Dilation Outcomes for Transgender and Nonbinary Patients Following Gender-Affirming Vaginoplasty in a US County Safety-Net System

Purpose: The study purpose was to report neovaginal dilation outcomes and identify factors associated with pain, dilation discontinuation, and sexual function for transgender individuals who underwent gender-affirming vaginoplasty. Methods: A retrospective cohort study design was employed of transgender patients 18 years or older undergoing full-depth vaginoplasty and pelvic floor physical therapy (PFPT) between May 2018 and April 2021 at a safety-net hospital through medical record review and an online survey developed with a patient advisory board. Exclusion criterion was minimal-depth vaginoplasty or loss to follow-up. Results: In total, 137 patients included underwent full-depth vaginoplasty (46.7% survey response rate) 796.2 days (mean) postoperatively. Patients received 4.3 PFPT visits, with the last visit 12.4 weeks postoperatively (mean). Ninety patients (64.3%) achieved the 2 widest dilators, and 68 patients dilated to a depth of 5.5 inches or more (49.6%). The mean progression time between dilators was 5 weeks. Twenty-nine patients (21.2%) had pain preventing dilation, associated with minor or any surgical complication (OR = 5.7; 95% CI, 1.3-25.0) and posttraumatic stress disorder ( P = .01), and had more PFPT visits for longer postoperatively than those without pain ( P = .03). Nineteen respondents (32.2%) reported not dilating and were younger ( P = .02), more likely to be lesbian, pansexual, or asexual ( P = .01), and experienced depression ( P = .01). Forty-four respondents (77.2%) were sexually active in the past 6 months, which was not associated with pain during dilation. However, respondents self-reporting dilation pain had greater dissatisfaction with their sex life ( P = .02). Discussion: Patient dilation practices following vaginoplasty differ from protocols recommended by surgeons. Dilation goals should be adapted to individual patient characteristics and needs.