Vaginoplasty

Complications
Cecile A. Ferrando, MD, MPH

KEYWORDS
 Transgender surgery  Gender affirmation surgery  Vaginoplasty  Complications

KEY POINTS
 Adverse outcomes vary in severity; some can be treated with conservative management strategies,
whereas other events are considered true complications and require prolonged care and/or
surgery.
 With regard to complications related to penile inversion and intestinal vaginoplasty, neovaginal
stricture or stenosis is the most commonly reported adverse outcome.
 After vaginoplasty surgery, patients may experience pelvic floor disorders including neovaginal pro-
lapse, voiding dysfunction, urinary urgency and urge urinary incontinence, and stress urinary incon-
tinence.

INTRODUCTION modifications have been made over time to

Complications after vaginoplasty surgery for the
transgender woman exist. These adverse out-
comes can be minor and easily treatable, although
others are considered major events and require
ongoing care. The purpose of this article is to re-
view the current data that exist on complications
associated with vaginoplasty surgery and to relay
important clinical pearls that may be useful to
assist providers in caring for this patient popula-
tion. Prospective data on vaginoplasty-related
complications are sparse; however, as we begin
to see more and more of these patients in aca-
demic centers, their medical needs are being stud-
ied and the literature on this patient population is
slowly becoming more robust.
PENILE INVERSION VAGINOPLASTY
Brief Overview of Technique
The most commonly performed technique for
primary male-to-female transgender vaginoplasty
improve both functional and cosmetic out-
comes.2–4 The procedure is irreversible and
includes orchiectomy, penile deconstruction, for-
mation of a sensate neoclitoris from a portion
of the glans penis on its dorsal neurovascular
pedicle, urethroplasty, creation of a vaginal cavity
between the rectum and bladder with a neovagina
that is lined with a local penoscrotal skin flap, and
vulvoplasty to create external female genitalia. The
surgery can be performed by a variety of surgical
specialists in plastic surgery, urology, and gyneco-
logic specialties.
Complications Associated with Penile
Inversion Vaginoplasty
Perioperative complications
Adverse outcomes related to vaginoplasty surgery
vary in severity and some can easily be treated with
conservative management strategies and/or small
revision surgeries, whereas other events are
considered true complications and require pro-
plasticsurgery.theclinics.com

is penile inversion vaginoplasty.1 The technique longed care and/or surgery to address the prob-
has been widely researched and described, and lem. In a recently published metaanalysis by

Disclosures: UpToDate, Inc. royalties for authorship.

Center for LGBT Care, Center for Urogynecology and Pelvic Reconstructive Surgery, Obstetrics, Gynecology and
Women’s Health Institute, Cleveland Clinic, Cleveland, OH 44195, USA
E-mail address: ungerc@ccf.org

Clin Plastic Surg - (2018) -–-

https://doi.org/10.1016/j.cps.2018.03.007
0094-1298/18/Ó 2018 Elsevier Inc. All rights reserved.
2 Ferrando
Horbach and colleagues,1 the authors sought to
report on outcomes after vaginoplasty procedures.
Their main outcome measures were complications,
neovaginal depth and width, sexual function, pa-
tient satisfaction, and improvement in quality of
life. The authors found that the majority of studies
were retrospective case series of low to intermedi-
ate quality. With regard to complications, neovagi-
nal stricture or stenosis was the most commonly
reported adverse outcome with an incidence of
12.0% (range, 4.2%–15.0%). Other complications
included partial necrosis of the vagina (range,
2.7%–4.2%), clitoral necrosis (range, 1%–3%),
genital pain (range, 3%–9%), rectal injury (range,
2%–4.2%), rectovaginal fistula (range, 0.8%–
17.0%), neovaginal prolapse (range, 1%–2%),
urethral meatal stenosis (range, 1%–6%), change
in voiding function (32%), urinary incontinence
(19%), wound dehiscence (range, 12%–33%),
local abscesses (5%), and hematoma (3%).
In a retrospective case series of transgender
women who had undergone vaginoplasty, Raigosa
and colleagues5 reported similar complications
published in the above analysis. In this series, 1
patient experienced a postoperative hematoma
requiring drainage, 2 patients returned with a neo-
vaginal stricture requiring a Z-plasty revision, 2 pa-
tients were found to have a rectovaginal fistula
(one underwent surgical repair, and the other
was managed conservatively), there was 1 intrao-
perative rectal injury that was repaired and did not
develop into a fistula, 4 patients experienced
wound dehiscence, and 5 patients were found to
have some degree of urethral stenosis necessi-
tating either catheter dilation or urethroplasty. Of
importance, the authors found that almost 1 in 4
patients requested esthetic revision surgery with
either lipofilling, scar revision, and/or removal of
excess skin.
Papadopulos and colleagues6 reported on 40
cases of male-to-female vaginoplasty using a
modified inversion technique using the spatulated
urethra and a scrotal skin graft anastomosed to
the penile skin flap to form the neovagina. The
most commonly reported adverse events were
wound healing delay (25%), an uncentered urinary
stream (22.5%), genital pain (15%), bladder infec-
tions (15%), and postoperative bleeding (12.5%).
The incidence of intraoperative rectal injury in
this cohort was 7.5% (n 5 3) with no reported
postoperative fistulae. Most of these complica-
tions were managed with conservative manage-
ment strategies and patients had satisfying
postoperative outcomes.
Some of these complications can be avoided at
the time of surgery with careful perioperative plan-
ning and the preemptive use of certain strategies.
In our practice, we routinely place vulvar/labial
drains to prevent postoperative hematoma forma-
tion, which can lead to delayed wound healing and
abscess/infection. These drains are left in place
during the patient’s hospital stay and are removed
once sanguineous drainage is determined to be
inconsequential (usually on postoperative day 3).
We also avoid the use of nonsteroidal analgesic
medications in the first 48 hours after surgery.
The use of broad-spectrum antibiotics can also
be helpful in reducing the risk of infection in the
immediate postoperative period. To prevent neo-
vaginal stricture and stenosis, patients are coun-
seled about the need for consistent vaginal
dilator use and aggressive dilator regimens are
recommended for the first 3 months after surgery.
Patients are then advised to dilate once daily
unless they are regularly sexually active and expe-
riencing penetrative neovaginal intercourse. Coun-
seling patients before surgery and showing them
how to use a dilator with live and video instruction
is helpful and may prevent poor compliance after
surgery. Patients who experience vaginal narrow-
ing or structuring remote from surgery may be
treated initially with aggressive dilation to attempt
to reform the neovaginal cavity. Instead of the rigid
dilators typically used for postoperative dilation,
soft silicone dilators should be considered
because they are easier to use when the neovagi-
nal caliber and length has been compromised as a
result of scarring. Adjunctive use of oil-based lubri-
cants can also be helpful to soften the tissues lin-
ing the vagina and may help with stretch at the
time of dilation. Patients with stenosis who fail
dilator therapy may require revision surgery with
re-creation of the neovaginal cavity and re-lining
of the cavity with a new graft. Other patients may
be candidates for intestinal vaginoplasty surgery
described elsewhere in this article.
Pelvic floor disorders after vaginoplasty
surgery
In a cohort study by Kuhn and colleagues,7 out of
52 male-to-female patients who had undergone
vaginoplasty surgery, 7.5% of patients were found
on examination to have a stage 2 or greater neova-
ginal prolapse (3.8% required surgery to repair
their prolapse), 47% reported voiding dysfunction,
25% reported urinary urgency, 17% reported urge
urinary incontinence, and 23% had stress urinary
incontinence.
Of the pelvic floor disorders discussed, prolapse
after vaginoplasty surgery is the most commonly
reported in the literature; however, most reports
are case based and few large studies exist looking
at the prevalence of prolapse after neovaginal sur-
gery in transgender patients. Some data exist on

the use of prophylactic suspensions at the time of
the index surgery. In 2014, Bucci and colleagues8
published a report on the incidence of neovaginal
prolapse in 282 patients who underwent male-to-
female vaginoplasty surgery. In this cohort, pro-
phylactic suspension had been performed using
either Denonvilliers fascia or the prerectal fascial
supports present within the vesicorectal space.
No true ligamentous suspensions were performed.
The authors reported a total of 17 prolapses (6%),
16 partial (5.7%) and 1 total (0.3%), all occurring
within 6 months of the index surgery.
Sacrospinous fixation is a possible neovaginal
suspension procedure that can be performed at
the time of vaginoplasty to prevent prolapse in
the future. The technique used can be adapted
from the original technique described by Nichols.9
The neovaginal space is created in a standard
fashion by transecting the central perineal tendon
and creating a space between the rectum, urethra,
and bladder with sharp and blunt dissection. The
right pararectal space can be opened by pene-
trating the pararectal fascia an identifying the
ischial spine and adjacent sacrospinous ligament.
A suture carrying device can be used to place
delayed absorbable or permanent sutures through
the ligament, which can then be placed through
the apex of the grafted neovaginal tube. Once all
sutures are anchored through the apex, they can
be tied down, suspending the apex to the
ligament.
The largest cohort studied to date was pub-
lished by Stanojevic and colleagues.10 The authors
looked at 62 male-to-female patients who under-
went concurrent prophylactic sacrospinous sus-
pension at the time of neovagina creation during
vaginoplasty surgery from 1997 to 2005. Patients
were followed for a median of 32 months (range,
7–102 months). The mean vaginal length was
10.7 cm (range, 9.5–16.0 cm) and 76% of patients
reported having the ability to have penetrative
vaginal intercourse. Of the patients, 3 presented
with an anterior vaginal wall bulge, which was cor-
rected with a simple excision. The only complica-
tion associated with concurrent suspension was
mild right buttock pain (n 5 2), which was short
lived and self-resolving.
It is not clear what method of colpopexy is best
to treat prolapse of the neovagina after vagino-
plasty. There are no large databases studying
this issue, and most of the data that exist are
from case reports and series. Transvaginal and
perineal approaches to prolapse are more compli-
cated in transgender women because the surgeon
performing the procedure must have a good
awareness of male pelvic anatomy, and the neova-
ginal reconstruction itself makes the tissue planes
Vaginoplasty Complications 3
of dissection more complicated. For this reason,
an abdominal approach with sacrocolpopexy
may be a better option for these patients. Both
Loverro and colleagues11 and Frederick and
Leach12 report the use of the open abdominal sac-
rocolpopexy technique to repair neovaginal pro-
lapse after vaginoplasty in male-to-female
patients and Henninger and colleagues13 and
Christopoulos and colleagues14 report on a lapa-
roscopic approach to sacrocolpopexy for the
treatment of neovaginal prolapse in a vaginal
agenesis patient. There are no large studies
comparing nonabsorbable mesh grafts with
absorbable biologic grafts and so a recommenda-
tion regarding graft material does not exist. Alter-
native approaches have also been described.
Condous and colleagues15 describe a laparo-
scopic paravaginal defect repair using principles
usually applied to colposuspension in the natal
female. The authors describe using a permanent
suture to reattach the lateral aspects of the neova-
ginal vault to the iliococcygeus fascia through an
intraperitoneal approach followed by suspension
of the paravaginal tissues to the iliopectineal liga-
ment bilaterally through a retropubic approach.
As mentioned, almost one-half of transgender
women may experience voiding symptoms after
vaginoplasty surgery. In a small series of 18
male-to-female patients, Kuhn and colleagues16
reported that a diverted stream (n 5 9 [50%]),
feeling of incomplete emptying (n 5 4 [22%]),
recurrent urinary tract infection (n 5 4 [22%]), over-
active bladder (n 5 1 [6%]), and stress urinary in-
continence (n 5 3 [16%]) were common
problems. The authors did not assess for the pres-
ence of these symptoms preoperatively; therefore,
the true effect of vaginoplasty surgery on these
symptoms is not clear. Despite this, they do point
out that patient self-reported “happiness” about
having had the surgery was not associated with
the absence or presence of these symptoms
and, overall, most patients were very happy having
undergone the procedure.
The underlying cause of urinary symptoms after
vaginoplasty in transgender women is not clear. In
their small study, Kuhn and colleagues16 postulate
that these symptoms could be a result of several
factors. Many of these patients have smaller pros-
tates compared with natal male counterparts as
the prostate becomes atrophic in the setting of
long-term exogenous estrogen use. A smaller
prostate could theoretically increase the risk of
stress urinary incontinence symptoms, allowing
more urine to pass through the urethra during
times of increased Valsalva pressures. Direct
sphincter injury and denervation can also
contribute to stress symptoms. Although most
4 Ferrando
techniques avoid this type of injury, it is plausible
that this could happen. It is also likely that there
is a pelvic floor component to these symptoms.
During this part of the procedure, the levator ani
muscles are partially transected and spread later-
ally to allow for the creation of a space large
enough to create a neovagina of normal caliber
and depth. Disruption of the muscles may lead to
pelvic floor dysfunction, which translates into diffi-
culty with emptying the bladder, sensations of
incomplete emptying, and other voiding and uri-
nary symptoms. Pelvic floor physical therapy
may be useful in these clinical scenarios, and in
our practice, we have trained therapists who
work with postvaginoplasty patients to help
manage postoperative urinary symptoms, as well
as patients presenting with postoperative myofas-
cial pelvic pain (discussed elsewhere in this
article).
Placement of a suburethral sling in a postopera-
tive patient is very challenging and anatomically
impossible in some cases, depending on how
the vaginoplasty surgery was performed. Although
male slings do exist and are placed by urologic
specialists, once the anatomy is altered after vag-
inoplasty, this type of procedure does not become
as routine. In our practice we have found that tran-
surethral bulking of the bladder neck (we use
Coaptite, Boston Scientific, Marlborough, MA)
often works in this patient population. In 1993,
Fitzpatrick and colleagues17 published a case
report describing successful management of
stress urinary incontinence with cystoscopic injec-
tion of collagen in a male-to-female patient who
had undergone vaginoplasty surgery. To our
knowledge, there are no other case reports
describing the management of incontinence in
transgender individuals. In our experience, bulking
works for patients with uncomplicated stress in-
continence and should be considered first line in
symptomatic patients.
Often, voiding symptoms are a result of urethral
meatal stenosis, abnormal scarring over the
meatus, or bulky residual corpus spongiosum tis-
sue that causes the urethral meatus to point for-
ward or upward. Most patients complain of
problems with their urinary stream, whereas others
report urinary retention (in cases of stenosis).
These problems can occur in up to 1 in 5 women
undergoing vaginoplasty and can often be cor-
rected with small revision surgeries of the
meatus.18,19
Very few data exist on the prevalence of myofas-
cial pain symptoms after vaginoplasty. In our
experience performing this procedure, these
symptoms can occur in a subset of the patient
population and can be troublesome, because
postoperative dilation to maintain the neovagina
can become challenging, and the patient’s quality
of life can be significantly affected. As described,
this type of pain is often a result of the dissection
needed to create the neovaginal cavity. Postoper-
atively, the patient may experience spasticity of
the pelvic diaphragm containing the levator ani
muscles and resultant pain and discomfort. The
clinical diagnosis can be made in the office with
patients positioned in lithotomy. An internal trans-
vaginal examination of the pelvic floor muscles re-
veals hypertonicity, spasticity, and tenderness. If
the diagnosis is made, referral to physical therapy
with dilator therapy is imperative and, in our expe-
rience, patients have significant improvement in
their symptoms if they comply with a rigorous
physical therapy regimen. Sometimes, concurrent
pain management is necessary. We recommend
avoiding narcotic medications and have found
success with the use of neuropathic medications
likes Neurontin. If pain symptoms are hard to
manage in the short term, referral to a pain man-
agement specialist may be necessary as an
adjunct to physical therapy.
Neovaginal fistula
Rectovaginal fistulae can occur as a result of rectal
injury (recognized and unrecognized) during vagi-
noplasty surgery; as a result of postoperative ab-
scess, infection, seroma or hematoma; as a
result of a dilation injury; and, rarely, in cases of
neovaginal malignancy. Recently, van der Sluis
and colleagues20 published a very large retrospec-
tive analysis of 1082 postoperative transfemale
patients who had either undergone penile inver-
sion vaginoplasty with a full-thickness scrotal graft
(primary surgery) or a laparoscopic bowel vagino-
plasty (revision surgery or primary surgery for pa-
tients with limited preoperative penile length).
The overall incidence of rectoneovaginal fistula in
this cohort was 1.2% (95% confidence interval,
0.6–2.1) and revision surgery was more likely to
be associated with the development of a fistula:
primary penile inversion surgery 0.8%, primary
bowel vaginoplasty 0%, and revision bowel vagi-
noplasty 6.3%. In this cohort, 23 patients (2.1%)
had suffered from an intraoperative rectal injury.
Of the patients who had a rectal injury, 4 patients
(17.3%) developed a fistula. The authors also re-
ported that 38% of the patients (n 5 5) requiring
management of a fistula likely had an unrecog-
nized rectal injury at the time of surgery, because
they were diagnosed in the immediate postopera-
tive period when the vaginal pack was removed.
Most of the patients in this study required surgery
to repair their fistula. The median time to surgery
was 3 months (range, 0.0–9.7 months). In most

cases, fistulectomy with primary closure or local
advancement flap was sufficient. Of those under-
going surgery, 4 patients underwent fecal diver-
sion with direct or delayed fistula repair.
Consultation and collaborative management
with a colorectal surgeon is often a good idea for
the management of the rectoneovaginal fistula,
because these fistulae should be considered
complex in nature. If an abscess is present, it
should be allowed to drain. Seton drains can be
used to facilitate this step. The fistula can be
repaired transanally, transperineally, through the
abdomen, or through the vagina. The route de-
pends on the status of the anal sphincter, the
integrity of the surrounding tissues, the size and
location of the fistula, and the surgeon’s experi-
ence managing these types of fistulae. A vaginal
approach is often not recommended due to the
poor tissue quality of the skin graft lining the neo-
vagina and the resulting fibrosis and scarring. If the
anal sphincter is affected (which occurs in rare cir-
cumstances), a transperineal approach may be
considered. Transanally, a rectal advancement
flap or an advancement sleeve flap can be attemp-
ted if the surrounding tissues are healthy. If they
are not, perioperative hyperbaric oxygen therapy
may be helpful to improve wound healing. If repairs
fail using these approaches, abdominal mobiliza-
tion should be considered. The Turnbull Cutait
procedure involves pulling the rectum through
the anus and performing a delayed coloanal
anastomosis. This procedure can be morbid, but
remains an option for management. Tissue inter-
position strategies must also be considered.
Fistula closures may be enhanced with the place-
ment of vascular flaps, such as a gracilis (mus-
culocutaneous) flap and a pudendal thigh
(fasciocutaneous) flap. The other consideration
that must be taken by the colorectal surgeon and
the team is when to create a diversion stoma.
Creating a stoma does not guarantee a successful
fistula repair, but it does have many advantages. In
our experience, a diversion stoma is usually asso-
ciated with low morbidity, may improve outcomes,
and should strongly be considered when manag-
ing the rectoneovaginal fistula.
Even fewer data exist on the prevalence and
management of genitourinary fistulae after vagino-
plasty. Similar to rectoneovaginal fistulae, devel-
opment of a fistula between the neovagina,
bladder, or urethra is likely a result of iatrogenic
intraoperative injury. A transvaginal or transabdo-
minal approach to the repair can be taken. Consul-
tation with a urologic specialist may be necessary
because they may have experience with manage-
ment of urethrorectal fistulae after prostatectomy
surgery. Surgeons must consider using tissue
Vaginoplasty Complications 5
interposition strategies for these cases as well as
this will improve healing and the chances of a suc-
cessful outcome.
INTESTINAL VAGINOPLASTY
Brief Overview of Technique
Transgender women with penoscrotal hypoplasia
(ie, those women placed on puberty blockers at
the onset of puberty) or those who have failed a
primary penile inversion vaginoplasty procedure
may be candidates for intestinal vaginoplasty.21,22
Intestinal vaginoplasty involves the use of a
segment of small intestine (ileum) or sigmoid colon
to create a neovagina. Contraindications to this
procedure include patients with a history of can-
cer, inflammatory bowel disease, or extensive
intraabdominal adhesions. The main advantages
of this technique include self-lubrication, achieve-
ment of good neovaginal depth, and reduced risk
of postoperative stenosis.23 The disadvantages
of the technique include the risks that are inherent
to abdominal bowel surgery, excessive mucus and
associated malodorous discharge, and prolapse
of the neovagina.23
The procedure is performed through a com-
bined abdominal and perineal approach.22,23 The
perineal portion of the procedure is very similar
to the inversion vaginoplasty surgery described
elsewhere in this article. The surgery can also be
performed by a variety of surgical specialists in
plastic surgery, urology, and gynecologic spe-
cialties such as urogynecology, but surgical exper-
tise in bowel surgery is required for the abdominal
portion of the procedure, which can be performed
laparoscopically or through an open abdominal
approach.
Complications Associated with Intestinal
Vaginoplasty
In their metaanalysis, Horbach and colleagues1 re-
ported an overall complication rate of 6.4% for the
sigmoid neovagina and 8.3% for the ileum neova-
gina. Neovaginal stenosis (1.2%–43.0%), and
discharge/malodor (0.7%–9.5%) were the most
commonly reported complications. There were
also case reports of mucosal prolapse, leakage
of an intercolic anastomosis, rectovaginal fistula,
urethral meatal stenosis, voiding dysfunction,
and wound healing disorders.
Prolapse after intestinal vaginoplasty surgery
also exists and there are many case reports
describing both partial thickness24–30 and full-
thickness prolapse.31–38 Most of these reported
cases are in individuals with congenital anomalies
who underwent intestinal vaginoplasty procedures
as children. Again, we can extrapolate findings to
6 Ferrando
the transgender population because the neovagi-
nal portion of the procedures is similar. In cases
of partial thickness (mucosal) prolapse, surgical
resection with fulguration is usually sufficient treat-
ment.31 In cases of full-thickness bowel prolapse,
more extensive surgery is necessary to repair the
prolapse and sacrocolpopexy, either performed
laparoscopically or via an open abdominal
approach, seems to be the most commonly re-
ported technique used to suspend the neovagina.
In a cohort study of 42 patients undergoing total
laparoscopic sigmoid vaginoplasty, Bouman and
colleagues23 reported a low incidence of intrao-
perative complications: 1 patient only experienced
rectal injury that was repaired with no postopera-
tive sequelae. Short-term complications included
3 reoperations (6.8%): two patients with an anas-
tomotic leak and one with postoperative bleeding.
Long-term complications (mean follow-up of
3.2  1.2 years) included 8 reoperations (19.5%):
6 patients with introital scarring, 1 patient with
mucosal prolapse, 2 patients suffered from exces-
sive mucus discharge as a result of neovaginitis,
and 3 patients requested cosmetic revisions of
the labia.
In 2015, Morrison and colleagues39 published a
retrospective review of 83 patients who underwent
sigmoid vaginoplasty over a 22-year period. In this
study, the mean clinical follow-up was 2.2 years
and phone interview for 25% of the cohort was
23 years. The author reported that 58% of patients
(n 5 48) experienced a complication, with the ma-
jority of complications (83%) classified as minor.
One of the most common complications reported
was excessive mucorrhea, experienced by 29%
of the cohort. Short-term major complications
included protrusion (6.1%), strictures/stenosis
(20%), rectovaginal fistula (2.4%), urethrovaginal
fistula (1.2%), and bowel obstruction (1.2%).
Long-term complications included prolapse
(2.4%), protrusion (15.6%), stricture/stenosis
(22.5%), colitis (2.5%), and bowel obstruction
(3.6%). Smoking was associated with higher
complication rates, especially stricture formation.
Bouman and colleagues40 performed a literature
review of surgical techniques and clinical out-
comes after vaginoplasty. In this review, 21
studies (n 5 894) met inclusion criteria and, similar
to other analyses, these studies were determined
to be of low to intermediate quality given that all
studies had a retrospective design. The main
complication reported was introital stenosis with
4% of sigmoid-derived patients and 1.2% of
ileum-derived patients undergoing revision sur-
gery to definitively treat the problem. Minor com-
plications after sigmoid surgery and ileum
surgery occurred at rates of 4.4% and 7.1%,
respectively, and included rectal injury, bladder
injury, bleeding requiring transfusion, hematoma,
urinary tract infection, ileus, and peritonitis. Mod-
erate complications after sigmoid surgery and
ileum surgery occurred at rates of 1.6% and
1.2%, respectively, and included abscess, fistula,
and intestinal obstruction. Severe complications
only occurred after sigmoid-derived surgery
(0.58%) and included colon anastomosis leak,
intraluminal neovaginal abscess, and necrosis of
the bowel conduit.
OFFICE MANAGEMENT OF COMMON
VAGINOPLASTY COMPLICATIONS
Neovaginal bleeding is not commonly reported as a
major complication, but for those providers who
care for this population, many patients present to
the office immediately and remotely after vagino-
plasty surgery for management of bleeding symp-
toms. In the immediate postoperative period,
neovaginal bleeding may be a result of a hematoma,
necrosis of the graft used to line the vagina, a dilation
injury, development of a fistula, infection, granula-
tion tissue, and, in cases of intestinal vaginoplasty,
neovaginal polyps, colitis, and carcinoma.
All patients presenting with bleeding should un-
dergo a thorough pelvic and neovaginal examina-
tion. Many patients do not tolerate a speculum
examination, especially immediately postopera-
tively. Patient should be coached to try and relax
the pelvic floor muscles so that an adequate ex-
amination may be done. Screening for sexually
transmitted infections should be performed. Neo-
vaginal biopsies should be performed for any sus-
picious lesions.
Granulation tissue is commonly the cause of
bleeding. In these cases, cauterization with the
application of silver nitrate should be performed
regularly until the granulation tissue regresses. In
most cases, this treatment is enough to resolve
the issue.
Patients who have had intestinal vaginoplasty
may require a vaginoscopy to complete the exam-
ination. Endoscopic evaluation will help diagnose
diversion colitis or inflammatory bowel disease.
Diversion colitis is more common than undiag-
nosed inflammatory bowel disease and signs of
inflammation may be present in up to 65% of pa-
tients who have undergone sigmoid vagino-
plasty.41 In addition to bleeding, patients may
present with malodorous discharge and pain.
Enema treatments using sodium butyrate and
5-aminosalicylic acid are recommended for
treatment.
Patients who have had bowel vaginoplasty pro-
cedures may also present with excessive mucus

discharge that is unpleasant. These conditions
should be ruled out before treatment recommen-
dations are made. Aggressive daily douching or
irrigation of the neovagina is advised for these
patients.
SUMMARY
Complications after vaginoplasty surgery for the
transgender woman exist. In this review, we pro-
vide data on outcomes after both penile inversion
vaginoplasty surgery and intestinal vaginoplasty.
Providers performing these surgeries and those
providers caring for postoperative patients should
be aware of the incidence of these complications
and the treatment options that exist to manage
them.
REFERENCES
1. Horbach SER, Bouman MB, Smit JM, et al. Outcome
of vaginoplasty in male-to-female transgenders: a
systematic review of surgical techniques. J Sex
Med 2015;12(6):1499–512.
2. Wangjiraniran B, Selvaggi G, Chokrungvaranont P,
et al. Male-to-female vaginoplasty: Preecha’s surgi-
cal technique. J Plast Surg Hand Surg 2015;49(3):
153–9.
3. Selvaggi G, Ceulemans P, De Cuypere G, et al.
Gender identity disorder: general overview and sur-
gical treatment for vaginoplasty in male-to-female
transsexuals. Plast Reconstr Surg 2005;116(6):
135e–45e.
4. Perovic SV, Stanojevic DS, Djordjevic ML. Vagino-
plasty in male transsexuals using penile skin and a
urethral flap. BJU Int 2000;86(7):843–50.
5. Raigosa M, Avvedimento S, Yoon TS, et al. Male-to-
female genital reassignment surgery: a retrospec-
tive review of surgical technique and complications
in 60 patients. J Sex Med 2015;12(8):1837–45.
6. Papadopulos NA, Zavlin D, Lelle JD, et al. Combined
vaginoplasty technique for male-to-female sex reas-
signment surgery: operative approach and outcomes.
J Plast Reconstr Aesthet Surg 2017;70:1483–92.
7. Kuhn A, Santi A, Birkhauser M. Vaginal prolapse,
pelvic floor function, and related symptoms 16 years
after sex reassignment surgery in transsexuals. Fer-
til Steril 2011;95(7):2379–82.
8. Bucci S, Mazzon G, Liguori G, et al. Neovaginal pro-
lapse in male-to-female transsexuals: an 18-year-
long experience. Biomed Res Int 2014;2014:
240761.
9. Nichols D. Sacrospinous fixation for massive ever-
sion of the vagina. Am J Obstet Gynecol 1982;142:
901–4.
10. Stanojevic DS, Djordjevic ML, Milosevic A, et al.
Sacrospinous ligament fixation for neovaginal
Vaginoplasty Complications 7
prolapse prevention in male-to-female surgery. Urol-
ogy 2007;70:767–71.
11. Loverro G, Bettocchi C, Battaglia M, et al. Repair of
vaginal prolapse following penoscrotal flap vagino-
plasty in a male-to-female transsexual. Gynecol Ob-
stet Invest 2002;53:234–6.
12. Frederick RW, Leach GE. Abdominal sacral colpo-
pexy for repair of neovaginal prolapse in male-to-
female transsexuals. Urology 2004;64(3):580–1.
13. Henninger V, Reisenauer C, Brucker SY, et al.
Laparoscopic nerve-preserving colposacropexy
for surgical management of neovaginal prolapse.
J Pediatr Adolesc Gynecol 2015;28(5):153–5.
14. Christopoulos P, Cutner A, Vashist A, et al. Laparo-
scopic sacrocolpopexy to treat prolapse of the neo-
vagina created by vaginal dilation in Rokitansky
syndrome. J Pediatr Adolesc Gynecol 2011;24(2):
e33–34.
15. 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.
16. Kuhn A, Hiltebrand R, Birkhauser M. Do transsex-
uals have micturition disorders? Eur J Obstet Gyne-
col Reprod Biol 2007;131:226–30.
17. Fitzpatrick C, Swierzweski SJ 3rd, McGuire EJ. Peri-
urethral collagen for urinary incontinence after
gender reassignment surgery. Urology 1993;42(4):
458–60.
18. Goddard JC, Vickery RM, Qureshi A, et al. Femi-
nizing genitoplasty in adult transsexuals: early and
long-term surgical results. BJU Int 2007;100:607–13.
19. Krege S, Bex A, Lummen G, et al. Male-to-female
transsexualism: a technique, results and long-term
follow-up in 66 patients. BJU Int 2001;88:396–402.
20. Van der Sluis WB, Bouman MB, Buncamper ME,
et al. Clinical characteristics and management of
neovaginal fistulas after vaginoplasty in transgender
women. Obstet Gynecol 2016;127(6):1118–26.
21. Huang TT. Twenty years of experience in managing
gender dysphoric patients: I. Surgical management
of male transsexuals. Plast Reconstr Surg 1995;
96(4):921–30 [discussion: 931–4].
22. Siemssen PA, Matzen SH. Neovaginal construction
in vaginal aplasia and sex-reassignment surgery.
Scand J Plast Reconstr Surg Hand Surg 1997;
31(1):47–50.
23. Bouman MB, van der Sluis WB, Buncamper ME,
et al. Primary total laparoscopic sigmoid vagino-
plasty in transgender women with penoscrotal hypo-
plasia: a prospective cohort study of surgical
outcomes and follow-up of 42 patients. Plast Re-
constr Surg 2016;138(4):614e–23e.
24. Nowier A, Esmat M, Hamza RT. Surgical and func-
tional outcomes of sigmoid vaginoplasty among pa-
tients with variants of disorders of sex development.
Int Braz J Urol 2012;38:380–6.
8 Ferrando
25. Djordjevic ML, Stanojevic DS, Bizic MR. Rectosig-
moid vaginoplasty: clinical experience and out-
comes in 86 cases. J Sex Med 2011;8:3487–94.
26. Rawat J, Ahmed I, Pandey A, et al. Vaginal agen-
esis: experience with sigmoid colon neovagino-
plasty. J Indian Assoc Pediatr Surg 2010;15:19–22.
27. Lima M, Ruggeri G, Randi B, et al. Vaginal replace-
ment in the pediatric age group: a 34-year experi-
ence of intestinal vaginoplasty in children and
young girls. J Pediatr Surg 2010;45:2087–91.
28. Khen-Dunlop N, Lortat-Jacob S, Thibaud E, et al.
Rokitansky syndrome: clinical experience and re-
sults of sigmoid vaginoplasty in 23 young girls.
J Urol 2007;177:1107–11.
29. Imparato E, Alfei A, Aspesi G, et al. Long-term re-
sults of sigmoid vaginoplasty in a consecutive series
of 62 patients. Int Urogynecol J Pelvic Floor Dys-
funct 2007;18:1465–9.
30. Parsons JK, Gearhart SL, Gearhart JP. Vaginal
reconstruction utilizing sigmoid colon: complications
and long-term results. J Pediatr Surg 2002;37:
629–33.
31. Hensle TW, Reiley EA. Vaginal replacement in chil-
dren and young adults. J Urol 1998;159:1035–8.
32. Swenson CW, DeLancey JO, Schimpf MO. Left-
sided sacrospinous ligament suspension for treating
recurrent sigmoid neovagina prolapse. Int Urogyne-
col J 2014;25:1593–5.
33. 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.
34. Delotte J, Ferron G, Lim YKT, et al. First laparoscopic
repair of neovaginal prolapse following ileocecal
reconstruction after resection of vaginal carcinoma.
J Laparoendosc Adv Surg Tech A 2009;19:67–9.
35. Yokomizo R, Murakami T, Naitou H, et al. Treatment
for prolapse of the sigmoid neovagina in Mayer-
Rokitansky-Kuster-Hauser syndrome. Obstet Gyne-
col 2002;100:1085–7.
36. Matsui H, Seki K, Sekiya S. Prolapse of the neova-
gina in Mayer-Rokitansky-Kuster-Hauser syndrome.
A case report. J Reprod Med 1999;44:548–50.
37. Freundt I, Toolenaar TA, Jeekel H, et al. Prolapse of
the sigmoid neovagina: report of three cases. Ob-
stet Gynecol 1994;83:876–9.
38. Peyromaure M, Villet R, Jung JL, et al. Prolapse of
neovagina after anterior pelvic exenteration for ure-
thral cancer. Prog Urol 2000;10:456–60.
39. Morrison SD, Satterwhite T, Grant DW. Long-term
outcomes of rectosigmoid neocolporrhpahy in
male-to-female gender reassignment surgery. Plast
Reconstr Surg 2015;136:386–94.
40. Bouman M, van Zeijl MCT, Buncamper ME, et al. In-
testinal vaginoplasty revisited: a review of surgical
techniques, complications, and sexual function.
J Sex Med 2014;11(7):1835–47.
41. Van der Sluis W, Bouman M, Meijerink W, et al. Diver-
sion neovaginitis after sigmoid vaginoplasty: endo-
scopic and clinical characteristics. Fertil Steril
2016;105:834–9.