Follow-Up of Patients After Male-to-Female (Mtf) Sex Reassignment Surgery (SRS)

Regret may be defined as follows [6]: (a) definite regret (patient openly regrets SRS and has applied for retransformation to original sex), (b) some regret (indirectly expressed regret and signs of ambivalence about SRS), and (c) no regret. Dissatisfaction and regret have been reported to be associated with the following factors: age over 30 at first request of surgery, personality disorders, personal and social instability, secondary transsexualism, heterosexual sexual orientation, poor surgical results, and poor support from the family [7]. The self-perception the patient has of her body after the surgery needs to be as close as possible to that of a true female. That is why it is often necessary to consider aesthetic surgical procedures, both for the genital area and the body figure, following SRS, to reach this goal. Poor results of SRS that remind the patient and partner of the patient’s transsexual background are an important risk factor for regret [1]. It is therefore of milestone importance to adequately counsel and follow the patient both in the preoperative and postoperative setting, being able to identify and modify the abovementioned factors as soon as they are noticed.

22.3 Sexual Outcomes

What the patients expect from SRS is that the surgery be performed with such skills that the sensitivity of his/her genitals would be preserved and the results would be true to nature both in appearance and function. The evaluation of patients’ sexual function after SRS is therefore of great importance to fully define success of the operation. In a Brazilian cohort of 19 patients (18 MtF, 1 FtM), sexual satisfaction was considered improved by 83.3 % of the patients, while it was rated poor or very poor by 11.2 % [7]. A Swedish population-based controlled study over 30 years [1] on 324 patients (191 MtF and 133 FtM) found a 60 % satisfaction rate and a 22 % dissatisfaction rate. In order to grade sexual satisfaction, one should address the following: overall sexual satisfaction after SRS, frequency of sex after SRS, pleasure with the neovagina, frequency and degree of pleasure with anal sex, and frequency and degree of pleasure with masturbation [5, 7]. It is interesting to note how the majority of patients report a more intense, smoother, and longer orgasm and two thirds of them report secretion of fluid in the neovagina [5].

In this setting, an aspect that needs to be stressed out is that of vaginal dilatation. Postoperatively a soft vaginal tutor is left continuously in place for 15 days, thereafter only at night until it comes out spontaneously. When this happens, it means that the neovagina is wide enough to stop using it. At this point the patient is encouraged to use, three times a day (morning, midday, evening), rigid tutors with gradual increase in diameter and length. This maneuver is essential, at least twice a day, to ensure neovaginal depth and elasticity. It is obvious how these maneuvers need to be performed with the aid of lubricating and moisturizing creams. A possible complication of rigid vaginal tutors is urethral neo-meatus stenosis. We have observed this circumstance in one patient, and it was successfully managed with progressive urethral dilatations.

At our institution, we push the patients to engage in sexual activity as soon as the neovaginal conditions allow safe intercourse, and we evaluate this area with the same questionnaire presented above plus a thorough gynecological examination.

22.4 Micturition Outcomes

SRS carries a high risk of micturition problems. Next to the change of urethral length, becoming it shorter, there is also a change in voiding habits, like voiding while seating. About 32 % of the patients undergoing MtF surgery reported changes in voiding, with 19.3 % of them affirming it was better, 12.9 % it was worse, and 67.8 % neither worse nor better [7]. The problems reported are incontinence, hesitancy, spraying, decreased or diverted stream, post-voiding dribbling, and UTIs. The most frequently presented changes are, however, incontinence (19.3–33 %) and UTIs (32 %) [8, 9].

As for incontinence, appearing as stress incontinence, urge incontinence, or mixed incontinence, various hypotheses have been proposed to justify it. First of all, we need to consider that the sphincter complex, the pelvic muscles, and the pudendal nerves are in the dissected area, so some of the stress incontinence might be due to surgical trauma. Another concurrent cause might be the reduction in prostate size. Obstruction, i.e. due to urethral scarring, as well as nerves damage, could also explain the increased incidence of overactive bladder (OAB) and urge incontinence in this population. Another proposed cause is the presence of a neovagina behind the bladder, thus altering its normal anatomic position and filling [8, 9].

Infections are another important issue, most of them being observed in the immediate postoperative period. The more plausible explanation is the shortening of urethra leading to an easier penetration of pathogens, especially after intercourse [8, 9].

Uroflowmetries have been done, showing a not statistically significant reduction in the mean Qmax (18 ml/s), without significant post-voidal residue in any of the patients [8, 9].

Interestingly, it is important to note how for the majority of the patients changes in micturition, including incontinence, which is by far the worst problem, were not considered as a problem, with only 11 % of them being unhappy or socially disturbed, and no correlation was noted between visual analogue scale and micturition symptoms given by the King’s health questionnaire [8, 9]. Despite these comforting data, we need not to forget to give appropriate information about these possible consequences before SRS.

In order to establish how SRS affects overall bladder functioning, besides using the same questionnaire reported above, we have recently started to study MtF patients with urodynamic assessment both before and after the surgery.

From a clinical point of view, these are the main observations we did on our patients:

No modification in defecation.
No dysuria nor difficulties during micturition; the majority of patients reported a spraying urinary stream.
No stress nor urge incontinence.
Mild to low irritative bladder symptoms in the immediate postoperative days.

We have performed urodynamic evaluation before and after SRS on six patients. What we have noticed so far, with regard to the different part of the functional studies performed, is:

Uroflowmetry: similar traces with no significant difference in maximum and average flows
Cystomanometry: no signs of overactive bladder nor modifications in bladder compliance and capacity
Urethral pressure profile: no significant alterations in urethral closure pressure, with reduced height and length of prostatic plateau

What we can infer from the previous results is: