By Elizabeth Akincilar, MPT, Cofounder, PHRC Merrimack
Although still out of reach for many, gender affirming surgical procedures are becoming more accessible as more surgeons are offering these services and more insurance providers are covering some of the costs associated with these procedures. As more people undergo these surgical procedures the need for rehabilitative services post operatively has increased. An integral component of post operative care should include physical therapy. Physical therapy can also be helpful for those who choose not to undergo gender affirmation surgeries. Learn how physical therapy can benefit those folks in a previous PHRC blog post.
Physical therapy can assist in the rehabilitation of surgical procedures for trans males such as:
- Chest reconstruction or chest masculinization surgery
- Hysterectomy with or without oophorectomy
- Metoidioplasty
- Phalloplasty
Physical therapy can assist in the rehabilitation of surgical procedures for trans females such as:
- Breast augmentation or feminizing augmentation mammoplasty
- Vaginoplasty
Physical therapy is often required or at least recommended after many surgical procedures to facilitate healing, decrease pain and regain function. Gender affirming surgeries should be no different. These surgical procedures should have the same postoperative rehabilitative expectations.
Chest reconstruction or chest masculinization surgery
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.
Hysterectomy with or without oophorectomy
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.
Metoidioplasty and Phalloplasty
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.
Breast augmentation or feminizing augmentation mammoplasty
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.
Vaginoplasty
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 on our blog. Additionally, with the penile inversion vaginoplasty, the neovagina is not able to self lubricate; therefore, using a lubricant during dilation or intercourse is necessary. You can also read our blog post that reviews the best lubricants to use and why.
Each surgeon will prescribe a dilation protocol post operatively. Each protocol may differ slightly depending on the preference of the surgeon. Below are two different examples of dilation protocols.
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 dilator session
- Increase to next dilator size every three 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 dilator session
- Use smaller dilator for five minutes then may increase to next size
Although different surgeons have slightly different dilation protocols, patients may progress at different rates making it even more important for each person to consult with a pelvic floor physical therapist who can guide them through this process and make suggestions and modifications as needed.
Whichever gender affirming surgery one goes through, rehabilitation is an important component of every recovery to minimize pain, facilitate healing and maximize function. Physical therapists are best suited to assist in the rehabilitative process.
For people who do not live near one of the Pelvic Health and Rehabilitation Center’s ten 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 Provide.
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Are you unable to come see us in person in the Bay Area, Southern California or New England? We offer virtual physical therapy appointments too!
Virtual sessions are available with PHRC pelvic floor physical therapists via our video platform, Zoom, or via phone. For more information and to schedule, please visit our digital healthcare page.
In addition to virtual consultation with our physical therapists, we also offer integrative health services with Jandra Mueller, DPT, MS. Jandra is a pelvic floor physical therapist who also has her Master’s degree in Integrative Health and Nutrition. She offers services such as hormone testing via the DUTCH test, comprehensive stool testing for gastrointestinal health concerns, and integrative health coaching and meal planning. For more information about her services and to schedule, please visit our Integrative Health website page.
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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.