Vaginoplasty is any surgical procedure that results in the construction or reconstruction of the

vagina In mammals and other animals, the vagina (: vaginas or vaginae) is the elastic, muscular sex organ, reproductive organ of the female genital tract. In humans, it extends from the vulval vestibule to the cervix (neck of the uterus). The #Vag ...

. It is a type of

genitoplasty Genitoplasty is plastic surgery to the genitals. Genitoplasties may be reconstructive to repair injuries, and damage arising from cancer treatment, or congenital disorders, endocrine conditions, or they may be cosmetic. __TOC__ Medical uses Ge ...

Pelvic organ prolapse Pelvic organ prolapse (POP) is characterized by descent of pelvic organs from their normal positions into the vagina. In women, the condition usually occurs when the pelvic floor collapses after gynecological cancer treatment, childbirth or hea ...

is often treated with one or more surgeries to repair the vagina. Sometimes a vaginoplasty is needed following the treatment or removal of malignant growths or

abscess An abscess is a collection of pus that has built up within the tissue of the body, usually caused by bacterial infection. Signs and symptoms of abscesses include redness, pain, warmth, and swelling. The swelling may feel fluid-filled when pre ...

es to restore a normal vaginal structure and function. Surgery to the vagina is done to correct

congenital defect A birth defect is an abnormal condition that is present at birth, regardless of its cause. Birth defects may result in disabilities that may be physical, intellectual, or developmental. The disabilities can range from mild to severe. Birth de ...

s to the vagina,

urethra The urethra (: urethras or urethrae) is the tube that connects the urinary bladder to the urinary meatus, through which Placentalia, placental mammals Urination, urinate and Ejaculation, ejaculate. The external urethral sphincter is a striated ...

and

rectum The rectum (: rectums or recta) is the final straight portion of the large intestine in humans and some other mammals, and the gut in others. Before expulsion through the anus or cloaca, the rectum stores the feces temporarily. The adult ...

. It may correct protrusion of the

urinary bladder The bladder () is a hollow organ in humans and other vertebrates that stores urine from the Kidney (vertebrates), kidneys. In placental mammals, urine enters the bladder via the ureters and exits via the urethra during urination. In humans, the ...

into the vagina (

cystocele A cystocele, also known as a prolapsed bladder, is a medical condition in which a woman's bladder bulges into her vagina. Some may have no symptoms. Others may have trouble starting urination, urinary incontinence, or frequent urination. Complic ...

) and protrusion of the rectum (

rectocele In gynecology, a rectocele ( ) or posterior vaginal wall prolapse results when the rectum bulges ( herniates) into the vagina. Two common causes of this defect are childbirth and hysterectomy. Rectocele also tends to occur with other forms of ...

) into the vagina. Often, a vaginoplasty is performed to repair the vagina and its attached structures due to trauma or injury.

Congenital disorder A birth defect is an abnormal condition that is present at childbirth, birth, regardless of its cause. Birth defects may result in disability, disabilities that may be physical disability, physical, intellectual disability, intellectual, or dev ...

s such as

adrenal hyperplasia The adrenal glands (also known as suprarenal glands) are endocrine glands that produce a variety of hormones including adrenaline and the steroids aldosterone and cortisol. They are found above the kidneys. Each gland has an outer cortex which ...

can affect the structure and function of the vagina and sometimes the vagina is absent; these can be reconstructed or formed, using a vaginoplasty. Other candidates for the surgery include babies born with a microphallus, people with

Müllerian agenesis Müllerian may refer to: * Müllerian mimicry, a type of mimicry or convergence named after Fritz Müller * Müllerian ducts, which enter the cloaca of an embryo (named after Johannes Peter Müller) * Mullerian anomalies are structural anomalies c ...

resulting in

vaginal hypoplasia Vaginal hypoplasia is the underdevelopment or incomplete development of the vagina. It is a birth defect or congenital abnormality of the female genitourinary system. Signs and symptoms Vaginal hypoplasia can vary in severity from being smaller ...

trans women A trans woman or transgender woman is a woman who was assigned male at birth. Trans women have a female gender identity and may experience gender dysphoria (distress brought upon by the discrepancy between a person's gender identity and their ...

, and women who have had a vaginectomy after malignancy or trauma.

Medical uses

Vaginoplasty is the description of the following surgical interventions: * separation of congenitally fused urethra and vagina * repair of a urethra that is short * vaginal construction * vaginal

reconstruction Reconstruction may refer to: Politics, history, and sociology *Reconstruction (law), the transfer of a company's (or several companies') business to a new company *''Perestroika'' (Russian for "reconstruction"), a late 20th century Soviet Union ...

* vaginal vault

prolapse In medicine, prolapse is a condition in which organ (anatomy), organs fall down or slip out of place. It is used for organs protruding through the vagina, rectum, or for the misalignment of the valves of the heart. A spinal disc herniation is al ...

* vaginal suspension and fixation * operations on

recto-uterine pouch The rectouterine pouch (rectovaginal pouch, pouch of Douglas or cul-de-sac) is the extension of the peritoneum into the space between the posterior wall of the uterus and the rectum in the human female. Structure In women, the rectouterine pouch ...

* repair of

and

* retropubic paravaginal repair * the repair of a cystocele using a

graft Graft or grafting may refer to: *Graft (politics), a form of political corruption *Graft, Netherlands, a village in the municipality of Graft-De Rijp Science and technology *Graft (surgery), a surgical procedure *Grafting, the joining of plant ti ...

prosthesis In medicine, a prosthesis (: prostheses; from ), or a prosthetic implant, is an artificial device that replaces a missing body part, which may be lost through physical trauma, disease, or a condition present at birth (Congenital, congenital disord ...

* the repair of a cystocele and a rectocele in the same procedure using a graft or prosthetic device * the repair of a rectocele using a graft or prosthetic material * the vaginal construction using a graft or prosthetic material * the vaginal reconstruction using a graft or prosthetic material * the vaginal suspension and stabilization using with graft or prosthetic material * treatment of MRKH syndrome (vaginal agenesis) *

hymenorrhaphy Hymenorrhaphy or "hymen reconstruction surgery" is the surgical alteration of the hymen, with the goal of producing bleeding on intercourse and a tight vaginal introitus, falsely believed to indicate virginity. The term comes from the Greek words ...

In some instances, extra tissue is needed to reconstruct or construct the vagina. These grafts used in vaginoplasty can be an

allotransplantation Allotransplant (''allo-'' meaning "other" in Greek) is the transplantation of cells, tissues, or organs to a recipient from a genetically non-identical donor of the same species. The transplant is called an allograft, allogeneic transplant, ...

, a

heterograft Xenotransplantation (''xenos-'' from the Greek meaning "foreign" or strange), or heterologous transplant, is the transplantation of living cells, tissues or organs from one species to another.autologous Autotransplantation is the transplantation of organs, tissues, or even particular proteins from one part of the body to another in the same person ('' auto-'' meaning "self" in Greek). The autologous tissue (also called autogenous, autogenei ...

material. A woman can use an autologous in vitro cultured tissue taken from her vaginal vestibule as transplanted tissue to form the lining of the reconstructed vagina. A reconstructed or newly constructed vagina is called a neovagina.

Vaginoplasties in children

Conditions such as

congenital adrenal hyperplasia Congenital adrenal hyperplasia (CAH) is a group of Genetic disorder#Autosomal recessive, autosomal recessive disorders characterized by impaired cortisol synthesis. It results from the deficiency of one of the five enzymes required for the Biosy ...

virilize genetic females due to a

21-hydroxylase Steroid 21-hydroxylase is a protein that in humans is encoded by the ''CYP21A2'' gene. The protein is an enzyme that hydroxylates steroids at the C21 position on the molecule. Naming conventions for enzymes are based on the substrate acted upo ...

deficiency. Specific procedures include: clitoral reduction,

labiaplasty Labiaplasty (also known as labioplasty, labia minora reduction, and labial reduction) is a plastic surgery procedure for creating or altering the labia minora (inner labia) and the labia majora (outer labia), the folds of skin of the human vu ...

, normalizing appearance, vagina creation, initiating vaginal dilation.

Vaginal atresia Vaginal atresia is a condition in which the vagina is abnormally closed or absent. The main causes can either be complete vaginal hypoplasia, or a vaginal obstruction, often caused by an imperforate hymen or, less commonly, a transverse vaginal sep ...

, or congenital absence of the vagina, can be another reason for surgery to construct a normal and functional vagina. Vaginoplasty is used as part of the series of surgeries needed to treat those girls and women born with the bladder located outside of their abdomen. After the repairs, women have been able to give birth but are at risk of prolapse. There are human rights concerns about vaginoplasties and other genital surgeries in children who are not old enough to consent, including concern with post-surgical sexual function, and assumptions of

cisnormativity Cisnormativity or cissexual assumption is the assumption that everyone is, or ought to be, cisgender. The term can further refer to a wider range of presumptions about gender assignment, such as the presumption of a gender binary, or expectatio ...

.Report of the UN Special Rapporteur on Torture

Office of the UN High Commissioner for Human Rights The Office of the United Nations High Commissioner for Human Rights (OHCHR) is a department of the United Nations Secretariat that works to promote and protect human rights that are guaranteed under international law and stipulated in the Univers ...

, February 2013. There is no consensus attitude among clinicians about their necessity, timing, method or evaluation. Vaginoplasties may be performed in children or adolescents with

intersex Intersex people are those born with any of several sex characteristics, including chromosome patterns, gonads, or genitals that, according to the Office of the United Nations High Commissioner for Human Rights, "do not fit typical binar ...

conditions or

disorders of sex development Disorders of sex development (DSDs), also known as differences in sex development, variations in sex characteristics (VSC), sexual anomalies, or sexual abnormalities, are congenital conditions affecting the reproductive system, in which developme ...

Techniques

Non-surgical vagina creation was used in the past to treat the

congenital A birth defect is an abnormal condition that is present at childbirth, birth, regardless of its cause. Birth defects may result in disability, disabilities that may be physical disability, physical, intellectual disability, intellectual, or dev ...

absence of a vagina. The procedure involved the wearing of a saddle-like device and the use of increasing-diameter

dilators Dilator or dilatator is a medical term with a number of uses, including: *A surgical instrument or medical implement used to induce dilation, that is, to expand an opening or passage such as the cervix (see cervical dilator), urethra, esophagus, ...

. The procedure took several months and was sometimes painful. It was not effective in every instance. Uncommon growths, cysts, septums in the vagina can also require vaginoplasty.

Reconstructive surgery after cancer treatment

Radiological cancer treatment can result in the destruction or alteration of vaginal tissues. Vaginoplasty is often performed to reconstruct the vagina and other genital structures. In some cases, normal sexual function can be restored.

McIndoe surgical technique

A canal is surgically constructed between the

and

in the anterior portion of the pelvic region and the

. A skin graft is used from another area of the person's body. The graft is removed from the

thigh In anatomy, the thigh is the area between the hip (pelvis) and the knee. Anatomically, it is part of the lower limb. The single bone in the thigh is called the femur. This bone is very thick and strong (due to the high proportion of bone tissu ...

buttocks The buttocks (: buttock) are two rounded portions of the exterior anatomy of most mammals, located on the posterior of the pelvic region. In humans, the buttocks are located between the lower back and the perineum. They are composed of a lay ...

, or inguinal region. Other materials have been used to create the lining of the new vagina. These have been cutaneous

skin flap The terms free flap, free autologous tissue transfer and microvascular free tissue transfer are synonymous terms used to describe the "transplantation" of tissue from one site of the body to another, in order to reconstruct an existing defect. ...

amniotic membrane The amnion (: amnions or amnia) is a membrane that closely covers human and various other embryos when they first form. It fills with amniotic fluid, which causes the amnion to expand and become the amniotic sac that provides a protective en ...

s, and

buccal mucosa The oral mucosa is the mucous membrane lining the inside of the mouth. It comprises stratified squamous epithelium, termed "oral epithelium", and an underlying connective tissue termed ''lamina propria''. The oral cavity has sometimes been describ ...

Gender-affirming surgery

Several techniques may be used in

gender-affirming surgery Gender-affirming surgery (GAS) is a surgical procedure, or series of procedures, that alters a person's physical appearance and sexual characteristics to resemble those associated with their gender identity. The phrase is most often associated ...

to create a neovagina.

Penile inversion

Inversion of the penile skin is the method most often selected to create a neovagina by surgeons performing gender-affirming surgery. The inverted penile skin uses inferior pedicle skin or abdominal skin for the lining of the neovagina. The skin is cut to form an appropriate-sized flap. The skin flap is sometimes combined with a scrotal or urethral flap. The penile inversion technique was pioneered by

Georges Burou Georges Burou (6 September 1910 – 17 December 1987) was a French gynecologist who managed a clinic in Casablanca, Morocco, and is widely credited with innovating modern sex reassignment surgery for trans women. Notable patients include Coccine ...

in his Morocco clinic in the 1950s. By the 1970s he had performed hundreds of them, and gave his first public presentation of his technique to a conference at Stanford University in 1973, after which it gradually became the predominant technique worldwide.

Bowel vaginoplasty

Peritoneal vaginoplasty

Other methods

Penile-

scrotal In most terrestrial mammals, the scrotum (: scrotums or scrota; possibly from Latin ''scortum'', meaning "hide" or "skin") or scrotal sac is a part of the external male genitalia located at the base of the penis. It consists of a sac of skin c ...

skin flaps are also used. Nongenital full-thickness graft (FTG) or split-thickness skin grafts from other parts of the body have been used.

Elective vaginoplasty

Critics have labeled such surgery as the "designer vagina". The

American College of Obstetricians and Gynecologists The American College of Obstetricians and Gynecologists (ACOG) is a professional association of physicians specializing in obstetrics and gynecology in the United States. Several Latin American countries are also represented within Districts of ...

issued a warning against these procedures in 2007 as did the

Royal Australian and New Zealand College of Obstetricians and Gynaecologists The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) is a not-for-profit organisation dedicated to the establishment of high standards of practice in obstetrics and gynaecology and women’s health. The Col ...

, and a commentary in the ''

British Medical Journal ''The BMJ'' is a fortnightly peer-reviewed medical journal, published by BMJ Publishing Group Ltd, which in turn is wholly-owned by the British Medical Association (BMA). ''The BMJ'' has editorial freedom from the BMA. It is one of the world ...

'' strongly criticized the "designer vagina" in 2009. The

Society of Obstetricians and Gynaecologists of Canada The Society of Obstetricians and Gynaecologists of Canada (SOGC) is a national medical society in Canada, representing over 4,000 obstetricians/gynaecologists, family physicians, nurses, midwives, and allied health professionals in the field of s ...

published a policy statement against elective vaginoplasty based upon the risks associated with unnecessary cosmetic surgery in 2013. Vaginal rejuvenation is a form of elective plastic surgery. Its purpose is to restore or enhance the vagina's cosmetic appearance.

Hymen surgical procedures

imperforate hymen An imperforate hymen is a congenital disorder where a hymen without an opening completely obstructs the vagina. It is caused by a failure of the hymen to perforate during fetal development. It is most often diagnosed in adolescent girls when men ...

is the presence of tissue that completely covers the vaginal opening. It is cut to allow menstrual flow to exit during a short surgical procedure. A

is the surgical procedure that reconstructs the hymen.

Balloon vaginoplasty

In this procedure, a

Foley catheter In urology, a Foley catheter is one of many types of urinary catheters (UC). The Foley UC was named after Frederic Foley, who produced the original design in 1929. Foleys are indwelling UC, often referred to as an IDCs (sometimes IDUCs). This dif ...

laparoscopically Laparoscopy () is an operation performed in the abdomen or pelvis using small incisions (usually 0.5–1.5 cm) with the aid of a camera. The laparoscope aids diagnosis or therapeutic interventions with a few small cuts in the abdomen.Medlin ...

inserted to the rectouterine pouch whereupon gradual traction and distension are applied to create a neovagina.

Pull through or Vecchietti procedure

In treating

, the Vecchietti procedure is a

laparoscopic Laparoscopy () is an operation performed in the abdomen or human pelvis, pelvis using small Surgical incision, incisions (usually 0.5–1.5 cm) with the aid of a camera. The laparoscope aids diagnosis or therapeutic interventions with a few ...

surgical technique that produces a

of dimensions (depth and width) comparable to those of a normal vagina (ca. 8 cm deep). A small, plastic sphere called an olive is threaded ( sutured) against the vaginal area; the threads are drawn though the vaginal skin, up through the

abdomen The abdomen (colloquially called the gut, belly, tummy, midriff, tucky, or stomach) is the front part of the torso between the thorax (chest) and pelvis in humans and in other vertebrates. The area occupied by the abdomen is called the abdominal ...

, and through the

navel The navel (clinically known as the umbilicus; : umbilici or umbilicuses; also known as the belly button or tummy button) is a protruding, flat, or hollowed area on the abdomen at the attachment site of the umbilical cord. Structure The u ...

. There, the threads are attached to a traction device, and then daily are drawn tight so that the olive is pulled inwards and stretches the vagina, by approximately 1 cm per day, thereby creating a vagina, approximately 7 cm deep by 7 cm wide, in 7 days. The mean operating room (OR) time for the Vecchietti vaginoplasty is approximately 45 minutes; yet, depending upon the patient and her indications, the procedure might require more time. The outcomes of Vecchietti technique via the laparoscopic approach are found to be comparable to the procedure using laparotomy. In

, traction vaginoplasty such as the Vecchietti technique seems to have the highest success rates both anatomically (99%) and functionally (96%) among available treatments. Other surgical techniques that have been developed include ileal neovagina (Monti's technique), Creatsas vaginoplasty, Wharton–Sheares–George neovaginoplasty, or the Davydov procedure. The most widely used is the Vecchietti laparoscopic procedure. Sometimes sexual intercourse can result in the dilation of a newly constructed vagina.

Vaginal dilators and expanders

The most techniques of vaginoplasty are using inflatable vaginal expanders or vaginal stents to design the vaginal diameter and length. At the end of the procedure the device stays in place to maintain the neovagina against the pelvic wall which also favors the process of microscopic neovascularization and reduces the risks of hematoma. In post-operative setting the expander can be used regularly to prevent post-operative vaginal retraction. Solid vaginal dilators can also be used immediately after surgery to keep the passage from attachments, and regularly thereafter to maintain the viability of the neovagina. The frequency required to use decreases over time, however remains obligatory lifelong.

Risks and complications

Reconstructive vaginoplasty in children and adolescents carries the risk of

superinfection A superinfection is a second infection superimposed on an earlier one, especially by a different microbial agent of exogenous or endogenous origin, that is resistant to the treatment being used against the first infection. Examples of this in bact ...

. In adults, rates and types of complications varied with gender-affirming surgery.

Necrosis Necrosis () is a form of cell injury which results in the premature death of cells in living tissue by autolysis. The term "necrosis" came about in the mid-19th century and is commonly attributed to German pathologist Rudolf Virchow, who i ...

of the clitoral region was 1–3%. Necrosis of the surgically created vagina was 3.7–4.2%. Vaginal shrinkage occurred was documented in 2–10% of those treated. Stricture, or narrowing of the vaginal orifice was reported in 12–15% of the cases. Of those reporting stricture, 41% underwent a second operation to correct the condition. Necrosis of two

flaps has been described. Posterior vaginal wall is a rare complication.

Genital pain Genital pain and pelvic pain can arise from a variety of conditions, crimes, trauma, medical treatments, physical diseases, mental illness and infections. In some instances the pain is consensual and self-induced. Self-induced pain can be a cause ...

was reported in 4–9%. Rectovaginal

fistula In anatomy, a fistula (: fistulas or fistulae ; from Latin ''fistula'', "tube, pipe") is an abnormal connection (i.e. tube) joining two hollow spaces (technically, two epithelialized surfaces), such as blood vessels, intestines, or other h ...

is also rare with 1% documented. Vaginal prolapse was seen in 1–2% of people

assigned male at birth Sex assignment (also known as gender assignment) is the discernment of an infant's sex, typically made at birth based on an examination of the baby's external genitalia by a healthcare provider such as a midwife, nurse, or physician. In the v ...

undergoing this procedure. The ability of emptying the

bladder The bladder () is a hollow organ in humans and other vertebrates that stores urine from the kidneys. In placental mammals, urine enters the bladder via the ureters and exits via the urethra during urination. In humans, the bladder is a distens ...

was affected for some patients after this procedure: 13% reported improvement, 68% said that there was no change and 19% reported that

voiding Urination is the release of urine from the bladder through the urethra in placental mammals, or through the cloaca in other vertebrates. It is the urinary system's form of excretion. It is also known medically as micturition, voiding, ures ...

got worse. Those reporting a negative outcome who experienced loss of bladder control and

urinary incontinence Urinary incontinence (UI), also known as involuntary urination, is any uncontrolled leakage of urine. It is a common and distressing problem, which may have a significant effect on quality of life. Urinary incontinence is common in older women ...

were 19%.

Urinary tract infection A urinary tract infection (UTI) is an infection that affects a part of the urinary tract. Lower urinary tract infections may involve the bladder (cystitis) or urethra (urethritis) while upper urinary tract infections affect the kidney (pyel ...

s occurred in 32% of those treated.

History

Reports of people seeking vaginoplasty go back to the 2nd century. The first modern vaginoplasty was performed in 1931 on

Dora Richter Dora Rudolfine Richter (16 April 1892 – 26 April 1966) was a German trans woman and the first known person to undergo complete male-to-female gender-affirming surgery. She was one of a number of transgender people in the care of sex-research p ...

Lili Elbe Lili Ilse Elvenes (28 December 1882 – 13 September 1931), better known as Lili Elbe, was a Danish painter, transgender woman, and one of the earliest recipients of gender-affirming surgery (then called sex reassignment surgery). Elbe was a p ...

also underwent a vaginoplasty the same year.

References

Bibliography

* * ^{electronic book, no page numbers.} {{Reproductive health Gynecological surgery Surgical oncology Surgical removal procedures Reproductive system Feminizing surgery Female genital modification Plastic surgery Vagina Pediatric gynecology Chromosomes Urethra disorders Intersex healthcare