How Pelvic Floor Physical Therapy Can Serve the Transgender/Gender Non-conforming Population: Part 2

In Transgender Pelvic Health by Shannon PacellaLeave a Comment

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.

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