Vaginoplasty: Procedure and Recovery

Vaginoplasty is the most requested gender-affirming surgery by trans women. A simplified and often distorted version circulates: it is either presented as a trivial procedure or, conversely, as something terrifying. The reality is that it is a complex surgical procedure, with decades of technical refinement, documented results, and a solid framework of scientific evidence. This article explains how it really works, from preparation to recovery, based on medical literature. It is not medical advice and does not replace the surgeon’s opinion: it is a starting point to understand what to expect. For an overview of all gender-affirming surgeries, refer to the article on gender-affirming surgery.

The prerequisites: who can access vaginoplasty

Vaginoplasty is not an on-demand surgery. Internationally defined clinical criteria exist, updated in 2022 with the publication of the Standards of Care Version 8 (SOC-8) by the World Professional Association for Transgender Health (WPATH) [1].

The main requirements include:

• Documented diagnosis of gender incongruence, confirmed by mental health professionals.
• Hormone therapy for at least 6 months (SOC-8 reduced the previous 12-month requirement) [1]. Estrogens modify fat distribution, skin, and tissues, also influencing surgical outcomes.
• Psychological evaluation: not to “prove” one’s identity, but to ensure the person is informed, stable, and supported. Mental health conditions that could negatively affect outcomes are assessed and, if necessary, treated before surgery.
• A letter of recommendation from a qualified mental health professional (SOC-8 reduced the previous requirement from two letters to one) [1].
• Minimum age of 18 years, with possible exceptions in specific cases depending on local legislation.
• Capacity for informed consent, fully understanding the risks, benefits, and irreversible implications, including loss of fertility.

In Italy, the process goes through reference centers coordinated by ONIG and requires a psychological evaluation of at least six months according to the national protocol [13]. Since 2024, thanks to Constitutional Court ruling no. 143, court authorization is no longer required to proceed with surgery [12].

Surgical techniques

Several vaginoplasty techniques exist. The choice depends on the patient’s anatomy, available tissue, personal preferences, and the surgeon’s experience.

Penile inversion vaginoplasty

It is the most common technique worldwide and represents the gold standard [3]. The principle is relatively intuitive: penile and scrotal tissue is repurposed to create the structures of the neovagina and vulva.

The procedure consists of several phases:

1. Tissue preparation: The penile skin is separated from the underlying structures (corpora cavernosa, corpus spongiosum) with a circumferential incision. This phase requires extreme precision to preserve innervation and vascularization.
2. Creation of the neoclitoris: The glans, which contains the highest concentration of nerve endings, is resized and repositioned in the anatomical position of the clitoris. The innervation of the dorsal neurovascular bundle is preserved to maintain erogenous sensitivity.
3. Formation of the vaginal canal: A cavity is created between the rectum and the prostate/bladder, in the rectovesical septum space. The penile skin, inverted like a glove, is inserted into this cavity to line the canal walls.
4. Construction of the vulva: Scrotal tissue is used to create the labia majora and minora. The urethra is shortened and repositioned. The clitoral hood is formed using dorsal penile tissue.
5. Placement of the conformer: At the end of the surgery, a conformer (stent) is inserted into the vaginal canal and kept in place for 5-7 days to prevent tissue collapse during initial healing.

The average depth of the neovagina with this technique is about 9-10 cm, although it varies based on the amount of penile tissue available [4]. If there is insufficient tissue (e.g., due to previous radical circumcision or prolonged use of puberty blockers), additional skin grafts can be used, typically taken from the scrotum or groin.

The surgery lasts an average of 4-6 hours.

Sigmoid vaginoplasty (Colonvaginoplastica)

This technique uses a segment of the sigmoid colon to create the vaginal canal instead of penile skin [8]. It is a more invasive procedure because it requires an abdominal surgery (often laparoscopic) to harvest the intestinal segment.

The main advantages are:

• Greater depth: The average is 13-16 cm, significantly higher than penile inversion [8].
• Self-lubrication: The intestinal mucosa naturally produces secretions, eliminating or reducing the need for lubricants during intercourse.
• Lower risk of stenosis: Intestinal mucosa is less prone to cicatricial contraction compared to skin, potentially reducing the need for intensive dilation.

Disadvantages include a longer and more invasive surgery, the risk of abdominal complications, and the possibility of secretions with a characteristic odor (which tends to decrease in the following months). Specific complication rates are: fistulas at 2%, stenosis at 14%, tissue necrosis at 1%, and prolapse at 6% [8].

Sigmoid vaginoplasty is particularly recommended for patients with a stretched penile length of less than 11.4 cm, penoscrotal hypoplasia, high BMI, or as a revision procedure after a failed penile inversion [8].

Peritoneal vaginoplasty (peritoneal pull-through)

This is the newest and most rapidly evolving technique, often performed with robotic assistance [10]. It uses the peritoneum, the thin membrane lining the abdominal cavity, to create the lining of the vaginal canal.

The peritoneum is harvested through a laparoscopic or robotic approach and “pulled through” downwards to line the neovaginal cavity. It can be combined with penile inversion to achieve greater depth (the peritoneal flap adds about 5 cm to the length).

Theoretical advantages include:

• Thin, flexible tissue with lubricating capacity
• Average depth of about 14 cm [10]
• No need to harvest intestinal tissue
• Minimal abdominal scarring

Being a relatively new technique, long-term data are still limited. Early results are promising, with reduced stenosis rates in newer versions of the procedure (from 48% in early case series to 10% with optimized techniques) [10]. The surgical community considers this technique to be in a consolidation phase: results progressively improve as centers accumulate experience.

Jejunal vaginoplasty

This technique uses a segment of the jejunum, a portion of the small intestine, to create the neovaginal canal [15]. The segment is harvested with its vascular pedicle intact, and the intestine is reconnected with a primary anastomosis. The jejunal tissue is then placed in the neovaginal cavity, often combined with peritoneal flaps and penile/scrotal skin for the external vulva.

Specific advantages over sigmoid vaginoplasty (which uses the colon) include:

• Naturally hairless tissue: Being intestinal tissue, it requires no preoperative laser or electrolysis hair removal, greatly simplifying preparation.
• Self-lubrication: Jejunal mucosa produces natural secretions, reducing or eliminating the need for lubricants during intercourse.
• Less mucus production: Compared to the sigmoid colon, the jejunum tends to produce fewer secretions and with less odor, although some degree of constant secretion is present.
• Reduced need for dilation: Compared to penile inversion, the intestinal mucosa is less prone to stenosis.

Disadvantages include greater surgical complexity (requires an abdominal approach, often robotic-assisted), risk of bowel complications, and the fact that secretions are constant and not linked to arousal, necessitating the use of panty liners. A 2024 study on six patients reported an average depth of 7 cm and a diameter of 1.3 cm at 8 months post-surgery, with a complication rate of 33% [15].

The technique is still relatively uncommon in gender-affirming surgery but has been successfully used for decades for vaginal reconstruction in cisgender women with Mullerian agenesis.

Preparation for surgery

Preparation for vaginoplasty begins months before the surgery date and requires active commitment from the patient.

Permanent hair removal

For many surgical techniques, permanent hair removal from the tissue that will be used to create the neovagina is an important preparation step. If hair follicles are not eliminated, they can cause hair growth inside the vaginal canal, with consequences ranging from discomfort to chronic infections, from the formation of hair stones to dyspareunia (pain during intercourse) [11].

Options are electrolysis and laser hair removal. Recent literature indicates that laser is more efficient, less painful, and less expensive than electrolysis, while achieving comparable results [11]. Most surgeons recommend starting 6-12 months before surgery, with a 3-month waiting period after the last treatment to verify no regrowth. Hair removal should not be performed in the two weeks prior to surgery.

The area to be treated is primarily the penile skin, which will be inverted to form the vaginal canal.

Important note: Preoperative laser hair removal is not always necessary. Techniques using intestinal tissue (sigmoid vaginoplasty, jejunal vaginoplasty) do not require it, as intestinal mucosa is naturally hairless. Additionally, some surgeons performing penile inversion practice intraoperative cauterization of follicles: the skin tissue is defatted during surgery to expose the follicles from the inner side, which are then cauterized one by one with an electrocautery. This technique significantly reduces regrowth, although it does not completely eliminate it. It is crucial to discuss with your surgeon what preparations are required based on the chosen technique.

Medical preparation

In the weeks preceding the surgery:

• Estrogen therapy is suspended (generally 2-4 weeks prior) to reduce thromboembolic risk.
• Complete blood tests, an electrocardiogram, and an anesthesiology consultation are performed.
• Medications that increase bleeding risk (aspirin, anticoagulants, specific supplements) are suspended.
• A specific diet is followed in the days leading up to the procedure.

Bowel preparation

The day before surgery, a mechanical bowel preparation (similar to a colonoscopy prep) is performed to completely empty the intestine. This reduces the risk of contamination during the creation of the neovaginal cavity, which occurs near the rectum.

Practical and logistical preparation

Often underestimated but fundamental aspects [14]:

• Organize at least 6-8 weeks off work.
• Set up a home environment suitable for recovery (accessible bed, nearby bathroom).
• Have a support person available during the first 2-3 weeks.
• Purchase a dilator kit, specific cushions, and comfortable underwear in advance.
• Prepare frozen meals or organize food delivery.

The day of surgery

Admission generally occurs the day before or the morning of the surgery.

The anesthesia is general, and the surgery takes an average of 4-6 hours for penile inversion, and can be longer for techniques requiring an abdominal approach. At the end of the operation, a urinary catheter (which will remain for 5-7 days), the vaginal conformer, and compressive dressings are placed.

Waking up happens in the recovery room or postoperative intensive care. Pain is initially managed with intravenous analgesics (often with a Patient-Controlled Analgesia - PCA pump), gradually transitioning to oral medications in the following days.

Hospitalization lasts an average of 5-7 days. During this period:

• The patient remains in bed for the first 24-48 hours.
• Gradual mobilization begins on the second or third day.
• The urinary catheter is removed between the fifth and seventh day.
• The conformer is removed, and the first examination of the neovagina takes place.
• The dilation technique is taught [14].

Postoperative care and dilation

The vaginoplasty postoperative period is long and demanding. Dilation is probably the most crucial and underestimated aspect of the entire surgical process.

Why dilation is essential

The human body reacts to every surgical intervention with a healing and scarring process. In the case of the neovagina, the natural tendency of the tissues is to contract and close. Dilation counteracts this process by keeping the canal open, preserving the depth and width achieved in the operating room [14].

Loss of depth or complete closure of the canal (stenosis) represents one of the most significant complications: recent studies report a cumulative incidence of complete canal loss of 5% every six months in the first postoperative year, with dilation fatigue as the main contributing factor [6].

The dilation protocol

The protocol varies between centers but follows a similar structure [14]:

Weeks 1-6 (acute phase): Dilation 3-4 times a day, for 20-30 minutes per session. You start with the smallest dilator (size 0 or 1) and gradually increase. This is the most demanding phase: the tissue is still healing, discomfort is common, and consistency is fundamental.

Weeks 6-12 (subacute phase): Frequency decreases to 2-3 times a day. Scar tissue begins to remodel. You progress to larger dilators (generally size 2 by the third week, size 3 by the fifth, size 4 by the seventh).

Months 3-12: Frequency decreases to 1-2 times a day, with 15-20 minute sessions. This is the consolidation phase.

After the first year: Dilation becomes part of a long-term routine, with variable frequency (from once a day to a few times a week). Penetrative sexual intercourse, when present, can partially replace dilation sessions, but not completely.

Dilation is a lifelong commitment. This must be clearly communicated before surgery and represents a determining factor in the decision.

Managing pain and discomfort

Postoperative pain is most intense in the first 7-10 days and is managed with analgesics. Swelling and bruising are normal and resolve gradually over 4-6 weeks. A feeling of perineal pressure is common in the first weeks.

Initial dilation can be uncomfortable or painful. Over time, discomfort decreases significantly. The use of abundant (water-based) lubricants is essential.

The recovery timeline

Here is a realistic overview of recovery times:

First week: Bed rest, pain managed with medications, catheter in place, first dressings.

Weeks 2-3: Gradual mobilization at home, start of autonomous dilation, removal of sutures. Significant but improving discomfort.

Weeks 4-6: Possibility of short outings, swelling visibly reduces, dilation becomes more manageable. Many patients start feeling autonomous.

Weeks 6-8: Possible return to work for sedentary activities. Surgical follow-up visit.

Months 3-6: Gradual resumption of physical activities (avoiding intense exertion). Aesthetic appearance progressively improves. Resumption of sexual activity can be considered, with caution and gradualness.

Months 6-12: Stabilization of results. Scars mature, sensation improves, the appearance approaches the final result.

Beyond the first year: Final results. The resumption of hormone therapy (suspended before surgery) helps maintain the tissues.

Complications and risk rates

Like any major surgical procedure, vaginoplasty carries risks. Transparency on this point is crucial for truly informed decisions.

General complications

These are common to any surgery under general anesthesia: infections (managed with antibiotics), bleeding (rarely requiring re-operation), deep vein thrombosis (prevented with heparin and early mobilization), adverse reactions to anesthesia.

Specific complications

An updated 2021 meta-analysis, which analyzed 57 studies for a total of 4,680 cases, reported the following rates for the penile inversion technique [2]:

• Vaginal stenosis (narrowing of the canal): 10%. It is the most common complication. It can be managed with intensified dilation or, in severe cases, with surgical revision.
• Tissue necrosis (partial death of transplanted tissue): 5%. Generally limited and manageable.
• Neovaginal prolapse: 2%. Requires surgical correction.
• Fistulas (abnormal connections between the neovagina and rectum or urethra): 1%. A serious complication requiring re-operation.

Urological complications

A 2023 systematic review analyzing 27 studies on 3,388 patients reported [7]:

• Weak or deviated urinary stream: 11.7%
• Urethral meatus stenosis: 6.9%
• Irritative symptoms (urgency, frequency): 11.5%

Most of these complications are manageable with conservative treatments or minor interventions.

Re-operation rate

About 15-20% of patients require one or more surgical revisions, generally for aesthetic improvements, correction of stenosis, or functional optimization [2]. Revisions are minor procedures compared to the original surgery.

It is important to contextualize: these complication rates are comparable to those of other complex reconstructive surgeries and are constantly improving thanks to the refinement of techniques.

Results: depth, aesthetics, and sensitivity

Vaginal depth

The average depth of the neovagina varies based on the technique:

• Penile inversion: about 9-10 cm (with variability from 7 to 15 cm depending on available tissue) [4]
• Peritoneal: about 14 cm [10]
• Sigmoid vaginoplasty: about 13-16 cm [8]

For comparison, the average vaginal depth in cisgender women is 9-12 cm. The depth achieved with penile inversion is therefore, in most cases, sufficient for sexual intercourse.

Aesthetic results

Aesthetic results have improved enormously in recent decades. Trans women post-vaginoplasty report scores on the Female Genital Self-Image Scale (FGSIS) comparable to those of cisgender women [2]. The appearance of the vulva, including the labia majora, labia minora, clitoral hood, and urethral meatus, is generally natural, although some variability is inevitable (just as it is in cisgender women).

Some centers offer aesthetic revision procedures (secondary labiaplasty, clitoral hood revision) to optimize the result.

Sensitivity and sexual function

This is one of the aspects about which patients have the most questions and understandably the most concerns.

The scientific literature is reassuring. A 2021 systematic review analyzed sexual function after vaginoplasty and found that [9]:

• 76-90% of patients report the ability to reach orgasm after surgery.
• The clitoris is the area with the highest reported sensitivity (67.7% of patients describe it as “sufficiently sensitive”).
• Clitoral stimulation is the primary method for achieving arousal and orgasm.
• 70% of patients rate their postoperative sexual confidence with scores higher than 7 out of 10.

The preservation of sensitivity depends largely on the surgical technique and the surgeon’s experience in preserving the dorsal neurovascular bundle during the creation of the neoclitoris [3]. A brief period of hypersensitivity in the weeks following surgery is normal and resolves spontaneously.

Overall satisfaction and regret

Satisfaction data are among the most solid in the entire surgical literature.

The 2021 meta-analysis reports an overall satisfaction of 91% and a regret rate of 2% [2]. These numbers are extraordinarily positive when compared to almost any other elective surgery. Knee replacement surgery, for example, has dissatisfaction rates between 6% and 30%.

In rare cases of regret, the associated factors are not related to gender identity but rather:

• Unresolved postoperative complications
• Unsatisfactory aesthetic or functional results
• Poor postoperative social support
• Pre-existing, inadequately treated mental health conditions

In other words, regret is almost always linked to how the surgery went, not to who the person is.

Vaginoplasty in Italy

Reference centers

In Italy, several public hospital centers perform vaginoplasties within the National Health Service (SSN) [13]. The main ones include:

• Rome - San Camillo-Forlanini Hospital (SAIFIP): historic center for gender-affirming surgery in Italy
• Turin - Città della Salute e della Scienza (CIDIGem): Piedmontese reference center
• Padua - University Hospital: designated in 2023 as the Regional Reference Center for Gender Incongruence (CRRIG) by the Veneto Region
• Florence - Careggi Hospital
• Bari - Policlinico
• Naples - Federico II

The centers are coordinated by ONIG (National Observatory on Gender Identity) and follow shared protocols.

NHS (SSN) coverage and waiting times

Vaginoplasty is covered by the National Health Service (SSN) [13]. The patient only pays the co-pay (ticket) cost, when applicable. Since 2024, thanks to Constitutional Court ruling no. 143, court authorization is no longer required to access the surgery: the decision is exclusively between the patient and the medical team [12].

The main problem remains availability: SSN centers perform a limited number of surgeries per year (about 60 in total nationally), and waiting lists range from 2 to 5 years [13]. This detail is important and must be considered when planning one’s journey.

Those who choose the private route, in Italy or abroad, must consider costs ranging from 15,000 to over 25,000 euros, depending on the center and the technique used.

Reimbursement for surgeries abroad: It is possible to obtain a reimbursement from the SSN even for surgeries performed in other European Union countries, through the directive on cross-border healthcare (Directive 2011/24/EU). The reimbursement covers the amount the SSN would have incurred for the same surgery in Italy. To obtain it, you must present your clinical documentation and invoices to your local health authority (ASL). In some cases, it is advisable to request prior authorization from the ASL before proceeding with surgery abroad, to have greater certainty about the reimbursement. Processing times vary depending on the region.

What to realistically expect

Vaginoplasty is not a magic wand, and it is not a horror. It is a serious surgical procedure with documented results. Here is what to expect:

It is reasonable to expect: an aesthetically natural vulva, a functional neovagina for sexual intercourse, the ability to achieve orgasm in most cases [9], a significant improvement in dysphoria and quality of life [5], and satisfaction with one’s decision [2].

It is not reasonable to expect: a perfect result without any compromise, the total absence of scars, a quick and painless recovery, or that the surgery alone will solve all problems related to dysphoria or mental health.

You must take into account: a significant postoperative commitment (dilation is a daily duty for months), the possibility of complications requiring patience and further treatments, and an emotional adaptation period that can be complex.

The decision to have surgery is deeply personal. It belongs to the person living it, with the support of competent professionals. What matters is arriving at it with accurate information, realistic expectations, and a solid support system. For those who are also researching other aspects of transition, refer to the article on medical transition.