Surgery, Recovery and Healing CARE AFTER SURGERY The Hospital or Surgery Center ❑ Check in early and meet your surgical team, including anesthesiologist. ❑Discuss any negative experiences with general anesthesia with your anesthesiologist and surgeon. ❑ Vaginoplasty surgery time = 4-6 Hours ❑ Vulvoplasty surgery = 3 Hours ❑ Orchiectomy surgery = 2 Hours ❑ Labiaplasty = 2 Hours ❑ After surgery: You will recover in the PACU for 2-3 hours. You may feel nauseous, elated, groggy, tearful, thirsty/hungry. ❑ Depending on surgery/surgeon, you will be discharged from PACU or moved to a hospital room. Recovery Comparison Vaginoplasty Vulvoplasty Labiaplasty Orchiectomy

Hospital Length of 7 nights 5-7 nights 1 night outpatient Stay

Initial Recovery 6-8 weeks 4 weeks 2 weeks 2-3 weeks

No Activity 12 weeks 4-6 weeks 2-4 weeks 4 weeks Restrictions Back to Baseline 6-9 months 12 weeks 4 weeks 4 weeks

Follow-up Appts Yes Yes Yes Yes

*This graphic illustrates a typical course of recovery, but individual recovery may vary Hospital Stay

❑ Helpful to have a friend or family member present in the room to remember details provided by nurse and surgeon ❑ One person is allowed to spend the night with you, if you’d like

❑ You may be asked to walk before you feel ready. Walking will help you recover more quickly and help decrease complications

❑ Main tasks for patients in the hospital are: rest, hydrate, control pain, ask questions A Note About Pain ❑ It is normal to experience pain and discomfort after surgery ❑ Stress associated with untreated and excessive pain can prevent healing ❑ While you are in the hospital, communicate with your nursing team about your pain level ❑ Before you are discharged you will be tapered to oral pain medication ❑ Discuss past negative experiences with pain medication or addiction history with your surgeon. ❑ DO NOT take NSAIDS (ibuprofen, Aleve) for pain for first 7-10 days ❑ DO NOT take Tylenol in addition to prescribed pain medications Normal Healing

❑ Incisions ❑ There will be incisions along the edges of the labia. These will need to be kept clean and dry. Applying ointment to the labia incisions may be advised.

❑ Packing (not needed for vulvoplasty) ❑ The vagina will be full of gauze packing that will usually be removed on day 6 in the hospital. ❑ After the packing is removed from the vagina, the surgeon will give instructions about dilating and douching. Normal Healing ❑ Pain ❑ Swelling: Expect quite a bit of swelling for a few months post operatively. Sudden swelling requires urgent attention. ❑ Nausea/vomiting: Common reaction to anesthesia as well as narcotic pain medications. ❑ Itching: Common reaction to anesthesia as well as narcotic pain medications. Also can be caused by adhesive dressings. ❑ Constipation: Take stool softeners to minimize strain and pressure to the genital area ❑ Blood in the urine for up to 6 weeks: As your new urethra heals, it is normal to have some blood in your urine. ❑ Incontinence of urine: While your neo-urethra is swollen, it is normal to have some incontinence (leaking). The urethra can remain swollen for up 12 weeks. Hospital Discharge

❑ You will need someone to drive you home from surgery

❑ You will need someone to be present when you are given discharge instructions ❑ Anesthesia impairs short term memory functioning Caregiving Needs ❑Plan for a caregiver around the clock for about 3-5 days after discharge from the hospital. ❑Have at least one identified caregiver in place. If you can, identify a team of caregivers so no one caregiver is overwhelmed and each caregiver can provide care based on their strengths ❑You will need help with lifting, laundry, cleaning, meal preparation, errands and care for children and pets for at least 3-4 weeks after surgery. ❑ You may need help with personal care including help in the bathroom with showering and cleaning. ❑It is common for patients to think they have more strength than they actually do in the first few months after surgery. Taking it slow at first is important. Dilation ❑ EXTREMELY IMPORTANT to follow dilation instructions to maintain vaginal depth ❑ EXTREMELY DIFFICULT to create more depth if vaginal canal narrows or shortens ❑ Surgeon will give you exact instructions about frequency of dilation and show you how to do it ❑General guidelines are:

Month One 4x per day

Month Two 3x per day

Month Three – Month Twelve 2x per day and then 1x per day once surgeon gives the ok

Month Thirteen – Rest of Your Life 1-2x per week

❑May need to increase frequency if dilation starts to feel difficult to maintain the vaginal opening and depth Troubleshooting Dilation What to do if dilation is difficult: • Increase frequency (number of times per day) • Once dilator is inserted, make gentle small circles with dilator, to help stretch tissue • Increase amount of lubrication • Try taking pain medication ~1 hour before dilation • Ask your surgeon about lidocaine jelly (to help with pain) • Try using Kegel Nation App (created by Cedars-Sinai Urologist, Maurice Garcia) • Helps to isolate pelvic muscles and relax them • Call Oakland or San Francisco nurse for advice! Douching ❑ Douching is a method of cleaning the inside of the vagina ❑ Surgeon recommends using water based solution with unscented castile soap to clean the inside of the vagina ❑ Important to follow surgeons directions and not to over use ❑ Not recommended to use scented products or chemical douches ❑ General guidelines: Starting on post op day 8, you should douche three to four times per week for the first month, then as discharge lessens, you can decrease frequency of douching. ❑ Douching will be recommended for lifetime maintenance ❑ Recommended to douche after sex when ejaculate is present A Note About Urine ❑ !fter urinating, wipe “front to back” ❑ Start by holding tissue at top of vagina (above clitoris) wipe down to base of vaginal opening ❑ Urine spray while urinating is normal ❑ May take a while for swelling of urethra to decrease and spray to consolidate ❑ Urine stream will be permanently changed and will not be a steady single stream Resuming Activities after Surgery o Each person’s healing is different o Listen to your body and if hurts, use caution or stop! o General guideline is wait at least 6 weeks before restarting moderate activities and obtain clearance from surgeon o Check in with surgeon about time before driving, swimming, taking a bath, bike riding, and strenuous exercise o Best to abstain from all nicotine and not to even be around cigarette smoke for 1 month. If resuming nicotine use, wait at least one month and avoid excessive alcohol intake. Sexual Health after Surgery o Surgeons generally recommend waiting at least 6 months after surgery before beginning penetrative sex (vaginal or anal). Check in with your surgeon about when it’s ok to start.

o Clitoral stimulation can be initiated around 2 weeks after surgery or when the patient feels comfortable

o It often takes longer (3-6 months) to feel comfortable with touch and to relearn what feels good. o Just like anyone else who has sex, people who have had vaginoplasty can also get or transmit a sexually transmitted infection (STI) or HIV. o Methods to reduce HIV and STI transmission: o Condoms and lube o Treatment as Prevention (TasP) o Pre-exposure Prophylaxis (PrEP) o Post-exposure prophylaxis (PEP) o Clean needle use o Use water-based lubricants to reduce tearing and for increased comfort Healthcare Tips o Other things to keep in mind to stay healthy: o Your doctor may still want to do routine prostate screenings after age 50

o Routine anal paps to screen for anal cancer is recommended if having anal sex

o In the first year after surgery vaginoplasty post-op care should be managed by your surgeon

o Since you will not have a cervix, there is no need for cervical cancer screenings (pap smears).

o Contact your surgeon if you experience any pain, new odors, new discharge What to do if you have concerns? ❑ First, contact your surgeon and review symptoms ❑ Surgeon may want to see you at the office ❑KP Advice Nurse: 415-833-2200 ❑Ask nurse to page on call plastic surgeon at KP SF

❑ If surgeon tells you to go to the emergency room: ❑ Go to your nearest Kaiser Permanente ER ❑ Tell the ER doctor that you’ve had surgery ❑ Ask them to contact your surgeon and the San Francisco Kaiser Permanente Plastic Surgery Department Sample Timeline for Surgery Recovery

1 week post-op 2 weeks post-op 4 weeks post-op 6-8 weeks post-op 12 weeks post-op 6-9 months post-op Surgery 24 hour care Caregiving needed needed for chores

Discharged 1st post-op • Able to Most • Most swelling from the visit return to activities gone and hospital work/school permitted sensation • 2nd post-op stable visit • 3rd post-op visit