Updated: Apr 8
5 Need To Knows: About Vaginal Depth and Avoiding Stenosis After Vaginoplasty
By Dr. Min Jun, Crane Center San Francisco
Vaginoplasty is a monumental life event in one’s transition. Like most other things in life, the effort you put into something determines what you get out of it, and vaginoplasty is no exception – literally. As I explain during every vaginoplasty consultation, your body will have a new harmony point after surgery, and the labor of love we call dilation is what you need to do to maintain your vagina’s depth and width. With that, let’s dive into the finer points of dilation.
To understand why dilation is even necessary requires an understanding of the pelvic anatomy. The pelvic floor musculature is a large and powerful group of muscles with the important function of supporting all the internal pelvic structures. Because the pelvic floor has to keep these structures supported at all times, the muscles are by default in the “on” position as opposed to your biceps, which are by default in the “off” position. You can think of the pelvic floor the way you think about the back muscles, another very large and powerful set of muscles that are “on” by default since they control posture. When people are stressed out, they often get tension headaches because their back muscles are too tightly contracted. Despite people’s best efforts, relaxing these muscles is easier said than done. The exact same phenomenon happens with the pelvic floors. That is, it can be very difficult to relax the pelvic floor muscles because it is simply not intuitive. And that is exactly what you are fighting when you dilate.
The vaginal canal is created in between the rectum on one side and the bladder, prostate, and urethra on the other side. This requires that we essentially make a hole in the pelvic floor, which is located at the border between the prostate and urethra. If your body is good at one thing, it is healing a wound, and your body will treat the vaginal canal as such. Left alone, the canal will seal itself shut, especially at the pelvic floor where the muscles are pinching the canal closed. The reason you need to dilatate is to keep it from healing shut. It is for this reason that it is my opinion that frequent dilation is the most important aspect of dilation in the months following surgery. Let’s say you dilate once a day for an hour. That means that your vagina has 23 straight hours to heal itself in the shut position. But if you dilate 4 times per day for 15 minutes each time, then you only allow your vagina about 6 hours to heal in the shut position. Overall, you are dilating the same 1 hour per day, but the more frequent dilation is going to give your vagina a much better chance at healing correctly.
By now, it should be obvious that if one does not dilate, the vagina will narrow and depth will be lost. But what if someone is dilating but still loses vaginal depth? In my experience, this almost always happens at… you guessed it!, the pelvic floor. The pelvic floor often has so much tone that it is easy to think that you have reached the end of vagina during dilation because you encounter resistance and pain. In fact, one study has shown that 78% of women who were to undergo vaginoplasty had preexisting pelvic floor dysfunction. This is a shockingly high number, but I for one am excited about this finding. This identifies an addressable issue that can lead to more successful vaginoplasties. So what can we do?
If only there were a way to get better control of your pelvic floor so that you can dilate more effectively and with less pain… wait, there is! Pelvic floor physical therapy is emerging as a critical tool for patients considering vaginoplasty. Urinary and colorectal function is closely linked to pelvic floor health and can be used as surrogate measures of pelvic floor dysfunction. In the previously mentioned study, physical therapy (PT) before surgery improved urinary distress and colorectal anal distress. This improvement was maintained through surgery and physical therapy further improved these functions after surgery. In another study, 69% patients undergoing vaginoplasty experienced resolution of their pelvic floor muscle dysfunction with PT. Unsurprisingly, in those patients with a history of abuse, pelvic floor muscle dysfunction was found 91% of the time. Impressively, 83% of these patients experienced resolution with PT. These data clearly show that PT can help a huge number of patients undergoing vaginoplasty. I highly recommend patients to seek pelvic floor PT both before and after primary vaginoplasty.
What about the patient who has already experienced vaginal stenosis and requires revision vaginoplasty? Revision vaginoplasty is always more difficult than primary vaginoplasty since there is scar tissue present, and almost always the stenosis occurs at the level of the pelvic floor. Therefore, it is reasonable to assume that pelvic floor dysfunction played a role in the vaginal stenosis. Furthermore, dilation after revision vaginoplasty will likely be more difficult because there is now scar tissue at the pelvic floor. Every little bit helps when it comes to revision vaginoplasty – for that reason, I believe pelvic floor PT is an absolute must both before and after revision vaginoplasty.
Pelvic floor muscles get in the way of dilation because they are always “on.”
Frequent dilation is the most important aspect of preventing vaginal stenosis.
Pelvic floor muscle dysfunction is common and a big factor in vaginal stenosis.
Pelvic floor PT is very useful before and after primary vaginoplasty and helps with dilation.
Pelvic floor PT is an absolute necessity before and after revision vaginoplasty.
Dr. Min Jun is a genital gender-affirming surgeon who trained at four different academic centers. He completed his residency training in urology at Detroit Medical Center under Dr. Richard Santucci.
During that time, he travelled to Serbia for additional transgender-focused training with Dr. Miroslav Djordjevic. Dr. Jun then completed a reconstructive and traumatic urology Fellowship at Temple University with Dr. Michael Metro. To further focus on gender-affirming surgery, Dr. Jun completed a Fellowship in gender affirming genital and robotic surgery at New York University with Dr. Lee Zhao and Dr. Rachel Bluebond-Langner.
Dr. Jun offers robotic peritoneal flap vaginoplasty in both primary and re-do (e.g. vaginal stenosis) cases, and care for urethral complications.