Clinical Opinion ajog.org

The gynecologic examination of the transfeminine person after penile inversion vaginoplasty Frances Grimstad, MD, MS; Hillary McLaren, MD; Meredith Gray, MD

with . As such, gynecologists As more transfeminine patients ( and gender-diverse persons, sex assigned must understand the typical physiology male at birth, who identify on the feminine spectrum of gender) are undergoing gender- and postoperative anatomy of patients affirming penile inversion vaginoplasty, gynecologists, as providers of vaginal care for who have undergone PIV to provide both native and neovaginas, should be prepared to welcome these patients into their competent care.4 TGD persons report a practice and offer long-term pelvic healthcare. lack of clinician knowledge as a barrier to receiving appropriate care.3 Gynecolo- Many parts of the anatomy, clinical examination, and aftercare differ from both native gists themselves (both who do and do vaginas and other neovaginal surgical techniques. Transgender and gender-diverse not care for TGD patients) have identi- patients cite a lack of clinician knowledge as a barrier to accessing affirming and fied education in TGD reproductive competent healthcare. Although publications are emerging regarding this procedure, health as a current need.5,6 Limited most focus on intraoperative and postoperative complications. These studies are not research exists on long-term complica- positioned to provide long-term pelvic health guidance or robust instruction on typical tions and outcomes regarding PIV— examination findings. most studies only follow patients a few This clinical opinion aims to address that knowledge gap by describing the gynecologic months to a few years postoperatively, examination in the transfeminine person who has undergone a penile inversion vagi- focus primarily on complications, and noplasty. We review the anatomic changes with surgery and the neovagina’s physiology. are not positioned to provide long-term We describe the examination of the , , and and discuss special pelvic health guidance or robust in- considerations for performing pelvic examinations on patients with a penile inversion struction on typical examination find- vaginoplasty neovagina. We will also address common pathologic findings and their ings.7,8 Thus, a need exists for initial management. This clinical opinion originates from the expertise of gynecologists experienced guidance. who have cared for high volumes of transfeminine patients who have undergone penile Our institutions have multidisciplinary inversion vaginoplasties at tertiary care centers performing gender-affirming genital transgender surgical teams (urologists, surgery, along with existing research on postpenile inversion vaginoplasty outcomes. plastic surgeons, and gynecologists) who Gynecologists should be familiar with the anatomic changes that occur with penile perform and care for patients who have inversion vaginoplasty gender-affirming surgery and how those changes affect care. undergone vaginoplasties. At our in- Providing transgender patients with comprehensive care including this sensitive ex- stitutions, gynecologists are the primary amination can and should be part of the gynecologist’s scope of practice. clinicians for long-term pelvic care of patients who have undergone PIV. This Key words: gender affirmation surgery, gynecologic examination, neovagina, pelvic clinical opinion originates from our examination, penile inversion vaginoplasty, postoperative care, transfeminine persons, expertise of providing care for high vol- transgender, transgender surgery, transgender women, vaginal surgery, vaginoplasty umes of these patients and incorporates existing literature when present. The aim Introduction is to empower other gynecologists to From the Division of Gynecology, Department of Increasing provider training, insurance provide this care by offering guidance Surgery, Boston Children’s Hospital, Boston, coverage, and accessibility has allowed regarding the neovulvar and neovaginal MA (Dr Grimstad); Department of , more transgender and gender-diverse examination. Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA (Dr Grimstad); and (TGD) patients to undergo gender- Department of Obstetrics and Gynecology, affirming surgery than ever before. The The Procedure University of Kansas Medical Center, Kansas most common gender-affirming vagi- Appreciating the postoperative anatomy City, KS (Drs McLaren and Gray). noplasty sought by transfeminine persons after a PIV requires a basic understand- Received April 19, 2020; revised Sept. 11, 2020; is the penile inversion vaginoplasty ing of the procedure (Figure 1).9,10 accepted Oct. 2, 2020. (PIV).1,2 The 2015 United States Trans- Before the procedure, patients undergo The authors report no conflict of interest. gender Survey (a national survey of the hair removal of the penile shaft and Corresponding author: Frances Grimstad, MD, experiences of 27,715 transgender adults) medial to decrease the risk of MS. [email protected] noted 66% of transfeminine respondents persistent hair inside the neovagina. The 0002-9378/$36.00 had or desired to undergo a vaginoplasty.3 only permanent hair removal method is ª 2020 Elsevier Inc. All rights reserved. ’ https://doi.org/10.1016/j.ajog.2020.10.002 The gynecologists scope of practice electrolysis; however, patients may use includes the pelvic health of all persons laser if electrolysis is unavailable.

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FIGURE 1 Steps of the penile inversion vaginoplasty

A, The perineal skin is incised. B, The perineal and scrotal skin is removed, the penile skin is degloved, and bilateral is performed. C, The neurovascular bundle is dissected, the erectile tissue is removed, and the scrotal skin is formed over the mold for the distal neovagina and sewn to the penile skin. D, The neurovascular bundle with glans (neoclitoris) is folded back on itself at the level of the adductor longus tendon, the urethra is transected and sutured to the overlying skin, and the neovaginal path is developed. E, The skin tube is inverted into the neovaginal path, wounds are closed, and the labia are created. F, The final path of the neovagina and the location of the neoclitoris. Key: 1, glans; 2, penile shaft; 3, scrotum; 4, incision; 5, testicle; 6, degloved penile skin; 7, truncated erectile tissue; 8, perineal body; 9, neurovascular bundle; 10, urethra; 11, scrotal skin; 12, level of adductor longus; 13, vaginal plane/neovagina; 14, neovulva; 15, suture line between penile and scrotal skin; 16, prostate; 17, bladder; 18, . Grimstad. Gynecologic examination after PIV. Am J Obstet Gynecol 2021.

The procedure begins with perineal For the neovaginal path, the perineum Immediately after the procedure, skin incisions followed by a bilateral is dissected and the perineal body divided, dilation protocols are initiated (Tables 1 orchiectomy (Figure 1, A and B). The releasing its fixation to the bulbar urethra. and 2) to maintain the vaginal patency perineal and scrotal skin is removed and The path of the neovagina (typically 14 while the patient is healing. Most com- used as a full-thickness skin graft for the cm in length) is then developed in the plications occur during this time and are neovagina. The penile skin is degloved plane between the Denonvilliers’ fascia reviewed elsewhere.1,7,8,11 The exami- with the glans preserved for clitoroplasty (inferior to the urethra and prostate) and nation addressed here is for care after the (Figure 1, B). The neurovascular bundle superior to the ventral rectal fascia, to the acute postoperative period. is dissected and the erectile tissue level of the perineal reflection (Figure 1, removed (Figure 1, C). The neuro- F). The scrotal skin is formed over a mold Indications for Examination vascular bundle supplying the neo- to create the distal neovagina and sewn to The American College of Obstetricians clitoris is folded back on itself to allow the penile skin (Figure 1, C). The skin and Gynecologists no longer recom- for it to fall at an aesthetically accurate tube is inverted into the previously mends annual pelvic examinations for location at the level of the adductor developed plane to create the neovagina asymptomatic patients, and no guideline longus tendon (Figure 1, D). The urethra (Figure 1, E). All wounds are then closed, for persons who have undergone PIV is transected, spatulated, and sutured to using existing tissues to create the labia states differently.11,12 Although we do the overlying skin (Figure 1, D). (Figure 1,E). not require routine pelvic examinations

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TABLE 1 Dilation techniquesa Technique Steps Preparation  Use the largest that can be comfortably inserted.  Ensure the dilator is clean before use, and if not, clean the dilator with warm water, dishwashing liquid, or antibacterial soap and wipe dry. Insertion  Apply a water-soluble lubricant to the dilator before insertion (may also insert lubricant directly into the vagina).  Take a deep breath when inserting the dilator, to allow for the pelvic floor relaxation.  Gently insert into the vagina with the dilator tilted about 45 degrees downward until under the pubic bone and then continue straight inward.  A mirror can be helpful with putting the dilator in correctly.  A small amount of resistance and tenderness is normal, but if too much resistance or severe pain is felt, stop and try a smaller dilator. Dilation  Insert the dilator into the full depth of the vagina (until moderate pressure or resistance is felt) and leave in place for 15 to 20 min. Approximately 3 inches of the dilator should remain outside the vagina. Keep light pressure on the dilator so that it does not slide out. Aftercare  Clean the dilator with warm water, dishwashing liquid, or antibacterial soap and wipe dry.  Wipe the external genitals clean with a moist hand cloth or wet wipe.  Douche every day to every other day for the first 2 mo after surgery, then once or twice weekly to flush out the extra lubricant.

a Adapted from the University of Kansas Medical Center and Boston Children’s Hospital Center for Gender Surgery Dilation Instructions. These techniques are an example. Clinicians should always ask patients about their surgeon’s specific schedule and protocol. Grimstad. Gynecologic examination after PIV. Am J Obstet Gynecol 2021. for asymptomatic patients, some pa- Regardless of the examination indica- by TGD persons and intentional or tients may request it (ie, based on tion, typical PIV pelvic anatomy and inadvertent maltreatment by medical counseling provided by their surgeon). physiology knowledge is crucial to providers are well documented.3 Clini- However, more importantly, trans- providing this care. cians should be sensitive to the impact of feminine patients may present for care their own implicit bias, potential gender and bring up pelvic health concerns that Creating a Welcoming Space dysphoria, and past trauma experienced necessitate examinations. Relevant in- Any pelvic examination requires a by the patient and discuss with them in dications for examinations include a trauma-informed and patient-centered advance all the components of the ex- wide variety of concerns or symptoms approach.14,15 This approach recognizes amination. Furthermore, patients should (eg, vulvar masses, vaginal discharge, that potential past trauma can influence be informed that they are in control of the dyspareunia, or sexually transmitted patient experiences of medical care. The examination and asked how the exami- infection [STI] acquisition).1,10,13 physical and sexual trauma experienced nation can be made safer and more comfortable.11,16 Finally, clinicians should ascertain patients’ chosen termi- nology for their anatomy and respect TABLE 2 a these terms; when possible, consideration Dilation schedule should be given to the use of these terms Timelineb Dilation frequencyc during the examination.17 Wk 1e3 4 times per day The Examination Wk 4e6 3 times per day As with persons with native vaginas and Wk 7e9 2 times per day those who have undergone other forms Wk 10e12 Daily of vaginoplasty, the genitalia of persons Ongoing 1e2 times per weekd who have undergone PIV vary greatly. Examples of examination findings and general anatomic position of genital a Adapted from the University of Kansas Medical Center and Boston Children’s Hospital Center for Gender Surgery Dilation Instructions. This schedule is an example. Clinicians should always ask patients about their surgeons’ specific schedule and structures are labeled in Figure 2. Each protocol; b Dilation typically begins (defined here as week 1) roughly 1 to 2 weeks after surgery, depending on the surgeon’s section below addresses expected physi- specific protocol; c If the vagina begins to feel tight, dilation frequency should increase; d Unless engaging in regular insertional intercourse. ological changes and pathologic findings Grimstad. Gynecologic examination after PIV. Am J Obstet Gynecol 2021. that may occur, with key pathologies summarized in Table 3.

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Vulva FIGURE 2 The examination of the vulva includes a Neovulvar and neovestibular anatomies after penile inversion thorough visual inspection moving vaginoplasty anteriorly to posteriorly. The labia majora, which are constructed from the scrotal skin, may have rugae as is typical of the scrotum (Figure 2, A). Suture lines running anteriorly to posteriorly along the labia majora are often visible (Figure 2, A). When the labia majora are separated, the labia minora, urethra, and clitoris can be evaluated. The labia minora are constructed from the scrotal skin (Figure 2, A) and the clitoris from the penile glans (Figure 2, B). The ure- thral orifice is inferior to the clitoris. There is often a greater distance between the clitoris and urethra in a person who has undergone PIV than someone with a native clitoris. Because the neovulvar tissues are scrotal, they carry the same risk for le- sions and infections. Herpes, condy- loma, syphilitic chancre, and chancroid are all possible infectious pathologies, and lesions suspicious for these should be evaluated and treated as per standard guidance.18 The human papillomavirus (HPV) can also infect the scrotal skin, so it is possible to develop genital warts. HPV-related has been found on the scrotal tissue.19 We recommend HPV vaccination to all patients at the age of 45 years.20 The scrotal skin can also carry the risk of dermatoses such as psoriasis, eczema, or lichen scle- rosus.21,22 Any visible or concerning lesion should be biopsied and followed up appropriately. Colposcopic assistance is reasonable. Patients may also present with cosmetic concerns regarding the labia.8 Postoperative healing may result in the labia majora spaced far apart or minimal A, Neovulvar anatomy after penile inversion vaginoplasty. B, Neovestibular anatomy after penile labia minora or clitoral hood.11 These inversion vaginoplasty. Key: the symbol - - - - indicates suture lines, and  indicates urethral should be referred to a surgeon who tissue. specializes in PIV. Grimstad. Gynecologic examination after PIV. Am J Obstet Gynecol 2021.

Vagina We recommend beginning a vaginal ex- rather than a speculum can be consid- length of the vagina beginning at the amination with a digital examination ered, although a speculum is a more apex and moving distally. using a single digit to assess the length accessible tool and most patients tolerate Because the neovagina comprises and path of the neovagina and to palpate the average Pederson speculum. We keratinized stratified squamous tissue, it the pelvic floor musculature for tender- recommend discussing with the patient is less elastic than the epithelium of a ness or spasm or to palpate the bladder which size tool may be appropriate.13 native vagina. It also lacks a and is or prostate for tenderness. An anoscope The clinician should examine the entire often both narrower and more posterior

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TABLE 3 Complaints and findings that may arise in a transfeminine patient with a history of penile inversion vaginoplasty Anatomic Postoperative changes or structure Native tissue complications Infections Other concerns Neovulva Scrotal and  Cosmetic concerns regarding  Analogous to scrotal tissue  Skin neoplasms (eg, mela- perineal labia majora spacing, small (eg, herpes, condyloma, noma, squamous cell size of labia minora tissue, or syphilitic chancre, chancroid, carcinoma) small size of clitoral hood HPV)  Dermatosis (eg, eczema, psoriasis, lichen sclerosus) Neovagina Penile and  Loss of length or width  Analogous to penile tissue  Noninfectious discharge (eg, scrotal  Stricture or vaginal webbing (eg, herpes, condyloma, lubrication, semen, sebum,  syphilitic chancre, chancroid, dead-skin sloughing)  Granulation tissue HPV)  Skin neoplasms (eg, mela-  Residual pubic hair (may be  Bacterial vaginosis noma, squamous cell ingrown or infected)  Gonorrhea, chlamydiab carcinoma)  (rectoneovaginal,  Dermatosis (eg, eczema, ureteroneovaginal, psoriasis, lichen sclerosus) vesiconeovaginal)a Urethra N/A  Stream diversion  UTI  Voiding dysfunction (eg,  Urethral stricture  Gonorrhea or chlamydia overactive bladder, incom-  Residual erectile tissue urethritis plete emptying)  Prostatic issues (eg, BPH, prostatitis, prostate cancer) Pelvic floor N/A  Pelvic floor dysfunction  Vaginismus BPH, benign prostatic hypertrophy, HPV, human papillomavirus; N/A, not applicable; UTI, . a Most commonly identified during the intraoperative or immediate postoperative period; b The neovaginal tissue is generally resistant to gonorrhea and chlamydia. Infections are more likely to present in the urethra. Grimstad. Gynecologic examination after PIV. Am J Obstet Gynecol 2021. in orientation than native vaginas frequency is recommended.11 Any (including lubrication during dilation or (Figure 1, F). Suture lines may be persistent pain or blockage with dila- intercourse, semen from intercourse, appreciated in the upper half of the va- tion or insertional intercourse should sebum, or dead-skin sloughing). No gina owing to the grafting of penile and be addressed with a surgeon skilled in publications address the optimal scrotal skin. PIV. Webbing across the vagina or approach to douching for a PIV neo- Patients who have undergone PIV stricture may need to be surgically vagina. We generally recommend a require lifelong dilation of the vagina addressed.1 Physical therapy or botuli- nonscented douche. Soap, water, and (Table 2). Of note, PIV are num toxin injections may be recom- vinegar or 25% povidone-iodine are typically larger than those routinely mended depending on a surgeon’s other suggested regimens.11 Douching used in other neovaginal surgeries and assessment.11 frequency may need to be increased in arenotmeanttobeleftinovernight.23 When assessing dilation, the dilator patients who have increased discharge or After surgery, patients should be should be inserted into the full depth of odor. Clinicians should assess for other dilating more frequently (Table 2). the vagina with moderate pressure felt. causes (eg, infections, lesions, or granu- Many PIV surgeons have specific pro- We describe dilation techniques in lation tissue) when douching does not tocols. Routine gynecologic care of greater detail in Table 3. For those who resolve the discharge. these patients includes evaluation and have lost length or width, a soft silicone Granulation tissue (Figure 2,B)isa supportofdilationcare.Thisincludes dilator may be used because they are common postoperative finding and may assessing the depth and width of the better tolerated with scar tissues.1 be the cause of bleeding, discharge, or vagina as the patient tapers down their In contrast to a native vagina where pain complaints.7,8 It can be exacerbated dilation schedule to ensure no dimin- douching is contraindicated and can by repeated trauma from dilation or ishment of either and eliciting the pa- increase the infection risk, a PIV neo- insertional intercourse. In cases that do tient’s dilation history and personal vagina contains keratinized epithelium not self-heal, we recommend consid- experience of progress or regression. A and does not self-clean. As such, routine ering silver nitrate as the first-line treat- common long-term finding is the loss of cleaning is recommended (eg, douching ment. Alternatives include low-potency length.7 If loss of either width or length 2e3 times per week) to maintain hy- topical or intralesional steroids or sur- is found, increasing the dilation giene and minimize buildup in the canal gical excision, possibly by the original

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Todos los derechos reservados. ajog.org Clinical Opinion surgeon, as per standard approaches for skin is also a known reservoir for HPV. may experience diverted streams, void- granulation tissue.24,25 As such, vaginal neoplasia similar to ing dysfunction (including overactive The keratinized stratified squamous HPV-related penile cancer could theo- bladder and incomplete emptying), and epithelium of the PIV neovagina is retically develop.33 Just as with the recurrent urinary tract infections colonized with skin flora and some neovulva, these tissues also carry the (UTIs), in part owing to a shortened vaginal species.26 Bacterial vaginosis, same risk for dermatosis that can affect urethra.1 Gynecologists should treat herpes, condyloma, syphilitic chancre, the penile and scrotal skin such as uncomplicated UTIs as per standard and chancroid are all possible infectious psoriasis, eczema, or lichen sclerosus. approach in cisgender female. However, pathologies. The University of California Any visible or concerning lesion should those who have recurrent UTIs should San Francisco (UCSF) Center of Excel- be biopsied. Colposcopic assistance is be evaluated by a gender-affirming lence for Transgender Health guidelines reasonable. urologist for urethral stricture.11,40 note (and which our experiences are in At this time, no Pap smear guidelines Gonorrhea or chlamydia can cause ure- agreement) discharge is less commonly address sampling in the PIV vaginal thritis, because the use of urethral mu- an infectious etiology in patients who vault. We do not recommend routine cosa for reconstructive purposes creates have undergone PIV compared with cytology or HPV collection.34 One environments particularly susceptible to patients with native vaginas.11 consideration is for patients living with these microbes.26,29 It is appropriate to Current data have not shown low pH HIV, as some recommend annual pelvic refer all other voiding concerns to a in the neovagina compared with native examinations for visual monitoring of gender-affirming urogynecologist or vaginas.11 Only a few cases of Candida HPV lesions after PIV because increased urologist.1 have been reported.27 Limited data exist screening frequency is practiced for pa- Some patients may experience pain regarding the transmission of gonorrhea tients with a cervix living with HIV.35,36 associated with residual erectile tissue and chlamydia in a person after PIV; the However, cervical cancer guidelines because it can become engorged with keratinized epithelium is likely more have not yet addressed this.37 arousal. It may be palpable on a digital resistant to these infections.28 However, Despite undergoing hair removal examination. Residual erectile tissue urethral tissue can still become infected before surgery, some patients have re- would typically be found in the labia with these microbes, manifesting in sidual pubic hair in the vagina, which majora but may be deeper in the vagina. either urethritis (explained in the Addi- may present along the entire length. This If the patient is experiencing pain pre- tional considerations section) or a neo- can cause pain during sexual penetration dominately with arousal and no erectile vaginal infection if the urethral tissue or dilation and may become infected or tissue is palpated, a T2-weighted mag- was used in its construction.26,29 No ingrown.38 We recommend referring to a netic resonance imaging may confirm its published data address HIV trans- skilled electrologist for the management presence.39 If it is present, they should be mission specific to PIV, although the of bothersome hair. Referral to a surgeon referred to a surgeon skilled in PIV. prevalence of HIV in the broader trans- skilled in PIV for counseling is also Pelvic pain with dilation or insertional feminine population in the United States appropriate. intercourse may also be caused by mus- is high (27.7%).3 Fistulas may occur owing to trauma or cle spasms or vaginismus. The pelvic For STI screening in patients after PIV, injury and are mostly identified in the floor muscles are separated at the time of The Centers for Disease Control and intraoperative or immediate post- surgery to create the vaginal canal path. Prevention guidelines on special pop- operative period.7,8,13,29 The most com- Patients who have undergone PIV may ulations recommend using anatomy- mon is a rectovaginal fistula (0.5% experience pelvic floor dysfunction just specific, rather than gender-specific, e17%).1,7,8 Presentation, even if imme- as patients with a native vagina, and the approaches.18 The UCSF guidelines diately identified, may include flatus or pelvic floor musculature may be assessed concur and add that the role of vaginal stool passage from the vagina. Urethral or on an endovaginal digital examination as swabs for gonorrhea and chlamydia in a bladder fistulas are far less common in cisgender patients. The authors person after PIV is unknown, and as (0.8%e3.9%) and may present with encourage collaborative care with the such, a urine test may be more valuable. complaints of incontinence, leakage of growing number of gender-affirming These guidelines also recommend vaginal liquid, or persistent discharge.8,39 pelvic floor physical therapists.41 testing for any symptomatic patient with Owing to their presentation timing, it will Neovaginal prolapse may also occur orifice-specific consideration depending be less likely that gynecologists providing (rates range from 1% to 7.5%) and on the patient’s sexual history.18 long-term pelvic health will encounter present early or late. Some surgeons have Patients who have undergone PIV do these scenarios and they should be reported placing suspensory sutures not have a cervix and thus do not referred to a surgeon skilled in PIV.7,8 proactively during PIV (including into require routine Pap smears. Cancer risk the Denonvilliers’ fascia or prerectal is primarily related to skin of Additional Considerations fascia or through the sacrospinous liga- thepenileorscrotalskin.30,31 Case re- Voiding complaints are not uncommon ment). However, this is not yet a com- ports have reported squamous carci- in patients after PIV. Some studies report mon practice.42,43 Only surgeons skilled noma in neovaginas after PIV.32 Penile that one-quarter to one-half of patients in vaginal prolapse or PIV should

MARCH 2021 American Journal of Obstetrics & Gynecology 271 Descargado para Anonymous User (n/a) en National Library of Health and Social Security de ClinicalKey.es por Elsevier en junio 04, 2021. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados. Clinical Opinion ajog.org attempt these repairs. Consideration Anorectal examinations do not retrospective study. Ann Chir Plast Esthet may be made for sacrospinous fixation change after PIV. Transfeminine patients 2019;64:24–32. 1 8. Gaither TW, Awad MA, Osterberg EC, et al. or sacrocolpopexy. with anorectal concerns should have Postoperative complications following primary In general, patients should not expe- these addressed as one would routinely penile inversion vaginoplasty among 330 male- rience decreased tissue sensitivity in their practice. to-female transgender patients. J Urol because this vaginoplasty technique 2018;199:760–5. preserves major sensory nerves.44 How- Conclusion 9. Shoureshi P, Dugi D 3rd. Penile inversion fi vaginoplasty technique. Urol Clin North Am ever, gender-af rming hormone therapy Gynecologists may provide care for in- – fi 2019;46:511 25. and orchiectomy may decrease libido in dividuals after PIV gender-af rming 10. Salim A, Poh M. Gender-affirming penile 45 some patients. We recommend refer- surgery and thus should learn about inversion vaginoplasty. Clin Plast Surg 2018;45: ring to clinicians skilled in managing the anatomy resulting from such sur- 343–50. gender-affirming hormone therapy or in geries. This appreciation of anatomy will 11. UCSF Transgender Care. Guidelines for the primary and gender-affirming care of trans- medical and psychological support for aid in the provision of the gynecologic gender and gender nonbinary people. 2016. low libido. examination for transfeminine patients Available at: transcare.ucsf.edu/guidelines The prostate remains in situ after PIV after PIV. By learning to perform this 2016. Accessed August 20, 2020. and is located along the neovaginal examination, gynecologists can offer a 12. ACOG Committee Opinion No. 754 sum- anterior wall. Just as with routine pelvic wider spectrum of care and create an mary: the utility of and indications for routine fi pelvic examination. Obstet Gynecol 2018;132: examinations, a great deal has changed af rming environment for a marginal- 1080–3. - regarding the necessity for routine ized population. 13. Weyers S, De Sutter P, Hoebeke S, et al. prostate screening examination. Cur- Gynaecological aspects of the treatment and rent guidelines do not endorse routine ACKNOWLEDGMENTS follow-up of transsexual men and women. Facts examinations in asymptomatic cis- Views Vis Obgyn 2010;2:35–54. The authors wish to thank the Departments of 14. Access Project. Con- gender male patients for the sole Obstetrics and Gynecology, Urology, and Plas- 46 traceptive pearl: trauma-informed pelvic exams. detection of prostate cancer. Further- tic Surgery at the University of Kansas Hospital Available at: https://www.reproductiveaccess. more, antiandrogens and estrogens may and the Division of Gynecology and De- org/resource/trauma-informed-pelvic-exams/. reduce prostate cancer risk and benign partments of Urology and at Accessed March 18, 2020. Boston Children’s Hospital who work as multi- prostatic hypertrophy (BPH), which 15. Raja S, Hasnain M, Hoersch M, Gove-Yin S, disciplinary teams to care for transfeminine pa- Rajagopalan C. 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