How Pelvic Floor Physical Therapy Can Serve the Transgender Population: Part 1

In Transgender Health by Elizabeth Akincilar-Rummer2 Comments

By: Shannon Pacella

Earlier this summer, Dr. Heidi Wittenberg wrote a blog post enabling medical providers to understand transgender healthcare needs, which you can read here.

Following Dr. Wittenberg’s lead, I was fortunate enough to attend an educational course focused on the physical therapy evaluation and treatment of transgender patients, and I believe it is imperative to convey how important pelvic floor physical therapy may be for this population.

As Dr. Wittenberg had mentioned, some transgender individuals may decide to undergo gender affirmation surgeries in order to have their physical body align with their gender identity. These surgeries may include:

Female to Male surgical options:

  • Chest reconstruction
  • Hysterectomy with or without oophorectomy
  • Metoidioplasty
  • Phalloplasty

Male to Female surgical options:

  • Breast augmentation
  • Vaginoplasty

No matter which surgical options are or are not chosen, physical therapy plays an integral part of each patient’s care both pre and post operatively. I will cover how physical therapy can benefit patients preoperatively for those who do not wish to undergo gender affirmation surgery. Part two of this blog series will cover the role of physical therapy in the treatment after gender affirmation surgery.

Binding
Transmen might bind the breast tissue down (called binding) in order to create a flatter appearance prior to chest reconstructive surgery or binding may be done indefinitely without surgery. Binding incorrectly or not binding safely can result in long term impairments. It is important to remove the binder prior to sleeping and to only bind between eight to twelve hours per day.1 According to the article, “Health impact of chest binding among transgender adults: a community-engaged, cross-sectional study,” there were 28 health outcomes found as a result of chest binding, which included back pain, chest pain, bad posture, shoulder pain, numbness, and scarring.1 All of these impairments can be addressed through physical therapy. Proper education on posture is crucial for those who utilize chest binding. For those who wish to have chest reconstructive surgery, ensuring adequate muscle length in pectorals (which tend to be shortened with improper rounded shoulder posture) and good myofascial tissue extensibility around the chest is important prior to surgery in order to prevent complication postoperatively.

Packing
To create the appearance of a bulge in the genital region, transmen may perform packing with the use of a prosthetic. Packing may be used prior to metoidioplasty or phalloplasty, or it may be done without the end goal of surgery. There are various packing prosthetics available including: soft packers (used for aesthetic purposes), hard packers (can be used for penetrative intercourse), and stand to pee (STP) devices/packers (used to be able to urinate while standing).2 The packer is typically placed inside the underwear, some have specific underwear in order to adequately keep the packer in place. The use of any of these packers can affect how someone walks and can lead to adductor muscle tension if the person is constantly clenching their legs together in order to keep the packer in place. These impairments can be addressed with proper education from a physical therapist. In addition, if the stand to pee prosthetic is used, some may find it difficult to fully void while standing without straining. Over time, this may lead to urinary dysfunction including urinary hesitancy, incomplete voiding, and urinary frequency, and ultimately pelvic floor muscle dysfunction. It may be beneficial to consult a pelvic floor physical therapist if you are having difficulty using a stand to pee device.

Prior to Metoidioplasty
A metoidioplasty is a surgical procedure that lengthens a transman’s enlarged clitoris (testosterone induced) to create a penis/neophallus. The patient may elect to have urethral lengthening done as well, in order to be able to urinate while standing. The use of a clitoral pump may be indicated in order to maximize the size of the clitoris prior to surgery. Seeing a pelvic floor physical therapist to ensure unrestricted connective tissue and myofascial tissue around the suprapubic region and bony pelvis, and good pelvic floor motor control is important prior to metoidioplasty.

Prior to Phalloplasty
Transmen may decide to have a phalloplasty done, which is a surgical procedure to create a penis/neophallus, urethral lengthening, and optional scrotoplasty with testicular implants. There are many different surgical techniques to perform a phalloplasty, but most require taking a flap with nerve and blood supply as well as a skin graft to cover where the flap was taken from another area on the patient’s body, in order to have enough tissue to create the neophallus. The most common areas to take a flap for a phalloplasty are the radial forearm and latissimus dorsi region. The most common areas for a skin graft to be taken are the gluteal fold, abdomen, and thigh. Both areas (where the flap was taken and where the skin graft was taken) can end up with severe scarring and scar tissue formation that if left untreated could lead to pain, postural changes, and underlying muscle dysfunction. Prior to the phalloplasty, it can be very beneficial to the patient to seek out a pelvic floor physical therapist trained in manual connective tissue and myofascial release to work on the areas of the body that will be used for the flap and skin grafts to allow for adequate tissue length. Good pelvic floor muscle tone and motor control should also be obtained prior to surgery.

Tucking
Transwomen may perform tucking, which is a technique used to hide external genitalia and provide a smooth appearance. This involves tucking the testicles and penis between the buttocks; the testicles may be pushed into the inguinal canals as well. Some people use tight fitting underwear, an undergarment called a gaffe, or adhesive tape to hold the genitals in place, but this comes with some risks.3 Due to the placement of the urethral orifice close to the anus when tucking, there can be an increased risk for developing urinary tract infections as well as compression of the urethra leading to urinary dysfunction.3 Tucking for extended periods of time may lead to symptoms of prostatitis, epididymitis/epididymo-orchitis, and cystitis, which can lead to pelvic pain and pelvic floor muscle dysfunction.3  If someone develops pelvic pain or urinary dysfunction from tucking, they should consult with a pelvic floor physical therapist to assess these impairments and treat any connective tissue/myofascial restrictions and possible postural changes at the pelvis, typically excessive anterior pelvic tilting used while tucking.

Prior to Vaginoplasty
A vaginoplasty is a surgical procedure done for transwomen in order to remove the external genitalia (penis, scrotum, and testicles) and the creation of a neovagina. Due to the complexity of this surgery, the better a patient’s pelvic health is prior to the procedure, the better outcomes they may have. It is important to note that the bulbospongiosus muscle is removed during all types of vaginoplasties, and the levator ani muscle are partially dissected to improve vaginal canal width. You can visualize these muscles in the pictures above. If there is underlying pelvic floor muscle dysfunction or hypertonicity, it may be exacerbated post surgery; this is something that can be addressed by a pelvic floor physical therapist in order to improve the recovery process.The urethra is shortened significantly during this surgery to about one fifth its natal length, which may lead to urinary hesitancy, difficulty voiding, urinary urgency/frequency, and pain with urination. Pelvic floor motor control exercises are very important to practice, especially bulging and dropping in a sitting position, since the patient will need to sit while urinating after the vaginoplasty. Practicing urinating while sitting before the surgery can allow the patient to gain better control and feel confident post surgery.

As you can see, there are many aspects in which pelvic floor physical therapy can help the transgender population prior to gender affirmation surgeries, as well as for those who do not wish to undergo any surgery. At PHRC, we believe that good pelvic health is important for overall well-being as it affects many vital functions including urinary/bowel/sexual function, posture, and movement. Everyone should have the opportunity to work on optimizing their pelvic health no matter what, and we at PHRC are here to help!

Resources:

  1. Peitzmeier S, Gardner I, Weinand J, Corbet A, Acevedo K. Health impact of chest binding among transgender adults: a community-engaged, cross-sectional study. Cult Health Sex. 2017 Jan;19(1):64-75. Epub 2016 Jun 14.
  2. Underwood T. A Guide to Packers for Transmen. FTM Guide. May 9, 2016. http://ftm-guide.com/guide-to-packers-for-transmen/.
  3. Zevin, B. Testicular and Scrotal Pain and Related Complaints. Center of Excellence for Transgender Health. http://transhealth.ucsf.edu/trans?page=guidelines-testicular-pain.

Comments

  1. This is a very helpful post—thanks! Question: can taking hormones influence the pelvic floor muscles and exacerbate pre-existing pelvic floor dysfunction / hypertonicity / spasticity / pelvic pain?

    1. Author Shannon Pacella says:
      Hi Carmilla,
      That’s a great question, there has not been very much research specifically looking at pelvic floor muscle changes with systemic hormone therapy in the transgender population. However there are some general pelvic and sexual health changes that have been studied that may influence underlying pelvic floor dysfunctions:
      Systemic Estrogen:
      Erectile function and capacity diminished – reduced or completely eliminated ejaculate.
      Decreased libido/sexual desire.
      Changes with orgasm response/sensation – whole body experience.
      Systemic Androgen Blockers (ex: spironolactone) – may be used in conjunction with Estrogen :
      Reduces orgasm ability/reduced libido.
      Can cause increased urinary frequency.
      May cause orthostasis/dizziness.
      Systemic Testosterone:
      Increased clitoral size and sensitivity.
      Increase in sexual desire/libido.
      Changes with orgasm response/sensation – more genital focused with higher peak intensity.
      Urogenital atrophy, genital tissues may be more friable, more susceptible to fissuring.
      Possibility of testosterone induced dyspareunia – may benefit from topical estrogen use at atrophic tissues.
      Increased susceptibility for bacterial vaginosis.
      Decreased lubrication – may contribute to discomfort with penetrative intercourse.
      For further information, here are some helpful resources:
      https://transcare.ucsf.edu/hormone-therapy
      http://transhealth.ucsf.edu/trans?page=guidelines-pain-transmen
      Best,
      Shannon Pacella, PT, DPT

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