Phalloplasty and metoidioplasty: results and what to expect

Among the questions that trans men — and the people close to them — ask most often, the concrete results of genital surgery are perhaps the least openly discussed topic. What does a surgically constructed penis look like? Does it work? Can you feel it? The short answer is: yes, it works and yes, you can feel it, but the details matter. This article presents the updated scientific data on phalloplasty and metoidioplasty — results, limitations, complications, and satisfaction rates — to offer a realistic and informed picture. This is not medical advice: it is a starting point based on peer-reviewed literature.

Two surgeries, two philosophies

Gender-affirming genital surgery for trans men involves two main options: phalloplasty and metoidioplasty. There is no “better” choice in absolute terms — only the one that best suits each person’s priorities.

Metoidioplasty: small but sensitive

Metoidioplasty utilizes the clitoris, which after at least 1-2 years of testosterone therapy hypertrophies significantly (average growth is 3-5 cm) [3]. The surgeon releases the clitoris from the suspensory ligaments, straightens it, and maximizes its length, creating a microphallus of 5-9 cm. The tissue is biologically native: it maintains its own vascularization, innervation, and erectile capacity.

The advantages are significant: since it is the patient’s own tissue, erogenous sensation is preserved in 100% of cases [3]. The testosterone-enlarged clitoris functions like a small penis that naturally becomes rigid during arousal — no erectile prostheses are needed. The largest available study, conducted on 813 patients, reported overall satisfaction of 79% (completely satisfied) with an additional 20% mostly satisfied [3].

The main limitation is size: the microphallus generally does not allow sexual penetration. For those for whom this is a priority, metoidioplasty may not be the most suitable choice [10]. For those who prioritize sensation, natural erection, and a less invasive surgical pathway, it represents an excellent option.

Phalloplasty: standard dimensions, complex pathway

Phalloplasty constructs a neophallus of 12-16 cm using a tissue flap harvested from another part of the body [1]. The two most common donor sites are:

• Radial Forearm Free Flap (RFF): considered the gold standard [2]. Forearm tissue is thin, flexible, and well-vascularized, producing a neophallus with good aesthetics and good sensory potential. The surgeon microsurgically connects the flap’s blood vessels and nerves to those of the pubic area. The disadvantage is the visible scar on the donor forearm.

• Anterolateral Thigh Flap (ALT): an alternative that avoids the forearm scar. Thigh tissue is thicker, which may require subsequent debulking (volume reduction) procedures. A comparative study of 413 cases showed that the ALT flap has higher rates of secondary revisions (45% vs 15%), but the donor site scar is less visible and long-term functional results are comparable [7].

Phalloplasty is a multi-stage procedure that takes place over 12-24 months, with 2-4 separate surgical interventions [1]. Each stage requires dedicated recovery.

What the complete surgical pathway includes

Stage 1: creation of the neophallus

The first procedure involves harvesting the flap, shaping it into a phallic form using the so-called “tube-within-a-tube” technique (an inner tube for the urethra and an outer tube for the penile shaft) and microsurgically connecting the blood vessels and nerves at the pubic site [1]. This stage lasts 8-12 hours in the operating room and is among the most complex in reconstructive surgery.

Stage 2: urethral lengthening and scrotoplasty

Approximately 5-6 months later, the second procedure may include urethral lengthening to allow standing urination and scrotoplasty — creation of the scrotum using the labia majora. Standing urination after urethral lengthening is achievable in 75-91% of cases, a figure that varies depending on the technique and the center’s experience [1].

Urethral lengthening is the component with the highest complication rate (discussed further below) [6]. Some patients choose not to undergo it, maintaining urination in the original position.

Stage 3: testicular prostheses and erectile device

Approximately 12 months after the second stage — the time needed for tactile sensation to be restored — testicular prostheses are inserted into the scrotum and, if the patient desires, an erectile device in the neophallus [9].

Glanuloplasty — reshaping the tip of the neophallus to simulate the glans — is also often performed at this stage or in a dedicated procedure, to improve the aesthetic appearance.

Sensation: tactile and erogenous

One of the most misunderstood aspects of phalloplasty concerns sensation. There are two distinct types:

Tactile sensation

Tactile sensation — the ability to feel touch, pressure, temperature — is restored through neurorrhaphy (microsurgical nerve connection). The donor flap nerves are connected to the cutaneous nerves of the pubic area [11]. Nerve regeneration is slow: it begins approximately 3 weeks after surgery, but significant recovery takes 6-12 months. At 12 months, nearly all patients recover at least partial tactile sensation. Systematic reviews report that 88% of patients develop tactile or erogenous sensation in the neophallus [1].

Erogenous sensation

Erogenous sensation — that related to sexual pleasure — depends on preservation of clitoral tissue. In most current techniques, the clitoris is not removed but is positioned at the base of the neophallus, maintaining its erogenous innervation intact [12]. This means that stimulation of the penile base produces sexual sensations.

Over time and with sensory re-education, many patients report progressively “mapping” these sensations onto the entire phallus — a phenomenon related to cortical plasticity, the brain’s ability to reorganize sensory maps [11]. The most recent approach to optimizing this process involves structured neurosensory re-education protocols that combine progressive tactile stimulation and sexual rehabilitation.

Comparison with metoidioplasty

With metoidioplasty, the matter is simpler: the tissue is native, the nerves are not severed, erogenous sensation is preserved at 100% [3]. Nearly all patients maintain the ability to reach orgasm through direct stimulation of the microphallus. A 2025 systematic review confirmed that sexual health outcomes after metoidioplasty are overall positive, with sexual satisfaction levels higher than those of phalloplasty [5].

Erectile devices

The neophallus constructed with phalloplasty does not contain erectile tissue: to achieve the rigidity needed for penetration, an erectile prosthesis is essential, inserted in a subsequent procedure (generally at least 12 months after phallus creation) [9].

Types of prostheses

• Semi-rigid (malleable) prostheses: flexible rods that maintain the phallus in a semi-rigid position permanently. Simpler to implant, with fewer mechanical components prone to failure. They bend downward when not in use and upward for intercourse [9].

• Inflatable prostheses: composed of cylinders inserted in the neophallus, a fluid reservoir, and a pump positioned in the scrotum. Pressing the pump fills the cylinders with fluid, producing an erection. They offer a more natural result (alternating flaccidity and rigidity), but are mechanically more complex [9].

Results and complications of prostheses

The data on erectile prostheses after phalloplasty are important to understand clearly. A study of 89 patients with a ZSI475 inflatable prosthesis showed that 53% of implants required at least one re-intervention, with the main causes including mechanical malfunction (40%), infection (6%), malposition (5%), and erosion (1.5%) [8].

Despite these complication rates — significantly higher than penile prostheses in natal penises (infection at 10% vs 1.1%) [9] — overall satisfaction remains high. In a cohort of 104 patients with an erectile prosthesis, 77% were able to have penetrative intercourse, 61% achieved orgasm, and 88% reported satisfaction with the overall result of the phalloplasty [1].

Prosthetic complications are decreasing over time thanks to the refinement of techniques. Centers with extensive experience — where the same surgical team performs both the phalloplasty and the prosthetic implantation — report significantly lower infection and explantation rates [9].

Urethral complications: the data to know

Urethral complications are the most significant challenge of phalloplasty. Urethral lengthening — necessary to allow standing urination — involves constructing a urethral channel within the neophallus, connected to the native urethra [6]. This junction is the most vulnerable site.

Urethrocutaneous fistulas

Fistulas are abnormal communications between the urethra and the skin, causing urine leakage from points other than the meatus. They occur in 17-40% of cases [6]. An important fact: up to two-thirds of fistulas resolve spontaneously without the need for re-intervention. The remainder require surgical repair.

Urethral strictures

Strictures are narrowings of the urethral lumen that obstruct urinary flow. They occur in 21-51% of cases, typically at the junction between the native urethra and the neo-urethra [6]. Treatment varies based on the length of the stricture: short ones can be managed endoscopically, while longer ones require reconstructive techniques such as buccal mucosa grafting.

The overall picture

The most experienced centers report a urethral complication rate of 24% — an improvement compared to the 51% general average [6]. The surgeon’s learning curve is a determining factor. For this reason, guidelines recommend seeking high-volume centers [13].

Metoidioplasty presents lower urethral complication rates — approximately 25% [3] — partly because the urethral lengthening is shorter and less complex. The Belgrade technique, developed by Prof. Djordjevic, reports the best outcomes in terms of urethral complications in metoidioplasty [3].

Scrotoplasty and testicular prostheses

Scrotoplasty involves creating the scrotum from the labia majora, which are joined at the midline. Insertion of testicular prostheses generally occurs at a later stage, at least 6 months later, to allow the tissues to heal adequately.

Silicone testicular prostheses are available in various sizes and are selected based on the patient’s body frame. In a large-scale study, the explantation (removal) rate of prostheses was 20.8%, with the main causes including infection, extrusion, discomfort, and urethral problems [9]. Here too, rates have improved over time with the evolution of surgical techniques and materials.

Overall satisfaction rates

The data on satisfaction — collected through standardized questionnaires and Patient-Reported Outcome Measures (PROMs) — offer an encouraging picture:

Phalloplasty

• Satisfaction with the effect on masculinity: 82% [1]
• Satisfaction with appearance: 66% [1]
• Satisfaction with overall life: 75% [1]
• Match between results and expectations: 61% [1]
• Satisfaction with sexual function: 34% (the lowest figure, related to the complexity of sensory recovery and prosthetic complications) [4]

Metoidioplasty

• Overall satisfaction: 79% completely satisfied, 20% mostly satisfied [3]
• Satisfaction with sexual function: significantly higher than phalloplasty [5]
• Erogenous sensation: 100% [3]
• Main source of dissatisfaction: the inability to have penetrative intercourse [10]

How to read these data

The satisfaction numbers need to be contextualized. The lower score for sexual function in phalloplasty does not mean that most patients are dissatisfied with their decision to have surgery — it means that sexual function is the area with the most room for improvement [4]. Overall satisfaction with life and sense of masculinity is high in both procedures.

Realistic expectations

Those considering these surgical options should know that:

The neophallus is not identical to a cisgender penis, but that is not its goal either. The goal is to create a functional organ that reduces dysphoria, allows standing urination (if desired), and permits — within the limits of current technique — a satisfying sex life. Aesthetic results continue to improve with scar maturation and tissue remodeling over the course of 12-18 months.

Complications are not failure: they are part of the journey. Phalloplasty is among the most complex procedures in reconstructive surgery [1]. Re-intervention rates are high, but most complications are manageable and do not compromise the final result. Knowing what to expect in advance makes the journey more sustainable.

The choice between metoidioplasty and phalloplasty is personal. There is no hierarchy between the two. Some trans men choose metoidioplasty and are completely satisfied; others desire the dimensions offered by phalloplasty and accept the complexity of the pathway. Some start with metoidioplasty and later choose phalloplasty. There is no wrong path.

The surgical center matters. Results vary significantly based on the team’s experience [13]. WPATH guidelines recommend seeking surgeons with a high volume of cases and specific training in gender-affirming genital surgery.

Time is an ally. Sensation, aesthetics, and functionality improve over time [11]. Results at 6 months are different from those at 18 months, which are different from those at 3 years. Recovery is not linear and requires patience.

The overall picture

Genital surgery for trans men has made enormous progress over the last two decades. Techniques are being refined, complication rates are decreasing, sensory recovery protocols are improving. None of these procedures is perfect — but no surgical procedure is. What the data show is that the vast majority of people who choose phalloplasty or metoidioplasty are satisfied with their decision [1][3].

Transparency about current limitations is not a deterrent: it is a form of respect toward those making an important decision about their lives. Knowing the real data — neither the sugar-coated versions nor the catastrophic ones — allows informed choices and realistic expectations.

For a broader overview of gender-affirming surgical options, including other available procedures and access in Italy, you can consult our article on gender-affirming surgery. To understand how testosterone changes the body over time, read the guide on what changes with hormone therapy.