By: Elizabeth Akincilar
Last week, Shannon Pacella, DPT, taught us how physical therapy can benefit transgender individuals prior to gender affirming surgery and for those who choose not to undergo gender affirming surgery. You can read her blog here. This week, I present Part two, where I will explain why physical therapy for transgender individuals after gender affirming surgery should be compulsory.
In an earlier blog post, Dr. Heidi Wittenberg outlined several gender affirming surgical procedures transgender individuals may undergo. These included:
Female to Male surgical options
- Chest reconstruction or chest masculinization surgery
- Hysterectomy with or without oophorectomy
- Metoidioplasty
- Phalloplasty
Male to Female surgical options
- Breast augmentation or feminizing augmentation mammoplasty
- Vaginoplasty
Each of these surgical procedures can have a significant effect on the surrounding tissue, muscles, and/or nervous structures which could result in pain and/or dysfunction. As physical therapists, we are the most qualified medical professional to address these neural and myofascial impairments post operatively. Physical therapy treatment is not only expected, but required after many surgical procedures to help patients regain their function and eliminate their pain. Gender affirming surgical procedures should have the same postoperative rehabilitation expectations.
After chest reconstruction or chest masculinization surgery for transmen, physical therapists can address the postural abnormalities that often exist if the patient had been binding his chest prior to surgery. In addition to postural re-education exercises, physical therapists can utilize manual therapy techniques to address the discomfort some patients may experience after binding. For example, physical therapists can utilize rib and spine mobilization and myofascial release techniques to decrease discomfort in the neck, trunk and chest that may be present after years of binding. Additionally, physical therapists can mobilize the surgical scars which can cause discomfort and limit mobility in the arms and trunk after surgery.
Patients undergoing hysterectomy with or without oophorectomy can experience pelvic floor dysfunction as a result of surgery, particularly if some level of pelvic floor dysfunction existed prior to surgery. If patients experience pelvic discomfort, urinary and/or bowel dysfunction after surgery, a pelvic floor physical therapy evaluation is warranted. If the new symptoms are caused by pelvic floor dysfunction, a physical therapist can help resolve those symptoms.
As mentioned in a previous blog post, a metoidioplasty is a surgical procedure that uses an enlarged clitorus to create a neophallus. A phalloplasty is a complicated surgical procedure that creates a functioning and cosmetically acceptable penis. There are several types of both metoidioplasty and phalloplasty. Both procedures are too complicated to explain in detail in this blog post. However, both surgical procedures come with possible musculoskeletal implications, including pelvic floor dysfunction and scar restrictions. In particular, the phalloplasty, requires a large skin graft from another part of the patient’s body. This skin graft creates a significant scar which would require postoperative manual therapy by a physical therapist to regain normal skin and scar mobility to minimize discomfort, normalize range of motion, and eliminate functional limitations.
Switching gears to male to female surgical options, physical therapists are also a necessary component in the post surgical rehabilitation. First, patients who undergo feminizing augmentation mammoplasty will often require physical therapy after surgery to address the musculoskeletal, myofascial, and postural changes that can occur. These patients may experience limited mobility in the chest, ribs, cervical and thoracic spine limiting breathing and range of motion. Physical therapists can utilize manual therapy techniques to help the patient regain normal mobility in the neck, trunk, and ribs as well as normalize postural abnormalities. Additionally, physical therapists can normalize scar mobility post operatively that can contribute to discomfort, limited upper body range of motion, and the appearance of the breasts.
Lastly, but probably most importantly, pelvic floor physical therapists play an essential role in the postoperative rehabilitation for patients undergoing vaginoplasty. As with the other surgical procedures, there are several types of vaginoplasty procedures a patient can undergo. However, each surgical procedure has several musculoskeletal and myofascial implications that are best treated by a pelvic floor physical therapist. Each surgical procedure can compromise the pelvic floor musculature, its neural and fascial structures, and the pelvic girdle. This can result in urinary, bowel, and/or sexual dysfunction and pelvic pain.
As with the other surgical procedures, each type of vaginoplasty results in various scarring. These scars can result in discomfort, or intolerance to clothing, such as underwear. Physical therapists can mobilize these scars to normalize their mobility minimizing discomfort and sensitivity
It is not uncommon, post vaginoplasty of any type, for patients to experience urinary symptoms such as urinary hesitancy, dysuria, spraying, or incomplete bladder emptying. Pelvic floor physical therapists can help resolve these urinary symptoms with manual therapy techniques and motor control training.
One of the vaginoplasty procedures involves using part of the bowel to create the neovagina. For these patients, bowel retraining is an important part of their postoperative rehabilitation to minimize bowel dysfunction. Pelvic floor physical therapists can utilize motor control training, manual therapy, visceral mobilization, and bowel education to help patients regain normal bowel function after surgery.
Lastly, it is imperative that patients understand the importance of vaginal dilation post vaginoplasty, the frequency with which they must dilate, and are 100% comfortable with self dilation. Many patients, understandably, are initially uncomfortable with self dilation secondary to discomfort and fear. Pelvic floor physical therapists are the most qualified medical professionals to teach this patient population vaginal dilation to maintain the length and width of the vaginal canal to allow for pain-free sexual function. Most surgeons who are performing these procedures suggest a dilation protocol specific to the type of vaginoplasty they perform. As with most rehabilitation protocols, most patients need the guidance of, and accountability to, a physical therapist to successfully follow a rehabilitation protocol following a surgical procedure. You can find rigid vaginal dilators here. Additionally, with the penile inversion vaginoplasty, the neovagina is not able to self lubricate; therefore, using a lubricant during dilation or intercourse is necessary. Read this blog post that reviews the best lubricants to use and why.
Below are two examples of a dilation protocol post penile inversion vaginoplasty.
Protocol #1
Months Post-Op | Frequency |
0-3 | 3x/day |
3-6 | 1x/day |
6-9 | Every other day |
9-12 | 1-2x/week |
- 10 minutes per dilation session.
- Increase to next dilator every 3 months.
Protocol #2
Time Post-Op | Frequency |
First 6 weeks | 3x/day |
Next 3 months | 2x/day |
Next 2 months | 1x/day |
6 months onward | 2-3x/week |
- 10-15 minutes per dilation session.
- Use smaller dilator for 5 minutes, then may increase to next size.
Physical therapy has always been an integral part of the post operative rehabilitation for many surgeries, such as an ACL repair of the knee, or a joint replacement, or spinal surgery. We are a necessary component of the rehabilitation team to assess the musculoskeletal implications of the surgical procedure, treat the present impairments, minimize the patient’s functional limitations and help the patient return to his or her desired level of function. Rehabilitation following gender affirming surgeries should have the same expectations.
For people who do not live near one of Pelvic Health and Rehabilitation Center’s eight locations, we suggest finding a physical therapist near you that can be part of your rehabilitation team post gender affirming surgery. Check out the American Physical Therapy Association Section on Women’s Health Physical Therapy Locator and the Herman and Wallace Pelvic Health Institute’s Find a Provider link.
FAQ
What are pelvic floor muscles?
The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.
What is pelvic floor physical therapy?
Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.
What happens at pelvic floor therapy?
During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.
What is pudendal neuralgia and how is it treated?
Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.
Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.
What is interstitial cystitis and how is it treated?
Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.
Who is the Pelvic Health and Rehabilitation Team?
The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.
How many years of experience do we have?
Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.
Why PHRC versus anyone else?
PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.
Do we treat men for pelvic floor therapy?
The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.
Do I need pelvic floor therapy forever?
The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.