Vaginoplasty: Everything You Need to Know

Medically reviewed by Andrea L. Braden, MDMedically reviewed by Andrea L. Braden, MD

Vaginoplasty is a surgical procedure that repairs or constructs a vagina. Cisgender women and people assigned female at birth may undergo a vaginoplasty to address vaginal injuries from medical conditions like vaginal cancer or conditions present at birth, such as vaginal agenesis (absence of a vagina at birth).

Vaginoplasty is also a gender-affirming surgery for transgender (trans) women and transfeminine people, helping align their physical characteristics with their gender identity. The first recorded vaginoplasty performed on a transgender woman took place in the 1930s, with significant advancements in surgical techniques occurring over recent decades.

Today, it is a well-established and refined gender-affirming procedure that offers a safe and effective way to achieve a functional and natural-appearing vagina. 

This article discusses the types of vaginoplasty procedures and surgical techniques, the potential benefits and risks, and what to expect during the recovery process. 

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Types of Vaginoplasty Procedures

Vaginoplasty encompasses various surgical procedures tailored to meet different medical and personal needs. Vaginoplasty focuses on creating or repairing the structural integrity of the vagina itself.

Other vaginal plastic surgery procedures—such as labiaplasty (reducing the length of the labia) or monsplasty (reducing the fatty tissue or skin on the hair-bearing part of the vulva)—address the appearance of external genitalia without altering or creating the internal vaginal canal.

Vaginoplasty as Gender Confirmation Surgery

Transfeminine gender confirmation surgery, or feminizing genital surgery, is a cornerstone of gender-affirming care for transgender women and transfeminine people. This procedure creates a functional neovagina (new vagina) and external genitalia that aligns with a trans woman’s gender identity. While there are many techniques surgeons can perform to create a neovagina, a penile inversion vaginoplasty is the most common. 

What Does Vaginoplasty Treat?

In cisgender women, vaginoplasty addresses conditions that affect the vagina’s structure or function, including:

• Trauma to vaginal tissues from childbirth (e.g., tears, rips) or other traumatic injuries that damage the tissues
• Vaginal agenesis (absence of a vagina at birth) 
• Vaginal hypoplasia (underdeveloped vagina)
• Vaginal tissue damage from previous genital surgeries or radiation therapy for treating conditions like vaginal cancer or infections 

What Are the Benefits of Vaginoplasty?

Vaginoplasty can be a life-changing procedure that offers positive outcomes and improves quality of life. Depending on the reason for undergoing the surgery, the potential benefits of vaginoplasty can include:  

• Enhanced urinary control: Weakening pelvic floor muscles can contribute to urinary incontinence. Vaginoplasty procedures that address these muscles can improve bladder control and reduce leakage.
• Improved quality of life: By addressing various functional, gender, or cosmetic concerns, vaginoplasty can lead to a significant improvement in overall quality of life, promoting greater intimacy, self-confidence, and sexual fulfillment.
• Improved sexual function: Both gender-affirming and reconstructive vaginoplasty can enhance sexual function. For transgender women and transfeminine individuals, vaginoplasty allows for vaginal intercourse and potentially greater sexual satisfaction. Reconstructive surgery for vaginal laxity or injuries can improve tightness, lubrication, and overall sexual pleasure.
• Increased confidence and body image: For many cisgender and transgender women, vaginoplasty can lead to a significant boost in self-esteem and body image and improve quality of life. 

The Vaginoplasty Procedure: Techniques and How It Works

There are several vaginoplasty surgical techniques. The type of vaginoplasty you undergo will depend on your anatomy and the desired outcome (gender-affirming or reconstructive).

Vaginoplasty procedures are performed under general anesthesia, ensuring you are completely unconscious and pain-free during the surgery. In some cases, your healthcare provider may place a pudendal nerve block—an injection of corticosteroids and a local anesthetic—at the end of the procedure to ensure you do not feel any pain in your pelvic region during recovery.

Penile inversion and colovaginoplasty (vaginoplasty with bowel tissue) are the two main surgical approaches for creating a neovagina. While the techniques differ, they produce the same result regarding neovagina appearance and function.

Penile Inversion Procedure

A penile inversion is the most common surgical technique for gender-affirming vaginoplasty. It involves using tissue from the penis and scrotum to construct a functional neovagina and labia. The surgeon inserts the skin of the penis to form the vaginal lining and sculpts the remaining penile and scrotal tissue into the labia.

Surgeons use various techniques for a penile inversion procedure, but generally, the procedure takes approximately six hours and involves the following steps:

1. Preparation: While you are asleep under anesthesia, the surgical team sterilizes your pelvic region and inserts a urinary catheter into the urethra to empty the bladder during the surgery and recovery period. 
2. Incision and dissection: The surgeon makes an incision along the length of the scrotum and carefully removes the skin of the penis shaft.
3. Creation of the vaginal canal: The surgeon creates a space between the bladder and the bowel to form the vaginal canal.
4. Inversion and suturing: The penile skin is inverted and inserted into the newly created space, forming the vaginal lining. The skin is sutured (stitched) in place. 
5. Testicle removal: The surgeon removes the testicles.
6. Clitoris and labia construction: The surgeon uses the glans and foreskin of the penis to create the clitoris and inner labia; they shorten the urethra to align with the neovagina. 
7. Closure: The surgical team inserts a makeshift tampon using gauze and a condom; they insert it into the neovagina and suture it into place to keep the vaginal cavity open and in the correct position. A healthcare provider removes it after five days. 
8. Recovery: The surgery is complete, and a healthcare team monitors you in the hospital for the initial recovery period. 

Colovaginoplasty (Bowel Vaginoplasty) 

A colovaginoplasty uses tissues from the colon (large intestine) to create a neovagina. This procedure is standard in cisgender women born without a fully developed vagina or when transgender women do not have enough penile tissue for a penile inversion. 

The colovaginoplasty procedure is laparoscopic, meaning it involves making small incisions in the abdomen. It takes approximately three hours and involves the following steps:

1. Preparation: The surgical team sterilizes your abdomen and pelvic region while you are asleep under anesthesia.
2. Incisions and catheterization: The surgeon makes three small incisions on the lower abdomen, through which the surgeon inserts a small camera and surgical tools. They place a catheter into the urethra to drain the bladder during the procedure and for a short time afterward. 
3. Scrotal incision: The surgeon makes an incision along the length of the scrotum, allowing access to the pelvic floor and creating a cavity between the rectum and bladder. 
4. Bowel dissection: The surgeon removes a small piece of intestinal tissue (approximately 15 centimeters long) and transfers it to the pelvic floor. 
5. Vaginal construction: The surgeon inserts the prepared segment of the colon into the newly created vaginal cavity and connects it to the penile skin after it is removed from the penis shaft, creating a self-lubricating vaginal lining. 
6. Clitoral and labial construction: The surgeon creates the clitoris using the glans and foreskin and the labia minora and majora using the scrotal skin.
7. Closure and recovery: The surgeon closes the abdominal incisions, and a healthcare team monitors you in the hospital for the initial recovery period. 

Preparing for Surgery

Undergoing vaginoplasty is a life-changing decision that requires careful planning and preparation. The initial step to prepare for your surgery is a comprehensive consultation with a qualified plastic surgeon specializing in vaginoplasty. During the consultation, you will discuss: 

• Your medical history: The surgeon will review your medical background to assess your suitability for surgery and identify any potential risks.
• Your reasons for considering vaginoplasty: Understanding your goals and expectations is crucial for the surgeon to recommend the most appropriate approach.
• Surgical options: The surgeon will explain the different vaginoplasty techniques available and discuss the best option for your needs.
• Benefits and risks: A thorough discussion of the potential benefits and risks associated with vaginoplasty is essential.
• Recovery process: The surgeon will outline the recovery timeline and provide detailed instructions on postsurgical care.

In some cases, particularly for gender-affirming vaginoplasty, your healthcare provider may recommend a psychological evaluation and counseling to help address any concerns about the surgery and ensure you're emotionally prepared for the process.

Physical Preparation

Depending on the specific type of vaginoplasty, your surgeon may recommend certain physical preparations before surgery, such as:

• Hormone therapy: For transgender women or transfeminine individuals on hormone therapy, your surgeon may ask you to stop taking hormone replacement therapy (HRT) for two weeks before the procedure.
• Hair removal: Permanent hair removal (e.g., laser hair removal) in the genital area is required for gender-affirming penile inversion vaginoplasty to prevent hair growth inside the vaginal canal.
• Smoking cessation: Smoking can slow wound healing. You can support your recovery by quitting smoking at least eight weeks before the procedure.
• Blood tests and medications: Preoperative blood tests may be required to assess your overall health. Before surgery, you may need to adjust or discontinue certain medications under a healthcare provider's guidance.

How Much Does a Vaginoplasty Cost?

The cost of vaginoplasty can vary significantly based on several factors, including the type of procedure, the location of the surgery, and insurance coverage. In the United States, the cost of gender-affirming vaginoplasty ranges from $45,000 to $60,000. This includes: 

• Anesthesia 
• Hospital or facility fees
• Medications 
• Preoperative and postoperative tests and care
• Surgeon fees

It’s important to discuss financial considerations with your surgeon during the consultation. They can provide an accurate estimate based on your procedure, insurance coverage, and fees. 

Insurance Coverage

Most insurance providers in the United States recognize gender-affirming surgeries as medically necessary for transgender people and provide coverage for the procedure. The extent of coverage can vary widely, depending on your policy. 

Most insurance companies require prior authorization and for you to meet specific criteria for the procedure to ensure quality coverage. Many insurance companies follow the World Professional Association for Transgender Health (WPATH) guidelines to determine who is an eligible candidate for vaginoplasty. WPATH criteria for undergoing the procedure include: 

• At least 12 months of continuous hormone therapy aligned with your gender goals and of living in a gender role that aligns with your gender identity 
• Being 18 years or older 
• Capacity to make an informed decision and consent to the surgery 
• Persistent, well-documented gender dysphoria
• Well-controlled mental health and medical conditions (if applicable) 

Carefully review your insurance policy and work with your healthcare provider to determine what costs are covered and what you can expect to pay out of pocket, including your deductible, co-pays, and any other expenses your insurance plan does not cover. 

Recovery and Aftercare

Vaginoplasty recovery takes about six weeks and includes a hospital stay, pain management, wound healing, follow-up appointments, and long-term aftercare. Understanding what to expect can help you prepare and navigate your recovery journey. After vaginoplasty, you can expect the following: 

• Hospital stay and immediate postoperative care: You will likely stay at the hospital for a few days after surgery so the healthcare team can monitor your initial recovery. The length of stay depends on the complexity of the surgery and your overall health.
• Pain management and wound healing: Pain management is crucial to postoperative care. You will receive prescriptions for pain medications at home, including oral and topical applications if necessary. It is essential to follow your healthcare provider’s instructions and communicate with them if your pain is not well-controlled.
• Follow-up appointments: Regular follow-up appointments are essential to monitor healing and address concerns.
• Long-term aftercare: Long-term aftercare involves maintaining a healthy lifestyle to support overall health and recovery.

Potential Risks and Complications

​​As with any surgical procedure, vaginoplasty comes with potential risks and complications. Studies report high satisfaction rates following vaginoplasty, significantly improving the quality of life for over 90% of those who undergo the procedure. However, some people may experience complications, including:

• Infection: One of the most common risks with any surgery is an infection at the incision site or internally, which may require treatment with antibiotics (drugs that fight bacterial infections).
• Bleeding and hematoma: Excessive bleeding during or after surgery can lead to a hematoma, a collection of blood outside of blood vessels. 
• Scarring: While efforts are made to minimize visible scarring, some are inevitable. Scar tissue can sometimes form internally, leading to complications such as vaginal stenosis (narrowing of the vaginal canal).
• Wound dehiscence: This occurs when the surgical wound reopens after it has been closed. It can occur due to inadequate healing or pressure on the surgical site.
• Urinary complications: Some people may experience difficulties with urination, such as urinary retention, incontinence, or urethral stricture (narrowing of the urethra).
• Fistula formation: A fistula is an abnormal connection between two body parts. In vaginoplasty, a rectovaginal fistula (between the rectum and vagina) can occur.
• Granulation tissue formation: This benign overgrowth of tissue can occur at the surgical site and may need to be treated with topical medications.
• Necrosis: In rare cases, the tissue used to construct the neovagina can die (necrosis), requiring further surgery to remove the dead tissue and reconstruct the area.

Lifestyle Changes After Surgery

For many women who undergo vaginoplasty, the outcome brings a sense of completeness and authenticity, enhancing self-esteem and overall psychological well-being. While most report positive outcomes, it’s important to remember that the journey to emotional and psychological well-being requires time, patience, and support. 

The immediate period after surgery can be emotionally challenging as you adapt to your new anatomy. Feelings of relief, happiness, and anxiety are common. Give yourself time to adjust and seek support from mental health professionals, friends, or support groups as needed. Regular counseling sessions can help address any lingering gender dysphoria, body image issues, or other emotional challenges.

Sexual function and intimacy are also important aspects of life, and vaginoplasty brings some significant changes. Consider the following: 

• Healing and dilation: Following vaginoplasty, regular dilation is necessary to maintain the depth and width of the neovagina. Follow your surgeon’s instructions for dilation to ensure an optimal outcome. 
• Resumption of sexual activity: Your surgeon will ask you to wait for some time before resuming sexual activity to ensure proper healing. 
• Sensory changes: Sensation in the neovagina can vary, and some people may experience changes in sexual sensitivity. Exploring your new body and communicating openly with sexual partners can enhance intimacy and sexual satisfaction.
• Regular checkups: It is essential to make and maintain regular medical checkups to monitor the health of your neovagina and address any issues that may arise. This includes checking for complications and ensuring that the dilation process is effective.

When to Contact a Healthcare Provider

After a vaginoplasty, it’s important to watch for any signs of complications. Early intervention can help prevent serious problems and ensure a smooth recovery. Seek immediate care if you experience any of the following symptoms: 

• Bright red blood soaking through an incision pad or bandage
• A fever of 100.4 degrees F (38 degrees C) or higher, which could indicate an infection
• Severe pain that does not improve with medication
• Signs of infection, such as redness, swelling, pus drainage, or warmth around an incision
• Vomiting that is preventing you from keeping fluids down 
• Difficulty urinating 
• Blood clot symptoms, such as leg pain, swelling, or redness in the calf or thigh 
• Shortness of breath or difficulty breathing

Summary

Vaginoplasty is a surgery that constructs or repairs a vagina. For transgender women, it is an empowering, gender-affirming procedure. It is also a reconstructive procedure for cisgender women with vaginal trauma or those with medical and congenital conditions affecting the structure or function of the vagina.

Vaginoplasty offers many benefits, including enhanced quality of life and improved sexual function and body image. Surgeons use various techniques to perform a vaginoplasty, such as penile inversion and bowel vaginoplasty. 

Considering vaginoplasty is a profound and personal decision that requires careful thought and professional guidance. Consulting with experienced healthcare providers, including surgeons and mental health professionals, can help you navigate this journey and make informed choices.

Thorough preparation, informed decision-making, and following your postsurgical instructions are essential for a successful vaginoplasty and a fulfilling life after surgery.

Read the original article on Verywell Health.