Physical Therapy Rehab After Gender Affirming Surgeries

In Pelvic Floor Dysfunction, pelvic floor physical therapy, Pelvic Health, Pelvic Pain, Transgender Health by Elizabeth AkincilarLeave a Comment

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

Melissa Patrick is a certified yoga instructor and meditation teacher and is also available virtually to help, for more information please visit our therapeutic yoga page

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