Post-Op Care (GRS)

Below is an overview of the instructions you will receive when you leave the hospital, and will answer many of your questions about post-operative care and dilation.  As ever, please contact us with any questions!

Discharge instructions:

You will be leaving Mills-Peninsula Hospital today. You should be reasonably mobile, able to walk at least. However, you may seek to have wheelchair assistance out to your transportation. Upon release from Peninsula, the drain tube is out but there remains packing inside you and a Foley catheter for urine drainage. The Foley needs simply to be emptied and the catheter secured to your inner thigh via the “stat lock”. All stitches are dissolvable. If you have a leg bag (for Foley urine drainage), it can allow you to get up and discretely wear it under clothing. Switch it out for the large drainage bag at night tho because the capacity of the leg bag is small. An outing is possible (2 – 3 hours) into the city or to Half Moon Bay or Stanford or Hillsdale Mall although your activity should consist mostly of short walks, visits for food and drink, and bathroom responsibilities.

You will be given dilators, lubrication and pads although most patients will buy additional supplies which we also have listed in your pre-operative packet, and can also be found in the GRS Checklist.  When you come back for your follow up visit (typically scheduled on the 6th day following surgery), you will be seeing Angelita, who will help you to learn all aspects of your post op responsibilities and take your questions. On Mondays, Dr. Bowers is available and often pop in if you are free. If you wish to see her more formally during this week, you may do so by scheduling an additional appointment. Dr. Bowers is often in surgery so have patience here. In general, if all is well, another visit is strictly optional. We like you to remain in the area for at least two-three nights after packing removal/dilation in case there are any issues with the initial dilating experience. Be certain that you are comfortable dilating prior to leaving the Bay Area!

Complications

Complications during your first week are quite rare but could include bleeding. There is also some blood noted occasionally when removing the foley catheter. In general, pressure on whatever seems to be bleeding is all it takes to stop the problem. There is naturally some oozing of old, darker blood from the incision sites as well as discharge of varying colors, mostly yellowish to blood-tinged. A gush of blood would prompt a call to Dr. Bowers  although this is rare.

Swelling takes weeks to months to go down and patience here is the rule. Occasionally, tight wraps and/or tight-fitting undergarments are recommended if swelling is noted while hospitalized.

Bowel function usually returns sometime late in your hospital stay or over the first few days outside as appetite returns and effects from the anesthesia and pain medications lessen. If you have not had a bowel movement by the time of packing/dilation, please let Michelle know. A diet high in fruits, vegetables and fiber is recommended during the first few weeks following surgery. Meat is ok, less dairy initially is better and do limit cheese intake.

Other potential but rare complications could include fever (greater than 101 degrees), swelling or excess pain and any of these could prompt a call to the office or any of us at our contact cell numbers (see below). Texting is also ideal. Wound separation remains a rare but significant problem for the occasional patient, roughly 1 in 15 or so. You must let us know if this happens as it may require a bit closer follow up with our office. Fortunately, this complication heals itself, normally without intervention beyond keeping the area clean and dry. Following showers, pat the area dry and consider using a hair dryer even.

Vaginal discharge is expected following surgery although it should not turn green. If this happens, the addition of stronger or new antibiotics could be necessary until your own bacterial milieu has established itself. Metrogel, used as a dab at the beginning of each dilation session could be helpful here prescribed as a new prescription.

Follow-up

Follow up at any time while you are in the Bay Area following surgery is possible. We like to see that you are doing well and are happy! Once you have returned home though, it is ideal to see your primary care doc one month following surgery or sooner, if needed. The best doc to arrange this with is the doctor you have had an ongoing relationship with. They are the most likely doctor who will want to see you, including your surgical site. Even if not a gynecologist, this person is likely to be able to see that you are doing well. We are also happy to speak with that provider at any time, if need be.

Long term follow up is also important and can include a pap smear (if sexually active with men especially) at a frequency similar to that of a natal woman who has had a hysterectomy (every 3 – 5 years). A speculum examination at one year minimum is strongly advised. This can detect granulation tissue or areas that have not fully healed, on occasion. Vaginal hair is possible but is normally minimal if present. Granulation tissue is fleshy and red and bleeds easily. If bleeding is experienced 6 months or more after surgery, see your doctor (or one of us) who can take a look. Whether present on the outside or on the inside, granulation tissue is easily treated with a combination of excision of the tissue in the office followed by local application of silver nitrate to the base. The treatment hurts but works immediately. But more often than not the results internally are as stunningly positive as they are on the outside. Mammography is recommended on an age-related basis. Prostate examination is best directed via the vagina (the prostate lies in front of the neovagina). The rectum needs examination also but not as the nearest portal to the prostate anymore! A PSA remains controversial for all male borns but can be helpful if near zero (as it should be) one year following GRS. So long as you remain on estrogen, the prostate should remain virtually non-existent and at low risk for cancer. Hormone dosing is usually less than what was recommended as a pre-op. Often this is half the pre-op dose. Our office prefers use of bioidentical hormones such as estradiol, which is the predominant estrogen normally produced in adult women. 2 mg of Estradiol daily is a typical post op dose. Progesterone is recommended for those who wish to cycle their hormones as would a premenopausal woman. Thus, progesterone (Prometrium 200 mg) is normally prescribed for two weeks on and 2 weeks off.

Sexual activity

Sexual activity resumption is recommended for those at least 12 weeks out from surgery. Earlier friskiness is possible anecdotally although not endorsed by our office. Orgasm should be an expectation of each and every patient. Keep in mind though that the clitoris is derived from the head of the penis. This area is extremely sensitive and most find it annoyingly so. There can be numbness to the area initially but, again, the arousable areas most likely to lead to an orgasm are probably not the clitoris itself. Orgasm is a complex and complicated combination of sensory inputs and imagination that make it happen. So be inventive and open minded! Each patient of Dr. Bowers will also have the much coveted “B-spot” which is the direct analogue of the natal female “G-spot”, basically the erectile tissue surrounding the internal urethra which now lies immediately in front of the vaginal wall just beneath the bladder. Dilating may never be fun for some although with this “b-spot” discovery and its entirely new sensory input, you should find penetration at least interesting. Be patient and persistent! Up to one year may be necessary before rediscovering that ‘killer orgasm’ although with a female hormonal composition, orgasms may be more appropriately called “kitten orgasms”. I say, “Meeeoooooow!”

Excitation and climax may result in a good amount of secretions from the connections to the prostate, seminal vesicle and cowper’s glands. These behave much like their female analogues. Actual vaginal lubrication is not as likely due to the nature of vaginal lubrication which is a result of a watery transudate across the walls of the natal vagina. Needing to use lubrication during penetration is the expectation. We recommend thicker, water-based lubricants such as Surgilube and K-Y or Wet. Let us know if you find others that work for you that we can recommend to others!

Exercise

Physical activity and exercise is recommended as soon as healing has finalized, usually no sooner than 3 – 4 weeks after surgery. Start slowly though and use common sense. Lifting is limited to ten pounds or less for ten days. Driving is discouraged for the first ten days as well. Full activity such as bicycling, motorcycle or horseback riding should be reserved until fully healed, usually by 12 weeks out. Hot tubs and swimming are also discouraged until 12 weeks post op.

Final appearance

Final appearance should really begin to take shape approximately 12 weeks following GRS. At times, it can take longer. Certainly, reductions in swelling, hardness and numbness will progress over the course of one year and beyond. 12 weeks tho is the big milestone. If things aren’t looking like you had hoped in any way, bring this up with our office and Dr. Bowers as this can be a time when planning a second surgery is reasonable. Although only rare patients have returned for a second surgery, all GRS previously were done (as some surgeons still do) in 2 stages, meaning the labiaplasty can be a great second surgery in terms of achieving better cosmetic results.

Above all, take care of yourself. Love yourself and you will be loved. Be patient, be kind but be yourself. Let us know how you do. We really do care.

Dilation Instructions – You will receive this information while you are in the hospital.  Please familiarize yourself with these instructions before your follow up appointment, six days after surgery.

Dilation Process

At rest, the vaginal walls of all women, natal and trans, lie exposed to one another. Dilation is a necessary process for trans women who lack the constant sloughing and lubrication that accompanies a natal vagina and keeps it from annealing together when at rest. There is also a tendency of the neovaginal graft to contract. Dilation allows the depth and diameter of the neovagina to remain adequate. The frequency of dilation recommended in our office is once 3 times daily for 15 minutes at a time for 3 months, then twice daily for 9 months, then once daily thereafter. Intercourse is a suitable but imperfect replacement for dilation. Thus, regardless of sexual activity, dilation is recommended. It is also true that after one year, dilation becomes slightly less necessary and many—but not all—patients are able to go to a frequency of less than once per day without losing depth or diameter. Once you have established depth as a recent postop, mark the dilator and use that permanent marking as a reference point. The dilators also have dots that equate to ½ inch increments. In future sessions, these marks can be used as references to assure that depth is maintained.
Dilators are medical instruments and, for that reason alone, must be handled with care and respect. Injuries have occurred with improper use. Take this process seriously as it is the absolutely most critical aspect of your postoperative care! Dilators are assigned based upon an assessment of diameter at the time of surgery by your surgeon. The sets are labeled ‘large’ and ‘small’ but these are misnomers as the sets have significant overlap. The large set (2, 3, 4) is only a notch larger than the small (1,2, 3). Both sets are plenty large and more than adequate for suitable dilation and/or sexual function. The neovaginal tissue can stretch and some patients are able or desire a larger diameter dilator. Similarly, if patients prefer to start with a smaller dilator, smaller sizes are available via our supplier, Soulsource Enterprises at soulsourceenterprises.com. Each dilator is tapered with a slight curve to the ends. When dilating, the curves should be directed upwards to allow the tip to glide beneath the pubic bone with pressure always away from the rectum.
Start dilating by laying a towel on your bed. Get comfortable with pillows but lay flat on your back. You may boost your head up slightly but no more than 15 degrees elevation—-the reason for this is that lying flat allows the rectum (which is very closely approximated to the vagina, lying just in front) to fall away from the new vagina. We do NOT want to injure the rectum while dilating. A mirror may also be helpful. Use plenty of lubrication but, upon placing the first dilator, apply a small dollup of Metrogel. Metrogel is a vaginal antibiotic that helps to suppress ‘bad’ bacteria and allow a more normal bacterial balance to be established. This is particularly true in the first 6-12 weeks following surgery. Metrogel is not necessary—except to treat bacterial vaginosis (bad smell due to bacterial imbalance)—once you have finished the initial tube prescribed to you at the time of surgery.
When initiating the dilation process, entering the vagina may require a slight downward direction to the tip but generally, the direction of the tip should be upwards towards the belly button as you move from outside to inside. Start with the largest dilator you feel comfortable although many patients simply begin with the smallest. First goal is to establish depth—do that with the smaller of the dilators but the largest you feel comfortable with. The second goal of dilation is to progressively move up in size to stretch and establish the diameter of the vagina. A slight back-and-forth twist as you advance the dilator is helpful. Re-lubing is also useful and may prevent the feeling of a suction type feeling as you remove the dilator. Generally, we prefer a water-based, thick lubricant like Surgilube as opposed to watery lubricants more popular in sex. But feel free to experiment! Following dilation, wash each dilator with soap and water and return each to the original pouch.
Dilation is essential. Do not neglect this duty to your new anatomy. In time, penetrative sex can be a substitute for dilation but even then, occasional dilation is recommended to “check in”. If you choose not to dilate, consider this carefully. The area will eventually scar closed to some extent, which may require surgery to recover. The consequences of not dilating are also uncertain.