La vaginoplasty represents one of the principal gender-affirming surgical procedures for transgender women, aimed at creating external and internal genitalia that are congruent with the individual’s gender identity. Over recent decades, advances in surgical techniques have significantly improved anatomical and functional outcomes; however, the long-term success of the procedure depends not solely on the surgical act itself, but also on appropriate and rigorous post-operative management.
The surgical stages, in brief
Vaginoplasty is a complex procedure carried out in several surgical stages, traditionally divided into an ablative phase and a reconstructive phase, each with specific objectives. The ablative phase involves the removal of the internal and external male genital structures, in particular the penis and the testes. This phase entails the irreversible loss of reproductive function and represents a fundamental step in the gender-affirmation pathway.
The subsequent reconstructive phase is aimed at the creation of functional and anatomically congruent female external genitalia. This includes the construction of the vulva, with the formation of the labia majora and labia minora, as well as the repositioning of the urethra to enable urination in a seated position. A central element of the reconstruction is the creation of the neoclitoris, fashioned from a previously preserved portion of the glans, with the aim of maintaining sensitivity and supporting a satisfactory sexual response.
Post-operative complications impacting vaginal function
Vaginoplasty may be associated with various post-operative complications which, to varying degrees, can affect the functionality of the neovagina and the patient’s quality of life. Such complications may arise in the early post-operative period or at a later stage following surgery, and may involve different anatomical regions:
- Tissue healing complications: these include delayed wound healing, wound dehiscence, tissue loss or areas of partial necrosis, sometimes associated with local infection or the formation of granulation tissue.
- Neovaginal canal complications: these may result from scarring processes or inadequate adherence to dilation protocols and include stenosis, reduced vaginal depth, or prolapse of the neovagina and adjacent structures.
- Bleeding and haematomas.
- Pain and sexual dysfunction: dyspareunia and pelvic or genital pain may be associated with vaginal stenosis, pelvic floor hypertonicity, or local hypersensitivity, with an impact on sexual function.
- Aesthetic and neoclitoral complications: an unsatisfactory aesthetic outcome may necessitate secondary revision procedures. Complications affecting the neoclitoris, such as altered sensitivity or ischaemic changes, may significantly influence sexual function.
- Urinary and rectal complications: these may include voiding dysfunction, urinary tract infections, urethral stenosis and, more rarely, urogenital or rectovaginal fistulas.
- Thromboembolic complications: a risk inherent to all major surgical procedures, which can be mitigated through appropriate perioperative prophylactic measures.
The fundamental role of dilators
Following vaginoplasty, maintaining the patency and depth of the neovagina represents a crucial objective in preventing many of the complications outlined above. In this context, the regular use of pelvic floor dilators constitutes an essential component of post-operative management. Dilators, available in rigid or flexible versions, allow gentle tissue stretching, counteracting scar contracture and promoting appropriate remodelling of the neovaginal canal.
The dilation regimen is tailored according to the surgical technique employed, the time elapsed since surgery, and the patient’s individual tolerance, typically involving daily use during the initial weeks and subsequently a reduced but consistent frequency. Adherence to this protocol not only decreases the risk of stenosis and the need for revision procedures, but also contributes to the preservation of sensitivity and comfort during sexual activity. Finally, the use of dilators forms part of a multidisciplinary follow-up pathway, which may include psychological support, pelvic floor physiotherapy and regular clinical monitoring, thereby helping to ensure satisf
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