Gender-affirming Surgery: What to Expect and How Pelvic PT Can Help

Gender-affirming surgery can be a deeply meaningful and transformative step. It can affirm identity, foster self-confidence, and improve quality of life.

As with any major surgery, gender affirming surgery comes with unique recovery needs. In this article, we’ll walk through the basics of gender-affirming surgeries, zoom in on vaginoplasty for transgender women, and explore how pelvic physical therapy can promote healing and improve long-term outcomes.

Top, bottom, and everything in-between: the types of gender-affirming surgeries

Gender-affirming surgery encompasses various procedures designed to align your body with your authentic self. These can include (but aren’t limited to):

• Facial feminization or masculinization surgery
• Chest or breast surgery such as breast augmentation or mastectomy (aka “top” surgery)
• Body contouring to create a more traditionally “male” or “female” shape
• Genital or "bottom" surgery
• Vocal surgery to change vocal pitch

In this article, we’ll focus on bottom surgery for people transitioning from male to female. For transfeminine folks undergoing bottom surgery, there are two main options:

• Vaginoplasty: uses existing tissue from the penis and elsewhere to create a new vaginal canal and the external genitalia (the vulva). 
• Vulvoplasty, aka limited-depth vaginoplasty: this procedure creates a vulva with a shallow opening, usually only a few centimeters deep. 

If you or a loved one are considering genital-affirming surgery, discuss your options with your surgeon. For those who can’t or don’t wish to undergo full vaginoplasty, vulvoplasty can be an excellent alternative.

How is vaginoplasty performed?

While surgical techniques vary, a vaginoplasty typically involves several steps, including: 

• Hair removal: this preoperative process prepares the tissue your surgeon will use to create your new vagina. It ensures no hairs remain that could grow back and cause problems after surgery.
• Orchiectomy: removal of the testes, sometimes performed separately.
• Clitoroplasty: creation of a clitoris from the skin at tip of the penis
• Urethroplasty: shortening and repositioning the urethra (the tube from which you pee).
• Vaginal canal construction: your surgeon will use leftover skin from the penis and another donor site to create the lining of your new vaginal canal. 
• Labiaplasty: creation of the inner and outer “lips” of the vulva from leftover penile and scrotal tissue.

After this complex procedure, the patient will need to stay in the hospital for several days. Managing bandages, a urinary catheter, and surgical drains will be important for a smooth recovery, and you’ll need help with basic self-care.

A period of healing and recovery from surgery follows discharge from the hospital. Let’s consider what to expect during gender affirming surgery recovery.

What to expect after surgery

Gender affirmation surgery healing is a gradual, months-long process which requires patience and self-care. Every person has a unique recovery timeline; here's what to expect:

Dilation (aka vaginal training)

Dilation or “training” of the new vaginal canal typically starts 7-10 days after surgery with specific instructions from the surgical team post-operation. 

Vaginal trainers come in sets of progressive sizes, and some sets are specifically designed for post-op trans surgery care. A pelvic physical therapist can teach techniques to make training more comfortable.

Typically, training is recommended three times daily for the first few months to prevent narrowing or shortening of the new vaginal canal. Consistent vaginal training is critical to maintaining a healthy vagina during bottom surgery recovery.

Vaginal training is required for life, but after the first 9-12 months can be done less frequently. 

Genital hygiene

Research on hygiene during transgender surgery recovery is still sparse, so most providers base their recommendations on clinical experience. 

Surgeons typically recommend regular douching of the vaginal canal, particularly after use of a vaginal trainer, to keep healing tissue clean. 

Some providers find that douching can help address hypergranulation, a common post-op complication in which the body creates too much new tissue at the healing wound site. 

Returning to activity

Every surgeon has their own recommendations for how and when their patients can resume work, exercise, sex, and more. In the absence of clear clinical guidelines, many tend to be quite cautious, preferring their patients to wait several months before returning to vigorous activities like running. Discuss activity restrictions with your surgeon before surgery.

Possible Complications

Many people have positive outcomes after vaginoplasty, from higher sexual satisfaction to improved body image. The risks of vaginoplasty for gender dysphoria treatment are similar to genital surgeries performed for other reasons. 

As with any surgery, complications can happen. Here are some of the most common: 

• Minor tissue breakdown or wound opening: fairly common and often manageable without additional surgery.
• Sexual dysfunction: after vaginoplasty, at least a quarter of people experience sexual health challenges such as pain, difficulty with arousal, or anxiety related to sex.
• Bladder problems: incontinence (leaking of urine) and/or discomfort while peeing occur in 15-20% of cases.
• Vaginal stenosis: narrowing or shortening of the vaginal canal, often due to inconsistent vaginal training.
• Pelvic organ prolapse: pelvic organs descend and push against the vaginal walls, creating sensations of vaginal heaviness or fullness.
• Rectal injury: a rare but serious complication of surgery, leading to problems controlling bowel movements.
• Narrowing of tip of the urethra: narrowing or blockage of the urethra that makes it difficult to empty your bladder. Often correctable with a minor surgery.

While this list may seem daunting, many potential problems are preventable or solvable with the right post-op trans surgery care, including pelvic physical therapy.

How can pelvic PT help with transgender surgery recovery?

Pelvic floor therapy for transgender patients can help with concerns ranging from incontinence to sexual dysfunction to pelvic pain. If you or someone you love is in the midst of vaginoplasty recovery, pelvic PT can be an essential part of the healing journey. 

Origin’s pelvic physical therapists are expertly trained to care for people with vaginas. Many of our PTs also specialize in LGBTQ+ healthcare and are qualified to support patients of any sex or gender identity, including those in transition.

Pre-op PT: Building a Strong Foundation

Ever heard of “prehab”? In prehab, we address and correct existing issues that could affect surgical outcomes after vaginoplasty. 

A 2019 study of over 70 transgender women preparing for vaginoplasty found that 42% had pre-existing pelvic floor problems. The rate of dysfunction was particularly high—91%—among those with a history of trauma. 

Fortunately, these researchers found that women who attended pre-operative PT had significantly lower rates of pelvic floor dysfunction after surgery than those who didn’t do prehab.

By working with an Origin PT before surgery, you can:

• Address existing pelvic floor challenges.
• Learn to relax and lengthen your pelvic floor muscles, which will help with successful dilation later.
• Build trust with a healthcare provider in a safe, affirming environment.

Post-op PT: Promoting Healing and Function

People can still benefit from pelvic physical therapy even if they didn’t see a PT prior to surgery. And many people who’ve undergone gender affirming surgery say pelvic PT is one of their most significant recovery needs.

Post-op pelvic PT can help patients:

• Learn to relax and control their pelvic floor muscles
• Address pain during dilation or sex
• Mobilize healing scar tissue
• Restore normal bladder and bowel function
• Improve sexual satisfaction
• Return to normal activities

A 2019 study of 40 transgender women found that post-vaginoplasty PT helped patients meaningfully reduce their levels of pain, urinary symptoms, and overall disruptions to daily activities. Over a quarter of these patients reported complete resolution of pelvic symptoms after physical therapy.

The Takeaway

Gender affirming surgery can be life-changing. While transgender surgery recovery can be complex, the right support can make all the difference. 

At Origin, we offer inclusive, compassionate care for everyone, whether you’re preparing for surgery, recently post-op, or seeking help years after your procedure. Reach out to learn how pelvic physical therapy with Origin can support you in your healing journey: book now.

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Sources Cited

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Dominoni, Mattia et al. “Pelvic floor and sexual dysfunctions after genital gender-affirming surgery: a systematic review and meta-analysis.” The journal of sexual medicine vol. 22,1 (2025): 184-195. doi:10.1093/jsxmed/qdae146

“Gender-Affirming Surgery.” Transgender Health Program, Oregon Health Sciences University, www.ohsu.edu/transgender-health/gender-affirming-surgery. Accessed 31 May 2025.

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McGee, Ken. “Return to Running after Vulvovaginoplasty.” QueerDoc, 16 Oct. 2023, queerdoc.com/running-after-vulvovaginoplasty/

Pariser, Joseph J, and Nicholas Kim. “Transgender vaginoplasty: techniques and outcomes.” Translational andrology and urology vol. 8,3 (2019): 241-247. https://pubmed-ncbi-nlm-nih-gov.ucsf.idm.oclc.org/31380230/

Potter, Emery et al. “Hypergranulation management following penile inversion vaginoplasty.” Canadian family physician Medecin de famille canadien vol. 70,7-8 (2024): 456-461. https://pubmed-ncbi-nlm-nih-gov.ucsf.idm.oclc.org/39122430/

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