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Assessment of Pelvic Floor Anatomy for Male-to-Female Vaginoplasty and the Role of Physical Therapy on Functional and Patient-Reported Outcomes

Manrique, Oscar J., MD; Adabi, Kian, BA; Huang, Tony Chieh-Ting, MD; Jorge-Martinez, Jorys, MD; Meihofer, Laura E., DPT; Brassard, Pierre, MD; Galan, Ricardo, MD

doi: 10.1097/SAP.0000000000001680
Reconstructive Surgery

Background Rapid increase in number of male-to-female vaginoplasties emphasizes the need for preoperative measures to optimize final surgical and patient-reported outcomes. Hormonal therapy and socioeconomic factors may contribute to a higher incidence of pelvic floor dysfunction in patients undergoing male-to-female vaginoplasty. The purpose of this study was to evaluate the incidence of pelvic floor dysfunction in this population and the role of physical therapy in its treatment.

Methods From July 2016 to July 2018, patients scheduled to undergo male-to-female vaginoplasty were evaluated by a physical therapist for pelvic floor dysfunction. Patient charts were reviewed for demographics, comorbidities, and length of hormonal therapy. Those with and without symptoms were compared. Symptomatic patients underwent therapy. Assessment of symptom severity and its impact on daily living were completed at 2- to 3-month intervals with physical therapy using the 6-item Urinary Distress Index 6 and 8-item Colorectal Anal Distress Index components of the 20-item Pelvic Floor Distress Inventory (PFDI-20) before and after surgery. A third component of the PFDI-20, the 6-item Pelvic Organ Prolapse Distress Inventory, was also included in the postoperative assessment.

Results Over a 24-month period, a total of 40 patients with a mean age of 40.7 (19–72) years and body mass index of 27.1 kg/m2 (22–39 kg/m2) were enrolled. Comorbidities included 4 patients (10%) with diabetes and 6 patients (15%) with hypertension. Patients with symptoms had a significantly higher mean age (P < 0.01). Only 1 patient (2.5%) had new-onset pelvic floor dysfunction after surgery, and there was no significant increase in severity of symptoms in those with a previous pelvic floor dysfunction postoperatively. Physical therapy significantly (P < 0.01) reduced severity of symptoms and its impact on daily living as assessed by the Urinary Distress Index and Colorectal Anal Distress Index before and after surgery and by the PFDI-20 and 7-item Pelvic Floor Dysfunction Index postoperatively.

Conclusions A high incidence of pelvic floor dysfunction may exist in patients undergoing male-to-female vaginoplasty preoperatively. Screening at this early stage with both preoperative and postoperative therapy can significantly reduce pelvic floor dysfunction and improve symptoms and quality of life for this population.

From the Mayo Clinic Minnesota, Rochester, MN.

Received August 1, 2018, and accepted for publication, after revision September 7, 2018.

O.J.M. and K.A. contributed equally to preparation of this publication.

Conflicts of interest and sources of funding: none declared.

Reprints: Oscar J. Manrique, MD, Division of Plastic and Reconstructive Surgery. E-mail:

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