zhao LC. Urologic sequelae following phalloplasty in transgendered patients. Urol Clin N Am. 2017;44:113–25.

    Article  Google Scholar 

  53. Levine LA, Elterman L. Urethroplasty following total phallic reconstruction. J Urol. 1998;160(2):378–82.

    Article  CAS  PubMed  Google Scholar 

  54. Monstrey SJ, Ceulemans P, Hoebeke. Sex reassignment surgery in the female-to-male transsexual. Semin Plast Surg. 2011;25(3):229–44.

    Article  PubMed  PubMed Central  Google Scholar 

  55. Lumen N, Monstrey S, Goessaert AS, et al. Urethroplasty for strictures after phallic reconstruction: a single-institution experience. Eur Urol. 2011;60(1):150–8.

    Article  PubMed  Google Scholar 

  56. Morey AF, McAninch JW. When and how to use buccal mucosal grafts in adult bulbar urethroplasty. Urology. 1996;48(2):194–8.

    Article  CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. Center for LGBT Care, Center for Urogynecology & Pelvic Reconstructive Surgery, Obstetrics, Gynecology & Women’s Health Institute, Cleveland Clinic, Cleveland, OH, 44195, USA

    Cecile A. Unger

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  1. Cecile A. Unger
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Cecile A. Unger declares that she has no conflict of interest.

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Unger, C.A. Urogynecologic Care of the Transgender Patient. Curr Obstet Gynecol Rep 6, 274–281 (2017). https://doi.org/10.1007/s13669-017-0224-0

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