Predictors of Neovaginal Stenosis After Gender-Affirming Vaginoplasty: A Retrospective Cohort Analysis

Purpose: Neovaginal stenosis is a common complication after gender-affirming vaginoplasty and may negatively affect postoperative satisfaction and function. Patient-level factors associated with stenosis are not well understood. This study aimed to identify demographic and clinical factors associated with neovaginal stenosis after vaginoplasty using a national electronic health record database. Methods: A retrospective cohort study was conducted using deidentified data from the TriNetX Research Network. Adults who underwent gender-affirming vaginoplasty between 2015 and 2025 were identified and categorized into cohorts with and without postoperative neovaginal stenosis. Demographics and preoperative comorbidities were extracted using International Classification of Diseases, Tenth Revision codes. Univariate and multivariate logistic regression analyses were used to examine associations between patient characteristics and odds of developing neovaginal stenosis. Results: A total of 1826 individuals met inclusion criteria; 222 (12.2%) developed neovaginal stenosis. Individuals with abdominal or pelvic pain (odds ratio [OR] = 2.70, 95% confidence interval [CI]: 1.91–3.82), major depressive disorder (OR = 1.45, 95% CI: 1.03–2.05), and spinal disorders (OR = 2.01, 95% CI: 1.35–3.00) had significantly higher odds of stenosis. Geographic location was also significant, with individuals residing outside the Northeast demonstrating lower odds of stenosis. No significant associations were found for age, race, ethnicity, marital status, obesity, tobacco use, anxiety, or gastrointestinal disorders. Discussion: Findings suggest that pain-related, musculoskeletal, and mental health conditions are associated with increased odds of neovaginal stenosis after vaginoplasty. These findings support a more targeted, symptom-driven approach to postoperative monitoring and referral for supportive services such as pelvic floor physical therapy and mental health care.