GENDER AFFRMING SURGERY & RECONSTRUCTIVE UROLOGY
Vaginal dilations are a very important part of your recovery process after vaginoplasty. Dilations keep the vagina open preventing vaginal stenosis – a process where the vaginal walls scars down and contract. The new vagina has a tendency to close because the body’s reaction to any procedure is to scar and try to heal itself – although in this situation this “healing” process is counterproductive.
After your vaginoplasty you will be sent home with a new set of vaginal dilators. Bring these dilators with you on your first visit to the office.
When you are discharged home you will have a catheter in place to drain the bladder and a packing left in the vagina. This packing is very important as it allows the vagina skin to heal and “stick” to the underlying tissue. During this time, as you recover, it is important to avoid any vigorous activity in part because you don’t want to have incisions disrupted but also because it allows time for the vaginal grafts to “take” which in the long term increase the chances of a good outcome.
The dilators you will be sent home with are usually from a company called Soul Source and come in four different sizes and colors (https://www.soulsource.com/collections/grs-vaginal-dilators). The dilators are gently angled at the tip to conform with with angle of the vagina. In addition, their are dots alongside the length of the dilators which correspond to the depth. If you are able to get the dilator to the final dot on the dilator then that is 6 inches of vaginal depth (a pretty good result!).
About one week after surgery when you come into the office he vaginal packing will be removed. This can be a little uncomfortable and the packing itself can have an odor to it. Once removed, I’ll show how to use the dilators by starting on the purple size (the thinnest dilator).
After you get home you should dilate once. Always use lubrication when you dilation. Often patients will start with metronidazole gel which can be used as a lubricant as well. For the first 2 weeks after surgery you should dilated twice a day for about 20-30 minutes each time. After 2 weeks you can increase the frequency of dilation to 3 times a day. After a month you can start to go up on the size oft eh dilatory to blue then green and finally orange. Consider increasing the size of the dilator if the dilator goes in easily to the final dot and you don’t have any discomfort placing it.
If the dilations are getting more difficult or the vagina is feeling tighter when you dilate you should dilate more frequently every day until it is easier to get the dilator in. You can also leave the dilator in for longer periods of time if it is difficult to dilate.
Make sure the dilator is clean before dilation and after dilation you can just wash out the dilator with a mild soup and water. It should be kept clean but does not have to be sterile.
You should also douche with a minimal amount of gentle soap and mostly water to keep the vagina clean starting about 2 weeks after surgery. Women typically will do this in the shower or on the toilet. Periodic douching washes out remnants of the lubrication and can hep decrease bacterial overgrowth.
Vaginal dilations are important to minimize one of the more common risks after vaginoplasty – vaginal stenosis or closure of the vaginal canal. But do different techniques of penile inversion vaginoplasty have different risks of vaginal stenosis? Unfortunately, like so many things in the field, there isn’t great comparative data on this topic. At a very basic level there are 2 types of tissues that we typically use to create the vaginal lining: tissue flaps or tissue grafts. The difference between the two is that flaps are still connected to their own blood supply while grafts are not- grafts survive initially by sucking up oxygen from surrounding tissue until new blood vessels develop over the course of a few days. Because of this blood supply difference, grafts have a higher chance for contraction and vaginal stenosis. The penile skin in the penile inversion vaginoplasty is a flap and scrotal or peritoneal skin are grafts.
So how do you minimize the risk of vaginal stenosis? Use as much of a flap as you can to create the vaginal lining. So this mean using as much penile skin as possible. Sometimes, patients have enough tissue to create a deep 6 inch vagina but in many cases there isn’t enough tissue to do this. In this case, before surgery you should decide whats important for you – If you want to absolutely minimize risk of stenosis and penetrative vaginal sex or vaginal depth is not important to you then you might stick with the penile flap and not add additional depth with a graft. if depth is important and there is not much phallic skin then you would almost certainly want additional depth with a graft and accept the risk of stenosis and post-op be very diligent about dilations.
Although there are disadvantages to using colon for a vaginoplasty, one of the advantages is that the segment of colon has its own blood supply so that the risk of stenosis is very low.